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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    NHS Blood and Transplant have estimated that almost 7,000 people are waiting for lifesaving transplants in the UK, the highest number in six years. During the first peak of the pandemic last year, several key services have had to be closed reveals the analysis from April 2020 to March 2021, although most were rapidly reinstated and 80% of NHS transplant work went ahead. Figures from the report found 474 patients died while waiting for organs, a higher number than the year before and the majority of patients were waiting for kidney transplants. Read full story. Source: BBC News, 15 July 2021
  2. News Article
    The Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) has warned there may be a risk to pregnant women when next weeks restrictions relax. Experts are warning that infection rates among pregnant women may increase once the restrictions are lifted and encourage them to protect themselves and their families as women who are pregnant are more likely to become severely ill with Covid-19. RCN chief executive Gill Walton, has said: "Along with mask wearing, hand washing and social distancing, vaccination is a vital tool in the fight to protect yourself against this virus. Read full story. Source: BBC News, 15 July 2021
  3. News Article
    Since lockdown, people have not been exposed to viruses that normally circulate during the winter months, but now that restrictions are lifting, there are concerns the viruses may make a comeback. Now, leading medics have warned there will be a surge in respiratory viruses alongside Covid-19 this winter and have urged anyone experiencing symptoms to self-isolate. Testing for flu, Covid and respiratory viruses common in children and elderly may help doctors treat cases quickly, doctors have said. A report by Professor Azra Ghani, from Imperial College London found a surge in winter viruses during the summer. She has said "Whilst we expect the peak in deaths to be considerably lower than last winter, under some scenarios we could see hospital admissions rise to similar levels." Read full story. Source: BBC News, 15 July 2021
  4. News Article
    The Royal College of Nursing has written to the Prime Minister demanding continued protective measures after the loosening of restrictions on July 19th. In a joint letter with the British Medical Association, the Royal Pharmaceutical Society, British Dental Association and College of Optometrists, they ask for support and protection for healthcare staff. The letter says “The need to recognise health and care settings as unique environments for the care and safety of the most vulnerable is paramount. While you state that you would expect the public to continue wearing face coverings in healthcare settings, we ask that this is translated into action". Read full story. Source: RCN, 14 July 2021
  5. News Article
    A new study has been published focusing on surgical innovation and how it could be made safer. The research set out to develop a 'core outcome set', an agreed minimum set of outcomes to measure and report for safe surgical techniques in all audits, research, and clinical practice. The study, co-led by Dr Kerry Avery, a Senior Lecturer at the University of Bristol and NIHR Bristol Biomedical Research Centre (BRC) has said "It may surprise many people to learn that surgical procedures haven’t traditionally been subject to the kind of regulation we see in other areas of medicine. But to ensure safety and improve efficiency, a core outcome set is an important step". Read full story. Source: University of Bristol, 13 July 2021
  6. Content Article
    This study looks at patients experiences of surgical site infections (SSIs) with the aim of improving clinical practice. The researchers conducted 17 narrative interviews with patients who had SSIs and then performed a thematic content analysis. Results found patients were not fully informed about SSIs and the nature surrounding them, with 7 patients saying they did not know they even had SSIs which may have been due to staff not informing the patients appropriately. Among the authors' conclusions, they suggest that if patients were more aware of SSIs, it may be able to help them adhere to preventative measures.
  7. Content Article
    The aim of the study was to create a core outcome set (COS), an agreed set of outcomes that could be measured, and report in all studies an evaluation of the introduction and evaluation of novel surgical techniques. The authors used data from several different sources such as innovation-specific literature, policy/regulatory body documents, and surgeon interviews. The results included 7,972 verbatim outcomes that were identified which were categorized into 32 domains. The researchers conclude the COS could be used to help encourage safer surgical innovation.
  8. News Article
    A new independent inquiry has been launched after reports of mother and baby deaths at Nottingham University Hospitals Trust. According to patient safety minister Nadine Dorries, the inquiry will be led externally and will be examining cases going back to 2016. The review has been welcomed by families but they have said they want to be fully involved in the process including setting the terms of reference and making sure it is a truly independent inquiry. Read full story. Source: The Independent, 13 July 2021
  9. News Article
    A new study has found nursing shortages may have negatively impacted patient safety, including unsafe practice management workarounds and cognitive failures. Research has found cutting corners when understaffed may have been the only way to get the work done quicker due to the added strain and heavier workload and in another study, it was discovered nurse staffing demand increased to 245 percent between September and December 2020. It was also reported that nurses who had little or no experience of working in the ICU environment were assigned to work there which may have led to higher stress levels and cognitive failures such as memory and attention lapses. Read full story. Source: Recycle Intelligence, 13 July 2021
  10. News Article
    New research has suggested unvaccinated young people may be at a higher risk of getting long-term symptoms. With restrictions being lifted on 19th July, concerns have been raised about the impact of the Delta variant. Professor Danny Altmann has said “From every version of Covid we’ve ever seen on the planet, we’ve got a rule of thumb that any case of Covid, whether it’s asymptomatic, mild, severe, or hospitalised, incurs a 10 to 20% risk of developing long Covid, and we haven’t seen any exceptions to that.” Read full story. Source: The Guardian, 13 July 2021
  11. News Article
    As restrictions are due to lift on the 19th July and the mandatory face masks mandate moving to recommended, Scotland have said they will keep the mandatory rule. BMA Council Chair, Dr Chaand Nagpaul has called the decision to lift restrictions 'irresponsible and perilous', with Dr Layla McCay, director of policy at the NHS Confederation saying there was "a real risk that dropping the restrictions including to wear masks, especially in health care settings and to socially distance will lead to a significant COVID-19 surge which will place even more strain on a system struggling to cope". Read full story. Source: Medscape, 13 July 2021
  12. News Article
    Researchers at Imperial College London have found a pattern of rouge antibodies that may allow a simple blood test to diagnose Long Covid in the next 6 to 18 months. Currently, there is no diagnostic test for Long Covid and the condition is not yet fully understood, and with the rise in cases, it is not yet known if the vaccination can protect patients from getting long-term symptoms. However, leading the research team at Imperial College London, Professor Danny Altmann believes the research could allow for a test to be performed in a GP surgery. And regarding the rising cases, Professor Altmann has said "If we're heading into a phase of 100,000 cases per day, and, we're saying that 10-20% of all infections can result in long Covid, I can see no certainty that we're not brewing those long Covid cases despite having a vaccinated population," Read full story. Source: BBC News, 12 July 2021
  13. News Article
    In November last year, Unison and RCN raised concerns with NHS Forth Valley chief executive Cathie Cowan amid bullying claims made by emergency department staff at Forth Valley Royal Hospital. In light of the reports of bullying, a review was commissioned and leaked details revealed junior doctors were left unsupervised on shifts, nurses and doctors had said they are 'battle-weary', and many senior staff members have resigned their posts. Karren Morrison, Unison Forth Valley health branch secretary has said: ‘Last year, concerns were being raised by our members who worked in, or who had previously worked in the ED. Staff talked to us about feeling bullied and intimidated, being frightened to speak up, concerns about the delivery of safe patient care, high staff turnover and other issues.’ Read full story (paywalled). Source: Nursing Standard, 12 July 2021
  14. Content Article
    This article discusses endometriosis and how the common treatment of performing laparoscopic surgery to remove damaged tissue may not be as effective as once thought. Lucia Osborne-Crowley writes about how experts have found that women who have the surgery don't always get better and if they do, it only lasts a short while. The article also describes what endometriosis is and how it is important not to continue encouraging women to undergo repeat surgeries as it may not improve the condition.
  15. Content Article
    This article discusses a new consultation that has been launched by Robert Francis QC regarding the terms of reference for an independent study into the infected blood scandal. The article covers the suggested scope, the approach and the rationale behind the research and what it won't do, such as run through evidence already heard by the Inquiry.
  16. Content Article
    This article focuses on common general surgical Never Events (NEs). The researchers analysed data from the National Health Service (NHS) in England and found a total of 797 general surgical NEs identified under three main categories: wrong-site surgery, retained items post-procedure and wrong implant/prosthesis. With this research, the authors aimed to raise awareness of these common themes with the hope it may help create better safety standards and safeguards and reduce the incidence of NEs.
  17. Content Article
    The Hierarchy of Controls is a system that is used to put in place effective controls within an organisation or wider community that identifies the most effective ways to control a hazard. In this diagram created by Doreen Geoghegan from the Galway-Mayo Institute of Technology the inverted cone shows the most effective controls at the top and the least effective at the bottom in relation to Covid-19.
  18. News Article
    The RCN council has agreed to support the principles behind a petition, started by RCN Professional Nursing Committee member Alison Leary, calling for the title of 'nurse' to be protected and reserved for those who are registered. Whilst the term 'registered nurse' is protected in law, the term 'nurse' is not, meaning anyone can call themselves a nurse, regardless of whether they have the appropriate qualifications or not. The RCN believes the title should be protected in order to help protect the public and ensure accountability. Read full story. Source: RCN, 12 July 2021
  19. News Article
    Spire Health Care in Bristol and the Mercy Hospital in Missouri have been awarded contacts by the Scottish government to perform surgical mesh removal for Scottish women, with costs for travel and surgery covered by the hospitals, the BBC reports. Each procedure has been estimated to cost between £16,000 and £23,000, with contracts to remove the mesh outside of Scotland expected to start later in the summer. Marian Kenny, 62, from Glasgow has said, "It has given me and lots of other women hope - and that's not something I've had in my life for quite some time." Read full story. Source: BBC News, 12 July 2021
  20. News Article
    Health secretary Sajid Javid has warned NHS waiting lists will soar amid the incoming third wave of coronavirus. Thousands of patients are on hold for at least 2 minutes before their 999 calls are answered, The Independent has revealed. Mr Javid has also been told by officials the situation will get worse in the coming weeks. Speaking to the Sunday Telegraph, Mr Javid has said "Hearing that figure of 13 million, it has absolutely focused my mind, and it’s going to be one of my top priorities to deal with because we can’t have that." Read full story. Source: The Independent, 11 July 2021
  21. News Article
    NHS staff have faced abuse by members of the public after demanding their second dose of the jab earlier than 8 weeks so they can go on holiday. A doctors has said covid-19 vaccinators are experiencing aggression and threats from people and after one incident, police had to be called over fears for safety. Chair of the Royal College of GPs, Professor Martin Marshall has said: “It is understandable that people want to be fully vaccinated as soon as possible. But it is entirely unacceptable for anybody working on the Covid vaccination programme, be it in GP-led sites, mass vaccination centres or hospital centres, to be at the receiving end of verbal abuse and intimidation. Read full story. Source: The Guardian, 10 July 2021
  22. News Article
    The Care Quality Commission has downgraded another maternity unit over 'blame culture' and concerns over safety. After an inspection was carried out, Salisbury Foundation Trust , which was downgraded from 'good' to 'inadequate' has been told it must make improvements after concerns were raised about safety and leadership of the maternity unit. Head of hospital inspection at the Care Quality Commission, Amanda Williams has said: “Following our recent inspection of Salisbury District Hospital’s maternity services, we found that women and babies using the service received effective care and treatment which met their needs most of the time. But most of the time is not good enough. Read full story. Source: The Independent, 10 July 2021
  23. Content Article
    This article describes how Never Events (NE) are serious clinical incidents that cause harm to patients. The authors analysed data from NHS England to categorise themes and identify common NE. Their results revealed 51 common NE themes in four main categories out of a total of 3247 between 2012 and 2020, identifying wrong-site surgery as the most common category. The authors conclude that with this research, awareness may help to reduce the amount of incidences in the future.
  24. Content Article
    This article discusses patient safety clinical incidents in relation to bariatric surgery with an aim to identify bariatric surgery-related learning points from the incidents. After analysing reports from the National Reporting and Learning System (NRLS) database in England and Wales, the authors found 541 bariatric surgery-related clinical incidents with 58 themes, including failure of thromboprophylaxis and medication errors. The authors hope that their research can raise awareness of these clinical incidents and propose a safety checklist and specific recommendations to help improve patient safety.
  25. Content Article
    This article describes how healthcare workers contracted Covid-19 through occupational exposure. The authors discuss how taking appropriate precautions, following primary and secondary prevention protocols and implementing proper control measures is needed to help contain the rate of infections. The authors also express how lessons need to be learned from previous outbreaks and that vigilance, protection and preventative measures need to remain in place in preparation for any future variants.
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