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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    In this report, the Care Quality Commission (CQC) explain the information they have gathered on the pressures that services and local systems have faced during COVID-19 and the efforts that have been made to tackle them. These insight reports are designed to help everyone involved in health and social care to work together to learn from the first stages of the COVID-19 pandemic by: sharing and reflecting on what has gone well understanding and learning from the experience of what hasn't helping health and care systems prepare better in the future. This issue is divided into three main chapters: Working together across systems Focus on primary care How the care for people from different groups is being managed.
  2. Content Article
    This paper, published in BMJ Quality & Safety, provides national estimates of the number and clinical and economic burden of medication errors in the National Health Service (NHS) in England. Authors conclude that ubiquitous medicines use in health care leads unsurprisingly to high numbers of medication errors, although most are not clinically important. There is significant uncertainty around estimates due to the assumption that avoidable adverse drug events correspond to medication errors, data quality and lack of data around longer-term impacts of errors. Data linkage between errors and patient outcomes is essential to progress understanding in this area.
  3. Content Article
    This editorial, published by the Lancet, highlights that racism is the root cause of continued disparities in health and mortality rates between black and white people in the USA and a global public health emergency. It discusses what medical journals can and must do to help.
  4. Content Article
    Providing patients with access to electronic health records (EHRs) may improve quality of care by providing patients with their personal health information and involving them as key stakeholders in the self-management of their health and disease. With the widespread use of these digital solutions, there is a growing need to evaluate their impact, in order to better understand their risks and benefits and to inform health policies that are both patient-centred and evidence-based. The objective of this paper, published by BMJ Quality & Safety, was to evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care: patient-centredness effectiveness efficiency timeliness equity safety.
  5. Content Article
    In response to the pandemic earlier this year, the priority became freeing up as much bed and staffing capacity as possible within hospitals in anticipation of the incoming tide of COVID-19 patients. One way of doing this was postponing all non-urgent elective operations for a period of at least three months. It was estimated that this would free up 12,000-15,000 hospital beds in England alone. This approach was successful in the short-term, helping the NHS to meet the immediate demand created by the pandemic. However, it has produced a longer-term challenge as we transition back to ‘normal’ with a large backlog of cases. Decisions about how these are prioritised will have significant implications for the health and wellbeing of patients. In this blog, Patient Safety Learning look at the patient safety implications and highlight where we need to focus on to avoid patient harm. Read the full blog on the Patient Safety Learning website.
  6. Content Article
    This article, published in Drug Safety, Robust, argues that active cooperation and effective, open communication between all stakeholders is essential for ensuring regulatory compliance and healthcare product safety; avoiding the necessity for whistle-blowing; and, most essentially, meeting the transparency requirements of public trust.
  7. Content Article
    This commentary from Nigel Poole, was published in the Journal of Patient Safety and Risk Management. Nigel discusses how the coronavirus pandemic will affect clinical negligence litigation in England and Wales. Subsections include: context is all the pandemic is not a license to act negligently expert evidence delay backlog in litigation a reduction in the number of new claims.
  8. Content Article
    This study, published in Health Services and Delivery Research, found the patient experience feedback cycle was rarely completed, and despite diverse approaches to gathering feedback in inpatient settings, approaches to analysing and using this information remain underdeveloped.
  9. Community Post
    The next big push is on community rehab but how will commissioners support community equipment providers who will play a crucial role in this? We (equipment provider) usually have 70 referrals per week - this is down to five at present. How will services catch up as well as providing support for those accessing community rehab? When will community health practitioners expect to be back in their usual roles following redeployment? These concerns were raised by a participant at our recent webinar. Join the conversation by adding your thoughts below. If you are not yet a member, you'll need to sign up here. It's quick and easy to do.
  10. Content Article
    In this blog, Suzanne Rastrick, Chief Allied Health Professions Officer for NHS England, urges colleagues to start describing service improvements they are undertaking as part of the COVID response and considering what evidence they may need to create a case to continue the good practice. She asks 'what could we be doing now to measure impact and are we capturing data already that could be developed or utilised to demonstrate and evidence the improvements created through changes in working practices?' 
  11. Content Article
    In this article, published by Diagnosis, Linden Brown reflects on his time working with COVID-19 patients. He recalls an incident where a case of sepsis was nearly missed due to what he calls 'COVID-blindness'. "In the panic of quarantine and isolation precautions, we put on cognitive blinders to our bread and butter: sepsis. Had this patient come into the hospital 2 weeks prior, he would likely have been placed on antibiotics immediately."
  12. Content Article
    The Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). It is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care. The objective of this study, published in Health Services and Delivery Research, was to determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure. Authors conclude that employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function.
  13. Content Article
    Healthcare Improvement Scotland is currently working with the Scottish Government to develop COVID-19 specific Anticipatory Care Planning (ACP) templates and guidance. ACP is a person-centred approach to help people to plan for their future. The essence of ACP is to encourage individuals to think ahead to help ensure that in the event of a change in their health or care needs, including loss of capacity, the right thing is done at the right time by the right person with the right outcome. ACP can benefit many individuals, from those with early onset of long-term conditions to people with chronic and complex illnesses, to plan ahead for care needs. ACP can be beneficial to individuals towards the end of their life, however the process can be more effective if started earlier in their journey. The link below takes you to an online resource that is designed to be used in conjunction with practitioner judgement, and is not for sole use by individuals and their families without guidance. 
  14. Content Article
    Returning to ‘normal’ levels of activity after the COVID-19 pandemic is expected to take some time and, even before COVID-19, there were substantial challenges with waiting times. As the NHS looks to start to recover services, this analysis from the Health Foundation looks at the context in which planned treatment will recommence. Specifically, it looks at what would have been needed – if the NHS were operating within a ‘business as usual model’ – to return to delivering the standard of 92% of patients being treated within 18 weeks, given the waiting lists and waiting times backlog that had built up by January 2020.
  15. Community Post
    Some more resources that may be useful... NHS Employers: Risk assessments for staff – COVID-19 NHS: Supporting our BAME NHS people and communities during and beyond COVID-19 (May 2020) Are some ethnic groups more vulnerable to COVID-19 than others?
  16. Community Post
    This topic has been created to provide our members with a space to share COVID-19 risk assessments for BAME staff. You can share your risk assessment resources by commenting below and adding an attachment. We've kicked things off by sharing an example below. If you are not yet a member of the hub, you'll need to sign up here first - it's quick and easy to do. By collaborating and sharing learning, we hope to reduce risk. Risk ax form .doc
  17. Content Article
    The number of people accessing COVID-19 testing in the UK continues to increase. Health Secretary, Matt Hancock recently announced, that anyone over the age of five years old who is showing symptoms is eligible for a test [1]. However, there are concerns that the rate of ‘false negative’ test results could be as high as 30% and a significant number of people are wrongly being told they do not have the virus [2]. This could be due to the particularly difficult nature of obtaining the swab, which requires someone to take a sample from the very back of the mouth or deep from inside the nose.  “Swabbing patients using the correct technique is paramount in ensuring an accurate result.  Nasal swabs need to be taken from far back in the nasal pharynx and is often uncomfortable for the patient.  By simply swabbing the inside of the nasal passage is not deep enough to verify that the virus is present. I am unsure that all clinical staff have been taught the correct way to swab patients.” Claire Cox, Intensive Care Outreach Nurse. Members of the public are now able to request self-testing kits to do at home if they are experiencing symptoms. If clinicians like Claire are finding the test challenging to perform on others, it is likely that patients could struggle to swab deep enough into their own nasal pharynx (7-8cm). There is a risk that as the number of people testing themselves increases, so too will the rate of false negative results.  Testing is a key element of the UK’s COVID-19 infection control strategy [3]. A high, and potentially rising, rate of false negative results means that a significant number of people could be carrying the virus, wrongly reassured they are not infectious. In this blog, we look at some of the associated safety risks. 
  18. Content Article
    Rehabilitation is fast becoming the new priority in dealing with the impact of this pandemic and is crucial for people recovering from COVID-19 infection.The Royal College of Occupational Therapists (RCOT) have published three guides to support people to manage post-viral fatigue and conserve their energy as they recover from COVID-19. These guides are endorsed by the Intensive Care Society.Practical advice for people who have been treated in hospitalPractical advice for people who have recovered at home’Practical advice for people during and after having COVID-19.You can download the guides via the link below.
  19. Content Article
    There is evidence of disproportionate mortality and morbidity amongst black, Asian and minority ethnic (BAME) people, including NHS staff, who have contracted COVID-19. The authors of this blog argue that this is not just an equality, diversity and inclusion issue but an urgent medical emergency and we need to act now.They look at how the NHS can support BAME staff through the COVID-19 pandemic and beyond, focusing on: protection of staff engagement with staff representation in decision making rehabilitation and recovery communications and media.  
  20. Content Article
    The National Falls Prevention Coordination Group has identified resources to address Covid-19 related falls and fracture issues including advice for patients on keeping active following hospital discharge. The advice leaflet has been designed for patients who are discharged home with no community rehabilitation and can be download via the Chartered Society of Physiotherapy link below. It explains why muscle wasting occurs with prolonged bed rest or inactivity and why it is important to be active when discharged home from hospital. 
  21. Content Article
    This is the letter from Monitor (now part of NHS Improvement) to all foundation trust chief executives about Sir Robert Francis’ Freedom to Speak Up review.
  22. Content Article
    This page contains guidance for employers on how to carry out risk assessments particularly for vulnerable groups, to understand the specific risks staff members face from exposure to COVID-19 and actions which employers can take to keep staff safe. This includes staff returning to work for the NHS, and existing staff who are potentially more at risk due to their race, age, disability or pregnancy.
  23. Content Article
    Paul Garner is Professor at the Liverpool School of Tropical Medicine. He is Director of the Centre for Evidence Synthesis in Global Health and Co-ordinating Editor of the Cochrane Infectious Diseases Group. In this blog for BMJ Opinion, Paul describes how he has struggled in the weeks following his COVID-19 infection and the relapses in fatigues that have occurred after any exertion.
  24. Content Article
    This statement outlines the UK's four nations’ collective strategic priorities and approach to Allied Health Professional (AHP) rehabilitation leadership during and after COVID-19. Rehabilitation is critical to ensuring our population’s recovery from the impacts of the pandemic and the long-term sustainability of the health and social care system. AHPs are at the centre in shaping the rehabilitation agenda while working as part of the wider multidisciplinary and multiagency teams across all sectors.
  25. Content Article
    In this video Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Helen Hughes the Chief Executive of Patient Safety Learning, on how we can better share learning about reducing harm in healthcare. Helen shares the resources that are available through Patient Safety Learning and how those passionate about safety can get involved.
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