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Content Article
Nasogastric tube safety: it’s personal
PatientSafetyLearning Team posted an article in Improving patient safety
Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and head of patient safety insight at NHS Improvement. -
Content ArticleMisplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a “never event” by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them. An e-learning package, robust standardisation in staff’s approach to patient care, re-setting “red lines” to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.
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Content ArticleThis position paper was prepared by the Nasogastric Tube Special Interest Group of BAPEN. Dr Trevor Smith, BAPEN President commented: “It is essential that patient safety is at the top of the agenda of every NHS Trust and Health Board. Nobody in need of artificial nutrition should be at risk of a Never Event, so we endorse the special NGT placement training for a select group of staff in every hospital. Our mission is to ensure everybody receives optimal nutritional care, but it is also important to us to protect frontline healthcare professionals from the risk of avoidable and incredibly distressing mistakes. We hope this paper goes some way to encouraging Trusts and Health Boards to move towards far safer practices.”
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Content ArticleThis article discusses evidence that doctors-in-training and medical students are still performing pelvic exams on anesthetized women without their consent.
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Content ArticleThis National Voices resources webpage hosts a number of I Statements; simple expressions of how patients hope to be treated presented as a straightforward, practical guide for application in health and care settings. Follow the link below or click on the image to access all of the associated resources.
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Content ArticleNational Voices were asked by NHS England and Improvement to explore the experience of waiting for care. They wanted to understand how waits, delays and cancellations impact on people and their families, particularly those living with long-term, multiple and chronic conditions. The findings have compelling insights into issues around communication, receipt of referral, contacting health and care teams, estimations around length of wait, updates on delays, access to support and self-management and much more. COVID-19 has led to many cancellations and delays, and it is clear that waiting will be an important feature of healthcare in England in years to come. Health inequalities also impact access to care and treatment and the experience of waiting. This makes the findings in Patient. Noun. Adjective even more important. "Health and wellbeing deteriorates whilst being on a waiting list. For instance, recent polls found that half of those with experience of joint replacement surgery said their physical health deteriorated and one third said their mental health deteriorated while they were waiting."
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Content Article
Ensuring safe vascular access
PatientSafetyLearning Team posted an article in Improving patient safety
This guide, published in the Health Service Journal, looks at how greater standardisation and ultimately accreditation of specialised vascular access teams would ensure a basic level of competency and quality of care. -
Content Article
The biopsychosocial approach (March 2021)
PatientSafetyLearning Team posted an article in Pain management
Authors of this article, published in Practical Pain Management, argue: "The biopsychosocial model has led to the development of the most therapeutic and cost-effective interdisciplinary pain management programs and makes it far more likely for the chronic pain patient to regain function and experience vast improvements in quality of life." -
Content Article
Op-Ed: Surgery is forever changed by COVID (April 2021)
PatientSafetyLearning Team posted an article in Surgery
During the COVID-19 pandemic, health systems and providers scaled back non-emergency care, including cancelling non-urgent surgeries during the COVID-19. While this cautious approach was necessary early in the pandemic, it limited health systems' and providers' ability to fulfil their mission and deliver needed care to patients. In this article, published by Medpage Today, Beverly Philip, looks at how looks at how we can find a safe way forward. -
Content ArticleThis article, published in The Journal of Patient Safety and Risk Management, Albert Wu argues a focus on maternal and newborn safety are critical to getting a strong start in the first 1000 days. "Simply providing skilled care to mothers during pregnancy, during and after birth would contribute greatly. But families and communities concerned about the quality of local services may still need to be convinced that such care is needed. And there is a continued need identify additional factors that can save lives in childbirth and to improve systems to address them."
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Content ArticleMore and more appointments are happening online. Healthwatch have put together some tips on how to get the most out of the virtual health and care appointments both for patients and health and care professionals.
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Content Article
Screening incidents: thinking differently
PatientSafetyLearning Team posted an article in Improving patient safety
In this blog, Suzette Woodward, an international expert on patient safety, advises Public Health England on its review of the screening incident guidance, setting out her thoughts on how learning from safety incidents could be strengthened. -
Content ArticleInfants and very young children with cerebral palsy need effective, early intervention to improve life outcomes and minimise secondary complications. This report, from the All-Party Parliamentary Group on Cerebral Palsy, outlines several recommendations to improve early identification, intervention and pathways of care of infants and young children with cerebral palsy.
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Content ArticleThe ongoing impact of COVID-19 on health services across Europe has in most cases led to significant reductions in cancer screening, testing and diagnosis. The resultant delays in diagnosis are impacting cancer treatment and survival and are likely to do so for many years to come. Responses in individual countries and for individual tumour groups have differed, but there are common challenges in all countries. Some solutions go above and beyond the obvious actions that all countries are taking, and there are examples of how the system has reacted so far that provides the basis for further discussion on building lasting resiliency into healthcare systems and preparing for post-pandemic recovery. This report, published by IQVIA, highlights some of the approaches already being taken, as well as suggestions for what should be done going forward. It considers different stakeholders – from local pharmacies to national and international organisations – and their roles, as well as multi-stakeholder collaboration and cooperation. It aims to highlight initiatives adopted in some countries that can be shared more widely.
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Content ArticleThis analysis, from The Health Foundation, looks at what we know about the impact of the second wave of the COVID-19 pandemic on elective care in England.Updated
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Content Article
Inpatient Diabetes Training and Support
PatientSafetyLearning Team posted an article in Diabetes
National data shows that 17.5% of inpatients have diabetes of whom 35 % are on insulin therapy. Less than 10% of these admissions are related to diabetes primarily. In the majority of admissions, diabetes is a secondary co-morbidity. These patients are often cared for by teams other than the diabetes team. Inpatient Diabetes Training and Support (ITS) forms the basis for a blended inpatient diabetes educational tool which includes a web based educational resource (including links to educational material and guidance) and short educational animated videos based on real scenarios. This web portal can also serve as a standalone platform for quick access to guidance, educational videos and top tips for reference. -
Content ArticleThis policy paper, published by the Department of Health and Social Care, sets out a UK vision to unleash the full potential of clinical research delivery to tackle health inequalities, bolster economic recovery and to improve the lives of people across the UK.
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Content ArticleEvidence tells us that involving people with diabetes, carers and the public in designing and improving diabetes services can transform people's lives, improve care and develop the resilience of individuals and communities. The link below directs you to the Diabetes UK webpage, where you'll find a number of resources and tools to improve user involvement in diabetes care.
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Content Article CommentHi @Thomas Dammrich, this report was developed by the Q Community which is part of The Health Foundation. It would be worth making contact with them, or the authors listed on the report, to find out more in regard to your questions. If you would like to share links to resources relating to patient safety, that you feel would be of interest to our members and wider audience, you can submit them via our 'share' option.
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Content ArticleMany adverse events arise from human factors, such as inefficient teamwork and communication failures, and the incidence of adverse events is greatest in the surgical area. Previous research has shown the effect of team training on patient safety culture and on different areas of teamwork. Limited research has investigated teamwork in surgical wards. The aim of this study, published in BMC Health Services Research, was to evaluate the professional and organizational outcomes of a team training intervention among healthcare professionals in a surgical ward after 6 and 12 months.
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Content ArticleThe prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes. This study, published in The New England Journal of Medicine, found that birth attendants’ adherence to essential birth practices was higher in facilities that used the coaching-based WHO Safe Childbirth Checklist program than in those that did not, but maternal and perinatal mortality and maternal morbidity did not differ significantly between the two groups.
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Content Article
Long Covid Kids: Schools Awareness Pack
PatientSafetyLearning Team posted an article in Patient recovery
This pack has been created by the Long Covid Kids advocacy group. It provides Headteachers with evidence and information to aid the understanding of COVID-19 in children, transmission and the importance of mitigating risk to reduce long-term health implications for children and staff. -
Content ArticleThis is the coroners report into the death of Brandon-Robert, who was born on 29 May 2020, and died of E. coli sepsis a week later.
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Content ArticleDr Claud Regnard (Honory Consultant in Palliative Care Medicine, St Oswald’s Hospice) explains the Mental Capacity Act (England and Wales) and the legal requirements for making best Interest decisions when someone lacks capacity to make a particular decision. This webinar was produced by the Palliative Care for People with Learning Disabilities (PCPLD) Network.
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Content ArticleThe COVID-19 pandemic has exposed huge problems with the way Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made, understood and communicated with people with learning disabilities and their families and carers. There have been reports of unlawful blanket decision-making and of DNACPR orders noted without discussion with the people involved. In this webinar, the Palliative Care for People with Learning Disabilities (PCPLD) Network focus on some of the questions that have been raised over the past year. What exactly is DNACPR? Why are the terms DNR or DNAR unhelpful, confusing and potentially dangerous? In what circumstances is CPR not a good option, and DNACPR therefore appropriate? How should those decisions be made? Who should be involved? What if the person lacks capacity for a DNACPR decision – how can we make decisions based on best interest?
