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Found 288 results
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Content ArticleI-Hydrate was a collaborative research project, which used service improvement methodology, and was undertaken at two privately operated North West London care homes in partnership with care home staff, residents and their carers and families. I-Hydrate aimed to optimise the hydration of residents in nursing homes, improve the quality and safety of care and decrease dehydration and the morbidity associated with it.
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Content Article
Malnutrition Task Force case study: Lyn's story
Claire Cox posted an article in Community care
Follow Lyns story, an animation highlighting the challenge of malnutrition in later life. The Malnutrition Task Force (MTF) are united to combat preventable and avoidable malnutrition and dehydration among older people in the UK. Established in 2012, they believe that good nutrition and hydration is fundamental to delivering dignified care, and enabling older people to live fulfilling and independent lives. Tackling malnutrition is everybody’s business. The MTF works with partners across sectors and settings to raise awareness of undernutrition in later life and its causes, provide information and guidance, and spread best practice and innovation to improve the lives of older people in the UK. -
Content ArticleVenous thromboembolism (VTE) is a condition in which a thrombus – a blood clot – forms in a vein. Usually, this occurs in the deep veins of the legs and pelvis and is known as deep vein thrombosis (DVT). The thrombus or its part can break off, travel in the blood system and eventually block an artery in the lung. This is known as a pulmonary embolism (PE). VTE is a collective term for both DVT and PE. With an estimated incidence rate of 1-2 per 1,000 of the population, VTE is a significant cause of mortality and disability in England with thousands of deaths directly attributed to it each year. One in twenty people will have VTE during their lifetime and more than half of those events are associated with prior hospitalisation. At least two thirds of cases of hospital-associated thrombosis are preventable through VTE risk assessment and the administration of appropriate thromboprophylaxis.
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Content ArticleBuilding on cultural dimensions of underperforming group homes, Bigby and Beadle-Brown analyses culture in better performing services. In depth qualitative case studies were conducted in three better group homes using participant observation and interviews. The culture in these homes, reflected in patterns of staff practice and talk, as well as artefacts differed from that found in underperforming services. Formal power holders were undisputed leaders, their values aligned with those of other staff and the organization, responsibility for practice quality was shared enabling teamwork, staff perceived their purpose as “making the life each person wants it to be,” working practices were person centered, and new ideas and outsiders were embraced. The culture was charactersed as coherent, respectful, “enabling” for residents, and “motivating” for staff. Though it is unclear whether good group homes have a similar culture to better ones the insights from this study provide knowledge to guide service development and evaluation.
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Content ArticleAt the second annual Patient Safety Learning conference, held on 2 October 2019, we interviewed Evelyn Prodger, Head of Community Services at Martlets Hospice, on her experience at the conference and her thoughts on the launch of the hub.
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News Article
Two patients die after hospitals ignore key safety warning
Patient Safety Learning posted a news article in News
Two patients have died as a result of NHS hospitals failing to heed warnings about the use of super-absorbent gel granules, which patients mistakenly eat thinking they are sweets or salt packets. A national patient safety alert has been issued by NHS bosses to all hospitals, ambulance trusts and care homes instructing them to stop using the granules unless in exceptional circumstances. An earlier alert in 2017 warned the granules, which are used to prevent liquid being spilled, had caused the death of one patient who choked to death after eating a sachet left in an empty urine bottle in their room. The 2017 alert warned hospitals there had been a total of 15 similar incidents over a six-year period between 2011 and 2017. The latest warning from NHS England says most hospitals concentrated on “raising awareness” rather than stopping the use of gel granules. Read alert Read full story Source: The Independent, 4 December 2019 -
Content ArticleSuperabsorbent polymer gel granules are used to reduce spillage onto bedding and clothing when patients use urine bottles or vomit bowls, or when staff move fluid-filled containers (eg washbowls or bedpans). If the gel granules are put in the mouth, they expand on contact with saliva risking airway obstruction. This National Patient Safety Alert requires any organisation still using these products to protect patients by introducing strict restrictions on their use.
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Content ArticleHomeLink Healthcare (HLHC) has been providing clinical care in the home with Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUHT) since January 2019, to release in-patient bed capacity and improve patient choice. The two organisations have co-created the service, NNUH at Home, creating additional capacity and promoting improvements in patient flow from hospital to home. A key feature of NNUH at Home is that it compliments and integrates with existing services, rather than replicating those already in place.
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Content ArticleThe home care environment has a number of unique challenges for care providers, partially due to the high amount of variability between patients and their residences. It was identified that a mobile application used to coordinate some home care services in Alberta had opportunities for improvement in how patient specific safety critical information was provided to staff.
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Content ArticleDue to the high morbidity and disability level among diabetes patients in nursing homes, the conditions for caregivers are exceedingly complex and challenging. The patient safety culture in nursing homes should be evaluated in order to improve patient safety and the quality of care. Thus, the aim of this study was to examine the perceptions of patient safety culture of nursing personnel in nursing homes, and its associations with the participants’ (i) profession, (ii) education, (iii) specific knowledge related to their own residents with diabetes, and (iv) familiarity with clinical diabetes guidelines for older people.
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Content ArticleIn recent years, there has been an increasing focus on the role of safety culture in preventing incidents such as medication errors and falls. However, research and developments in safety culture has predominantly taken place in hospital settings, with relatively less attention given to establishing a safety culture in care homes. Despite safety culture being accepted as an important quality indicator across all health and social care settings, the understanding of culture within social care settings remains far less developed than within hospitals. It is therefore important that the existing evidence base is gathered and reviewed in order to understand safety culture in care homes.
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Content ArticleA 24/7 clinical tele-triage service for care homes in Wirral has resulted in an average 66% decrease in the number of NHS 111 calls and a 10% decrease in ambulance conveyances to A&E for care home residents. The service is delivered by all the area’s health and social care partners with funding support from the Innovation Agency. Care homes have been provided with iPads and secure nhs.net email addresses, and staff have been trained to take basic observations and equipped with blood pressure monitors, thermometers, urine dipsticks and oximeters.
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Content ArticleBasic assessment tracking form for nursing home residents from the Centers for Medicare and Medicaid Services.
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Content ArticleAdverse events and poor health outcomes are continuing challenges for nursing home residents and staff. Research has shown that many resident harms are avoidable and may be caused by situations in which residents do not receive needed care, often called omissions of care. Omissions of care research in nursing home settings is limited and definitions of omissions of care vary. Therefore, the US Agency of Healthcare Research and Quality (AHRQ) has developed a definition of omissions of care for nursing homes intended to be meaningful to stakeholders, including residents and caregivers, and actionable for research or improving quality of care. They developed the definition through a literature review and feedback from subject matter experts and stakeholders in the US. To develop and describe the definition, project staff produced an environmental scan and final report, including resources to help nursing homes operationalise and apply the definition of omissions of care.
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Content ArticleThe RCNi (the publishing company of the Royal College of Nursing) have brought together a selection of their most popular articles on the topic of sepsis from across their journals to inform your practice. Sepsis remains a significant cause of death – it is estimated that 44,000 people die from ‘the silent killer’ every year. RCNi has a wide range of resources available to help nurses improve diagnosis and early management of the condition.
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Content ArticleThis report from the AHSN Network shines light on ways we can do more to improve safety for residents of care homes. The publication showcases over 30 examples of projects delivered by England’s 15 Patient Safety Collaboratives (PSCs) and the Academic Health Science Networks (AHSNs) which host them. They include case studies in medicines safety, dementia, monitoring and screening, and workforce development.
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Content Article"It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
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Content ArticleThis evidence briefing from the Improvement Academy states what providers of care homes and commissioners of older peoples services should do to improve outcomes.
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Content ArticleThe Agency for Healthcare Research and Quality (AHRQ) created On-Time Preventable Hospital and Emergency Department Visits to help nursing homes with electronic medical records identify residents at risk for events that could lead to a hospital visit. The tools are designed to help a multidisciplinary nursing home team prevent hospital and emergency department visits that can be avoided with good preventive care.
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Content ArticlePressure ulcers remain a serious problem in nursing homes despite regulatory and market approaches to encourage prevention and treatment. The US-based Agency for Healthcare Research and Quality created On-time pressure ulcer healing to help nursing homes with electronic medical records address pressure ulcers that are slow to heal.
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Content ArticleUrinary tract infection (UTI) was identified as the main reason to call a GP out-of-hours or to result in an unplanned admission to hospital from residential and nursing homes. Care home staff were using a urine dipstick to diagnose a urinary tract infection then calling a health care professional (HCP) for antibiotics, resulting in inappropriate use of antibiotics and over-treating what is perceived as a UTI in the absence of clinical symptoms.
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Content ArticleA digital tablet intervention to record and communicate data on the health of residents was used in care homes in Sunderland. Between April 2017 and March 2018, a small-scale evaluation compared data between eight of the care homes routinely using the intervention with eight similar care homes who weren’t. The evaluation found that the eight care homes using the intervention made an estimated saving of around £756,144 in A&E attendances and ambulance services during this period.
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Content ArticleThis paper published by Mangar Health gives an insight into the costs, personal and financial, of falls and how simple investment of equipment in the right place at the right time could potential save lives and significant money.
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Content Article
Delirium awareness and management of delirium superimposed dementia
Claire Cox posted an article in Dementia
Delirium in older adults often goes unrecognised by healthcare professionals and can be poorly managed. People with dementia have a higher risk of developing delirium. Health Education England North East have produced this video to raise the awareness of delirium superimposed dementia and signposts ways of managing it using a tool developed (delirium wheel) that can be used in a care home, hospital or community setting. -
Content ArticleThis toolkit has been designed for staff in care homes and carers in the community. It provides a readily accessible and practical guide to help them assist older people in their care to achieve optimum hydration. It was developed through collaboration between Kent Surrey and Sussex Academic Health Science Network, Wessex Academic Health Science Network and NE Hants and Farnham CCG
