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Found 141 results
  1. Content Article
    “Failure to rescue” (FTR) is the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. There is a growing body of evidence that identifies causes and interventions that may improve institutional FTR rates. Why do patients “fail to rescue” after complications in hospital? What clinically relevant interventions have been shown to improve organisational fail to rescue rates? Can successful rescue methods be classified into a simple strategy?
  2. Content Article
    CQUIN stands for Commissioning for Quality and Innovation. This is a system introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care. This means that a proportion of a Trusts income depends on achieving quality improvement and innovation goals, agreed between the Trust and its commissioners. The sum attached to the CQUINs is variable each year based on a percentage of the contract value and depends on achieving quality improvement and goals.
  3. Content Article
    The aim of this qualitative service evaluation, published by Nursing in Critical Care, was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable. This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re‐escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams.
  4. Content Article
    Child deterioration: human factors is a presentation by Peter-Marc Fortune, Consultant Paediatric Intensivist, Associate Clinical Head, Royal Manchester Children’s Hospital.
  5. Content Article
    RESTORE2 TM is a physical deterioration and escalation tool for care/nursing homes. It is designed to support homes and health professionals to: recognise when a resident may be deteriorating or at risk of physical deterioration act appropriately according to the resident’s care plan to protect and manage the resident obtain a complete set of physical observations to inform escalation and conversations with health professionals speak with the most appropriate health professional in a timely way to get the right support provide a concise escalation history to health professionals to support their professional decision making. Here you can find all the official resources to accompany the initiative.
  6. Content Article
    Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. In this paper published in the BMJ, Gerry et al. carried out a systematic review and critical appraisal of early warning scores for adult hospital patients. The results found that many early warning scores in clinical use had methodological weaknesses.The study's authors concluded that the early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care.  “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.”
  7. Content Article
    Dr Hein Le Roux is Primary Care Patient Safety GP Lead at the West of England Academic Health Science Network. Here Hein interviews Dr Emma Redfern on their programme to encourage the use of the National Early Warning Score (NEWS), followed by a conversation with Dr Sheena Yerburgh on a standardised admission sheet they have helped to develop, which is being used by GPs in the Gloucestershire area when referring patients to emergency departments.
  8. Content Article
    The West of England Academic Health Science Network has produced this webpage on caring for the deteriorating patient. One of the priorities identified by their Patient Safety Collaborative was the emergency management of the deteriorating patient, in particular identifying patients at risk and avoiding patient deterioration. This webpage includes examples and resources to help others implement similar changes and initiatives.
  9. Content Article
    The objective of this study, published in the Journal of Clinical Nursing, was to determine the predictive value of individual and combined dutch-early-nurse-worry-indicator-score indicators at various Early Warning Score levels, differentiating between Early Warning Scores reaching the trigger threshold to call a rapid response team and Early Warning Score levels not reaching this point.
  10. Content Article
    The reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery. The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
  11. Content Article
    Dr Matt-Inada-Kim, National Clinical Lead for Sepsis and Deterioration, shares the proforma he has developed to document management and treatment for the deteriorating patient for the new CQUIN, coming soon. This proforma ensures that all the CQUIN data is captured when it comes to audit. He has shared his accompanying slide set explaining about the CQUIN.  
  12. Content Article
    This article, published by the University of Hertfordshire, addresses the need for reasonable adjustments, and other issues, by using examples of: a hospital passport assessing the mental capacity of a person how to improve care provided how to reduce clinical risks for people with intellectual disability.
  13. Content Article
    This video introduces England's 15 Patient Safety Collaboratives (hosted by Academic Health Science Networks) and how they support the NHS Patient Safety Strategy in areas such as COVID-19, managing deteriorating patients, maternal and neonatal safety, medicines safety, mental health and more. Download the slides here
  14. Content Article
    A rapid-learning report on the role of Patient Safety Collaboratives (PSCs) during the pandemic has been published by the AHSN Network. PSCs are just one part of the health and care system which responded quickly to the immediate crisis from COVID-19 in March. They reprioritised their day-to-day work and took on new programmes at speed, such as promoting safer tracheostomy care. The report has been published as part of the NHS Reset campaign and gives examples of how PSCs refocused their work ‘almost overnight’ to respond to the pandemic. It illustrates some of the creative ways AHSNs supported their local systems and how this experience will be built into future patient safety programmes.
  15. Content Article
    RESTORE2 is a physical deterioration and escalation tool for care/nursing homes based on NEWS2 and has been a key element of the process of implementing NEWS2 within care Homes, initially across Wessex and subsequently nationally via the AHSN network. In July 2019 RESTORE2 won a Parliamentary Award for Excellence.
  16. Content Article
    This information sheet produced by South Australia Health's Safety and Quality Unit describes how patients and staff can work together to make sure that if clinical deterioration occurs, it will be acted upon in a timely and effective manner. The information also applies to carers, family members, friends or the patient’s appointed responsible person. It includes information relating to deterioration during an emergency department visit or hospital stay, and at and after discharge.
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