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Showing results for tags 'Handover'.
Found 109 results
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News ArticleAn acute trust has had to stand down a new service which led to a ‘marked improvement’ in ambulance handover times, due to a lack of permanent funding to support it. In recent months, York and Scarborough Teaching Hospitals Foundation Trust has deployed additional staff to receive and care for patients arriving by ambulance, meaning ambulance crews could be released more quickly. A report to the trust board last month said of the scheme: “Data shows a marked improvement in ambulance release times when deployed.” However, it would cost £1m per year to fully implement the service and the report said commissioners had confirmed there is “no external funding to support this cost”. There have been mounting concerns in recent months over the handover delays experienced by paramedics when taking patients to hospital, which have severely affected their response times for new incidents. In a statement, the trust said it was discussing with system partners how the service, which was introduced on a “short-term basis”, could be supported in future. It was delivered by independent ambulance and healthcare provider CIPHER Medical and used at peak times such as bank holiday weekends. Read full story (paywalled) Source: HSJ, 6 July 2022
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News Article
Baby died two days after birth despite mum begging doctors to assess her
Patient Safety Learning posted a news article in News
A two-day old baby died just days after his mother begged doctors to assess her ahead of a c-section despite her pregnancy being deemed high risk. Davi Heer-Do Naschimento was born via emergency caesarean section during the early hours of 29 September 2021, after doctors at Royal London Hospital failed to communicate crucial details during handover meetings. An inquest at Poplar Coroners Court heard that his parents, Ruth Heer and Tiago Do Naschimento, had asked numerous times for assistance and were not seen by the obstetrics team the day before her planned caesarean. Tragically, after becoming "feverish" during the night, she was rushed into theatre with Devi sadly dying two days later. Speaking on behalf of the family, Francesca Kohler said that there had been “multiple occasions” throughout the day when Ms Heer and her partner had called for assistance and had raised concerns, but were not attended. She had also not been seen by the obstetrics team and had not been spoken to about the upcoming caesarean section. Read full story Source: My London, 4 July 2022 -
News ArticleStudent paramedics are missing out on learning how to save lives because they are wasting hours in ambulances outside A&E instead of attending calls, it has been revealed. The College of Paramedics and ambulance directors say the hold-ups mean trainees are missing vital on-the-job experience, leading to fears over the safety of patients. Will Boughton, of the College of Paramedics Trustee for Professional Standards, said handover delays had become a problem for trainees’ development and exposure to real-life experience, meaning training had become “unpredictable”. If steps weren’t taken to increase training opportunities and address wider quality concerns in education, “it is very possible that patient safety may be at risk due to missed experience during practice education”, he warned. “A student could complete a regular shift and see lots of patients, getting lots of things in their portfolio signed off, or they could be the unlucky ambulance that joins the back of a queue and is then at hospital X for however many hours waiting to release that patient, so and it varies from county to county and service to service,” he said. Read full story Source: The Independent, 22 June 2022
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Content ArticleHandover in healthcare settings can be a time when the risk of error and harm is increased. This blog summarises the results of global survey that asked the opinions of healthcare workers on the safety of handover. It highlights ten key points raised by the results: Handover causes frequent errors and patient safety incidents Handover errors can cause serious harm to patients Most people think they are better than average at handover The longer you’ve been around, the scarier handover appears Different types of handovers have a similar safety profile The safety of handover is a problem all over the world Most practitioners use manual or informal systems to support handover EPR systems are not up to the job of supporting handover Staff need more training, and we need more time Healthcare leaders want better electronic systems The results of the survey have been published in Preprints.
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Content ArticleHandover is a critical process for ensuring quality and safety in healthcare, and research suggests that poor handover results in significant morbidity, mortality, dissatisfaction and increased financial costs. However, the safety of handover has not received much research attention to date. This study aimed to measure the perceived risk, degree of patient harm and the systems used to support handover, and to understand how this varied by care setting, type of clinical practice, location and level of experience. The authors suggest that the results of the study indicate that action needs to be taken to improve communication and reduce risk during all types of handovers. Clinical leaders should find ways to train and support handover with effective systems, particularly focusing on training less experienced staff. More research is needed to demonstrate which interventions improve the safety of handover.
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News Article
Loss of 25,000 NHS beds caused ‘serious patient safety crisis’, finds report
Patient Safety Learning posted a news article in News
The NHS has lost almost 25,000 beds across the UK in the last decade, according to a damning report says the fall has led to a sharp rise in waiting times for A&E, ambulances and operations. The Royal College of Emergency Medicine said the huge loss of beds since 2010-11 was causing “real patient harm” and a “serious patient safety crisis”. At least 13,000 more beds are urgently needed, it added, in order to tackle “unsafe” bed occupancy levels and “grim” waiting times for emergency care and handover delays outside hospitals. Patients are increasingly “distressed” by long waiting times, the college said, as are NHS staff who face mounting levels of burnout, exhaustion and moral injury. The UK has the second lowest number of beds per 1,000 people in Europe at 2.42 and has lost the third largest number of beds per 1,000 population between 2000 and 2021 (40.7%), the report said. There are currently 162,000 beds in the NHS across the UK, according to the college. “The situation is dire and demands meaningful action,” said Dr Adrian Boyle, the college’s vice-president. “Since 2010-11 the NHS has lost 25,000 beds across the UK, as a result bed occupancy has risen, ambulance response times have risen, A&E waiting times have increased, cancelled elective care operations have increased. “These numbers are grim,” Boyle added. “They should shock all health and political leaders. These numbers translate to real patient harm and a serious patient safety crisis. The health service is not functioning as it should and the UK government must take the steps to prevent further deterioration in performance and drive meaningful improvement, especially ahead of next winter.” Read full story Source: The Guardian, 31 May 2022 -
EventUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. With each transition of care (as patients move between health providers and settings), patients are vulnerable to changes, including changes in their healthcare team, health status, and medications. Discrepancies and miscommunication are common and lead to serious medication errors, especially during hospital admission and discharge. Countries and organizations need to optimise patient safety as patients navigate the healthcare system by setting long-term leadership commitment, defining goals to improve medication safety at transition points of care, developing a strategic plan with short- and long-term objectives, and establishing structures to ensure goals are achieved. At this webinar, you will be introduced to the WHO technical report on “Medication Safety in Transitions of Care,” including the key strategies for improving medication safety during transitions of care. Register
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News Article
Ambulance service will collapse by August, predicts its nursing director
Patient Safety Learning posted a news article in News
A struggling ambulance trust could face a ‘Titanic moment’ and collapse entirely this summer if the region’s worsening problems with hospital handover delays are not taken more seriously, its nursing director has told HSJ. Mark Docherty, of West Midlands Ambulance Service (WMAS), said patients were “dying every day” from avoidable causes created by ambulance delays and that he could not understand why NHS England and the Care Quality Commission were “not all over” the issue. He revealed that handover delays at the region’s hospitals were the worst ever recorded, that rising numbers of people were waiting in the back of ambulances for 24 hours, and that serious incidents have quadrupled in the past year, largely due to severe delays. More than 100 serious incidents recorded at WMAS relate to patient deaths where the service has been unable to respond because its ambulances are held outside hospitals, according to the minutes of the trust’s March quality and safety committee. "Around 17 August is the day I think it will all fail,” he said. “I’ve been asked how I can be so specific, but that date is when a third of our resource [will be] lost to delays, and that will mean we just can’t respond. Mathematically it will be a bit like a Titanic moment. ”It will be a mathematical certain that this thing is sinking, and it will be pretty much beyond the tipping point by then.” Read full story (paywalled) Source: HSJ, 25 May 2022 -
News Article
Patient waited 24 hours in ambulance for A&E
Patient Safety Learning posted a news article in News
Nearly 600 patients waited 10 hours or more in the back of an ambulance to be transferred into emergency departments last month – with one taking 24 hours, HSJ can reveal. The 24-hour wait was the longest handover delay recorded in the past year, and probably ever, according to information released by ambulance trust chief executives. In May last year the longest recorded rate was seven hours. This has risen steadily during the year to hit 24 hours in April. In March a patient in the West Midlands had to wait 23 hours. The figures also show 11,000 patients waited more than three hours for handover last month, with 7,000 of them taking more than four hours and 4,000 over five hours. Some 599 waited more than 10 hours. The Association of Ambulance Chief Executives estimates 35,000 patients were potentially at risk of harm from delayed handovers last month, with just under 4,000 of those risking severe harm. This is based on work it did looking at patients waiting more than 60 minutes in 2021 and was a slight fall on March. They are based only on handover delays and do not include harm from patients left waiting for an ambulance response. Hours lost to ambulance handover delays restrict ambulance trusts’ ability to reach other patients waiting for an ambulance in the community. Read full story (paywalled) Source: HSJ, 16 May 2022 -
News Article
Struggling system asks NHSE for help with ambulance handovers
Patient Safety Learning posted a news article in News
Health leaders in Lincolnshire have admitted they do not have a ‘robust’ response to managing the risks posed by ambulance handover delays and poor response times. The system’s acute provider, United Lincolnshire Hospitals Trust (ULHT), was consistently among the trusts accounting for the highest proportion of ambulance delays over winter. In a document submitted to NHS England, the county’s integrated care system said: “While the system has good visibility of the level of risk across the system, and there are discussions about this on daily system calls, it is recognised that the system doesn’t currently have a robust response approach to ambulance handover delays. “A request has been made to regional NHSE/I team for support in developing a Lincolnshire system risk and response approach to ambulance handover delays.” ULHT’s board has recently noted “increasing concerns” from regulators. Its board papers have described capacity outside the acute sector as key, but there was “currently… not a sense of collective impact to scale and scope that would make a difference to reach the trajectory described”. Read full story (paywalled) Source: HSJ, 5 May 2022 -
News Article
Ambulance chief calls out acute trust over ‘lack of action’ on handover delays
Patient Safety Learning posted a news article in News
An ambulance service has raised concerns over the record number of ‘hours lost’ to handover delays at an acute hospital on its patch, which it says is happening despite the number of arrivals being at its lowest level in seven years. West Midlands Ambulance Service University Foundation Trust has said the situation at Royal Stoke Hospital presents a “significant risk to patient safety”, but “we don’t currently see actions being taken that are reducing this risk”. It comes amid rising frustrations from ambulance chiefs around the country at a perceived lack of support from acute hospitals around handover delays. Ambulance response times for some of the most serious 999 calls have ballooned in recent months, in part due to lengthy handover delays at emergency departments. In a letter sent to a member of the public on 31 March, Mark Docherty, director of nursing at WMAS, said: “WMAS [is] experiencing difficulties as a direct result of delays in patient handovers at acute hospitals. We have been highlighting our concerns for over six years as the situation has become progressively worse every year." Read full story (paywalled) Source: HSJ, 10 April 2022 -
News Article
Stroke and heart patients routinely waiting over an hour for ambulance
Patient Safety Learning posted a news article in News
Stroke and heart attack victims are now routinely waiting more than an hour for an ambulance, after a further fall in performance in recent weeks, and with hospital handover delays hitting a new high point, HSJ reveals. Figures for ambulance performance this week, seen by HSJ, showed average response times for category two calls at more than 70 minutes for successive days. 3,000 patients may have suffered “severe harm” from delays in February, ambulance chief executives say. Several well-placed sources in the sector said response times had deteriorated further this month, and that more than half of ambulance trusts were this week seeing average category two responses of longer than an hour. Some cited an average category two response last week of around 70 minutes, with the services under huge pressure from a combination of demand, long handover delays, and covid-related sickness. Category two calls include patients with suspected heart attacks and strokes, and the national target for reaching them is 18 minutes. The figures seen by HSJ for this week showed average response times for category one calls — the most serious, including cardiac arrests and other immediately life threatening emergencies — of more than 10 minutes on Wednesday, against a target of just 7 minutes. Monthly average performance for category one has never reached 10 minutes. Read full story (paywalled) Source: HSJ, 1 April 2022 -
News Article
NHSE wants ‘urgent’ meetings over ambulance handovers risk
Patient Safety Learning posted a news article in News
NHS England and the Care Quality Commission have asked systems with large numbers of ambulance handover delays to urgently hold a meeting to try to fix the problem by “balancing the risks” of long 999 waiting times. The request was made in an email to chief executives, which warned the service was “in a difficult position with all parts of the urgent and emergency care pathway under considerable strain… most acutely in ambulance response times which in turn is linked to challenges in handing patients over to emergency departments”. The NHSE headed letter was signed by its chief operating officer, nursing director and medical director, but also by the CQC’s chief inspector of hospitals Ted Baker. It said there was a “strong correlation” between handover delays at hospitals — which take place where A&Es are unable to receive patients from ambulances — and long delays for category two ambulances. This is because ambulances have to wait for long periods outside the hospitals. The letter said: ”It is vital that we have a whole-system approach to considering risks across the urgent and emergency care pathway to provide the best outcomes for our patients. This may mean consideration of actions to be taken downstream to help improve flow and reduce pressures on emergency departments.” Read full story (paywalled) Source: HSJ, 17 February 2022 -
Content ArticleIn this chapter, from the book 'Resilient Health Care, Volume 2: The Resilience of Everyday Clinical Work', Sujan et al. explore tensions and dynamic trade-offs through an example from our research on the safety of handover across care boundaries in emergency care. The authors describe the case study and then discuss the key theoretical concepts and their relationship to Resilience Engineering. It concludes the chapter with implications for research and for practice.
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Content ArticleThis report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a local pilot, which has been launched to evaluate HSIB’s ability to carry out effective investigations occurring between specific hospitals and trusts. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB. On her admission to her local emergency department (ED) after a fall at her nursing home, Mrs E, a woman aged 93 with dementia, was booked into the ED with incorrect patient details, resulting in a new patient record being created. She was discharged that day but readmitted the next day after a second fall. She was booked into ED with the new patient record (which contained the incorrect patient details) and had an x-ray which confirmed she had a broken hip, subsequently being admitted to hospital for surgery. Mrs E had surgery the next day, during which the pathology department identified a problem with the accuracy of her patient identification information and following surgery her two sets of patient records were merged.
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Content ArticleImproving patient safety culture (PSC) is a significant priority for OECD countries as they work to improve healthcare quality and safety—a goal that has increased in importance as countries have faced new safety concerns connected to the COVID-19 pandemic. Findings from this OECD benchmarking work in PSC show that there is significant room for improvement.
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Content ArticleThis article, published in the Journal of Cognitive Engineering and Decision Making, discusses communication during end-of-shift handovers and how improved communication between staff may reduce errors and adverse outcomes for hospitalised patients.
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EventThis Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the Covid-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. Attending this conference will enable you to: Network with colleagues who are working to improve Hospital at Night Practice Learn from developments as a results of Covid-19 Improve your skills in the recognition management and escalation of deteriorating patients at night Understand and evaluate different models for Hospital at Night Examine the role of task management solutions for Hospital at Night, including handover and eObservations Ensuring effective and safe staffing at night, including adequate breaks Examine Hospital at Night team roles, competence and improve team working Improving safety through the reduction of falls at night Supporting staff and reducing fatigue at night Develop the role of Clinical Practitioner and Advanced Nursing Practice at night Identify key strategies to change practice and ways of working in Hospital at Night Understand how hospitals can improve conditions for night workers and support Junior Doctors Improve the management of pain at night Work across whole systems to improve support for patients out of hours Self assess and reflect on your own practice Gain CPD accreditation points contributing to professional development and revalidation Evidence Register There are a limited number of free places for hub members. Email: info@pslhuborg if interested. Follow on Twitter @HCUK_Clare #hospitalatnight
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Content ArticleThis article, published in The Joint Commission Journal on Quality and Patient Safety, explores the effectiveness of shift handoffs (handovers) by staff. It discusses how poor-quality handoffs have been associated with serious patient consequences, and that standardisation of handoff content and delivery improves both quality and safety.
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News Article
160,000 risk harm each year from ambulance handover delays
Patient Safety Learning posted a news article in News
Ambulance handover delays could harm 160,000 patients a year, 12,000 of them severely, according to a structured clinical review of cases by service bosses earlier this year. The Association of Ambulance Chief Executives examined a sample of 470 cases where handover to A&E was delayed for an hour or more on 4 January this year. The review, whose findings were shared with HSJ, involved every mainland ambulance service in England. It found that 85% of those who waited more than an hour suffered potential harm, with nine per cent potentially severely harmed. Extrapolated across an entire year, using levels of delays up to September 2021, this suggests 160,000 patients are potentially harmed annually. Patients who waited the longest for handover were at greatest risk of some level of harm, and the risk of severe harm more than tripled for those waiting more than four hours compared with those waiting for 60 to 90 minutes. Read full story Source: HSJ, 14 November 2021 -
Content ArticleThis review by Healthcare Inspectorate Wales considers the impact of ambulance waits outside emergency departments on the overall experience of patients, which included their safety, care, privacy and dignity. It covers the period between 1 April 2020 and 31 March 2021, during the Covid-19 pandemic. The report highlights that although patients were positive about their experience with ambulance crews, handover delays are having a detrimental impact upon the ability of the healthcare system to provide responsive, safe, effective and dignified care to patients. It makes 20 recommendations for consideration by the Welsh Ambulance Services NHS Trust, health boards and the Welsh Government.
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News Article
Patient harm 'almost certain' due to ambulance handover delays
Patient Safety Learning posted a news article in News
Patients are being put at "catastrophic risk" of harm due to ambulance handover delays, health bosses say. West Midlands Ambulance Service (WMAS) has raised its risk rating for such delays to its highest level for the first time in its history. The risk rating shows the trust believes patient harm is "almost certain" due to the handover hold-ups. Mark Docherty, director of nursing and clinical commissioning, said it was a "completely unacceptable situation". It comes as a patient died after waiting more than five hours in the back of an ambulance in Worcestershire. At a meeting on Wednesday, the ambulance service's board of directors heard the amount of time being lost to delays had reached previously unseen levels, the Local Democracy Reporting Service said. Mr Docherty warned the situation was set to get worse over the coming months as a result of winter pressures. "Despite everything we are doing by way of mitigation, we know that patients are coming to harm as a result of delays," he said. "We know that there are patients that are having significant harm and indeed, through our review of learning from deaths, we know that sadly some patients are dying before we get to them." Read full story Source: BBC News, 28 October 2021 -
News Article
Ambulance handover delays at A&E are putting patients at risk
Patient Safety Learning posted a news article in News
Between April 2020 and March 2021 there were approximately 185,000 ambulance handovers to emergency departments throughout Wales. However, less than half of them (79,500) occurred within the target time of 15 minutes. During that period there were also 32,699 incidents recorded where handover delays were in excess of 60 minutes, with almost half (16,405) involving patients over the age of 65 who are more likely to be vulnerable and at risk of unnecessary harm. Data published by the Welsh Government highlighted that in December 2020 alone, a total of 11,542 hours were lost by the ambulance service due to handover delays. This figure has been rising sharply and has now reached pre-pandemic levels once again. Inspectors said these delays have consistently led to multiple ambulances waiting outside A&E departments for excessive amounts of time, unable to respond to emergencies within their communities. "These delays have serious implications on the ability of the service to provide timely responses to patients requiring urgent and life-threatening care," the report stated. Read full story Source: Wales Online, 7 October 2021 -
News Article
Increased ambulance handover delays threatening patient safety
Patient Safety Learning posted a news article in News
A new snapshot survey by the Royal College of Emergency Medicine has found that in August 2021 half of respondents stated that their Emergency Department had been forced to hold patients outside in ambulances every day, compared to just over a quarter in October 2020 and less than one-fifth in March 2020. The survey, sent out to Emergency Department Clinical Leads across the UK, also found that half of respondents described how their Emergency Department had been forced to provide care for patients in corridors every day, while nearly three-quarters said their department was unable to maintain social distancing every day. One-third said that the longest patient stay they had had in their Emergency Department was between 24 and 48 hours, with 7% reporting the longest stay to be more than 48 hours. Dr Ian Higginson, Vice President of the Royal College of Emergency Medicine, said: “It is shocking to see the extent of the challenges faced by Emergency Departments across the UK. Holding ambulances, corridor care, long stays – these are all unconscionable practices that cause harm to patients. But the scale of the pressures right now leaves doctors and nurses no options. We are doing all we can to maintain flow, maximise infection prevention control measures, and maintain social distancing. Our priority is to keep patients safe, and ensure we deliver effective care quickly and efficiently, but it is extremely difficult right now." Read full story Source: The Royal College of Emergency Medicine, 6 September 2021 -
News Article
Ambulance trust reveals patient’s death amid handover delays row
Patient Safety Learning posted a news article in News
An ambulance trust has highlighted the death of a woman which it says was due to “being delayed on the back of an ambulance”, just two days after it warned that lives were ‘at risk’ from long handovers. West Midlands Ambulance Service University Foundation Trust’s board papers this month reveal the woman in her 90s — who has not been named — was taken to hospital because a severe nose bleed would not stop. Its clinical quality board paper says the “patient story” showed ”how a patient being delayed on the back of an ambulance resulted in significant deterioration and ultimately the death of a patient”. Read full story (paywalled) Source: HSJ, 28 May 2021
