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Found 326 results
  1. Community Post
    Can any one share? The trust I work in delivers patient safety training as part of the mandatory training. I was wondering if any other trust does this, if so would they mind sharing Thier slides as I'm not sure what it should include. Thanks!
  2. Content Article
    The government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round. This study, published by Health Services and Delivery Research, aimed to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances.
  3. Content Article
    The Mental Health Optimal Staffing Tool (MHOST) was created, with the support of Health Education England, in recognition that there was no published, evidenced based mental health workforce tool which could be used in mental health hospitals. It has been developed alongside clinical leaders and workforce staff in mental health trusts and rigorously tested and validated.
  4. Content Article
    The need for effective teamwork and improved communication amongst caregivers is increasingly recognised in healthcare policy worldwide. As healthcare organisations navigate in highly complex contexts, they are largely dependent on thorough collaboration and sharing of information between staff at all levels. Promoting high‐quality teamwork based on effective and frequent communication is therefore essential for developing well‐functioning healthcare organisations
  5. Content Article
    Significant changes in how autistic people with a learning disability access and experience healthcare can and should be informed by stakeholders, including the patient and their family. This article, published by the University of Hertfordshire, provides different examples and suggestions from experts by parental experience.
  6. Content Article
    In the worst moment of your life, what would you need? In 2017, Jen Gilroy-Cheetham’s life changed forever. Just six months after having her second child, she was diagnosed with a rare neuroendocrine tumour and was advised that she would need to undergo open surgery to have half of her stomach removed. Complications led to one of the darkest and scariest times of Jen’s life, as she was put into a hospital ward feeling unwell, vulnerable and unsafe. Now recovered, Jen shares her experiences as a patient from a hospital bed - or audience member - watching all of the healthcare staff around her - actors on a stage - doing everything they could to make her feel safe. In reliving her journey to recovery, Jen highlights what’s needed within a healthcare setting to make patients feel safe. Jen feels that highlighting what’s worked well to help her to feel safe and what needs to change is valuable and may help others in the future.
  7. Content Article
    This report,from Healthwatch, argues that hospitals, indeed the NHS more broadly, need to shift the mindset on complaints. Reporting needs to look beyond the numbers and response times and focus more on how to effectively demonstrate to patients and the public what has been learnt. This is the only way to give the public confidence that their concerns are being listened to and acted on. 
  8. Content Article
    Major critical illness events, such as cardiopulmonary arrest and intensive care unit (ICU) transfer, disrupt workflow in a hospital ward. Other patients on the same ward may receive inadequate attention, especially if their care team is distracted by the emergency. Most studies have concentrated on patient-level variables associated with outcomes.This paper, published by JAMA, looks at the risk to ward occupants associated with patients on the same ward experiencing critical illness.
  9. News Article
    Hospitals are having to redeploy nurses from wards to look after queues of patients in corridors, in a growing trend that has raised concerns about patient safety. Many hospitals have become so overcrowded that they are being forced to tell nurses to spend part of their shift working as “corridor nurses” to look after patients who are waiting for a bed. The disclosure of the rise in corridor nurses comes days after the NHS in England posted its worst-ever performance figures against the four-hour target for A&E care. They showed that last month almost 100,000 patients waited at least four hours and sometimes up to 12 or more on a trolley while hospital staff found them a bed on the ward appropriate for their condition. “Corridor nursing is happening across the NHS in England and certainly in scores of hospitals. It’s very worrying to see this,” said Dave Smith, the Chair of the Royal College of Nursing’s Emergency Care Association, which represents nurses in A&E units across the UK. "Having to provide care to patients in corridors and on trolleys in overcrowded emergency departments is not just undignified for patients, it’s also often unsafe.” A nurse in south-west England told the Guardian newspaper how nurses feared the redeployments were leaving specialist wards too short of staff, and patients without pain relief and other medication. Some wards were “dangerously understaffed” as a result, she claimed. She said: “Many nurses, including myself, dread going into work in case we’re pulled from our own patients to then care for a number of people in the queue, which is clearly unsafe. We’re being asked to choose between the safety of our patients on the wards and those in the queue." Read full story Source: The Guardian, 12 January 2020
  10. Content Article
    This moving video accompanied by a poem by Molly Case, speaks of the last 1000 days of a persons life, most of which is often spent in hospital. This is part of the #EndPjParalysis campaign and was commissioned by Prof Jane Cummings, Chief Nursing Officer for England,
  11. Content Article
    Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review, published in BMJ Open, is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.
  12. News Article
    Hundreds of sexual assaults are reported each year on mixed-sex mental health wards in England, HSJ can reveal, highlighting the urgent need for investment to improve facilities. New figures obtained by HSJ show there have been at least 1,019 reports of sexual assaults between men and woman on mixed wards since April 2017 to October 2019. This compares to just 286 reports of incidents on single-sex mental health wards over the same period. Of those reports made on mixed-sex wards, 491 were considered serious enough to refer to safeguarding, and 104 were reported to the police. The level of incidents still being reported suggests patients are not being protected from sexual assault on mixed wards, despite the issue being highlighted by several national reports in recent years. Read full story (paywalled) Source: HSJ, 7 January 2020
  13. Content Article
    Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. The authors of this paper, published in BMJ Quality & Safety, performed a systematic review of the literature on in-hospital adverse events.
  14. Content Article
    The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level across the NHS in England using a standard and transparent methodology. It is produced and published monthly as a National Statistic by NHS Digital. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
  15. 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.
  16. Content Article
    People with a learning disability are more likely to experience major illnesses that will require acute care (Disability Rights Commission, 2006) and more people with learning disability are living longer, and are therefore more likely to use health services as they get older. As a group, they experience more admissions to hospital (26%) compared to the general population (14%) (Mencap, 2004).
  17. 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.
  18. Content Article
    According to the National Institutes of Health (January 2019), more than 130 people in the United States die after overdosing on opioids every day. Among these deaths are patients in the hospital setting, recovering from surgical procedures or undergoing sedation, who are often prescribed opioids such as morphine and oxycodone to manage pain – a necessity for healthy and comfortable recovery. But at certain doses, these drugs can also cause respiratory failure, and, because each patient is different, there is no one dose that is 'right' or 'wrong'. Hospitals must take action to ensure their staff are aware of these risks, and put protocols in place to prevent patient deaths. The authors of this US article, published by Medium, offer recommendations for improving patient safety in this area.
  19. Content Article
    Lecture from Dr Gordon Caldwell on ward rounds, covering quality, safety, personalising care and checklists.
  20. News Article
    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
  21. Content Article
    Superabsorbent 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. 
  22. Content Article
    HomeLink 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.
  23. Content Article
    This is the story of a nurse's experience when attending a coroner's court and how the Trust supported them through this difficult time.
  24. Content Article
    The hospital environment in general and single room accommodation in particular are potentially important factors influencing the quality of the care provided and patient outcomes. Two areas that have received much attention for the effect of single rooms on healthcare quality are infection rates and adverse events. New hospital design includes more single room accommodation but there is scant and ambiguous evidence relating to the impact on patient safety and staff and patient experiences. This study from Maben et al. found that both staff and patients perceived advantages and disadvantages in having all single room accommodation in hospitals, but more patients expressed a clear preference for single rooms. Single rooms are associated with higher costs but the difference is marginal over time.
  25. Content Article
    Electronic health records (EHR) can improve safety via computerised physician order entry with clinical decision support, designed in part to alert providers and prevent potential adverse drug events at entry and before they reach the patient. However, early evidence suggested performance at preventing adverse drug events was mixed. In this study published in BMJ Quality & Safety, Bates et al. used data from 1527 hospitals in the USA from 2009 to 2016 who took a safety performance assessment test using simulated medication orders to test how well their EHR prevented medication errors with potential for patient harm. Results found that the average hospital EHR system correctly prevented only 54.0% of potential adverse drug events tested on the 44-order safety performance assessment in 2009; this rose to 61.6% in 2016. Hospitals that took the assessment multiple times performed better in subsequent years than those taking the test the first time, from 55.2% in the first year of test experience to 70.3% in the eighth, suggesting efforts to participate in voluntary self-assessment and improvement may be helpful in improving medication safety performance. The authors conclude that medication order safety performance has improved over time but is far from perfect. The specifics of EHR medication safety implementation and improvement play a key role in realising the benefits of computerising prescribing, as organisations have substantial latitude in terms of what they implement. Intentional quality improvement efforts appear to be a critical part of high safety performance and may indicate the importance of a culture of safety.
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