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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks

These comments were made by people with diabetes in response to a Twitter thread asking "Why is a hospital stay scary if you have diabetes?" If you have diabetes, or care for someone who does, please share your experience with us by adding a comment to this community thread, “I was in ICU after a car accident—none of the staff knew how to work my CGM and/or my insulin pump. I had to manage my own care” “For me it was when I went into hospital for surgery and the nurse said 'Type 1... so do you take insulin for that?'... that's not a reassuring thing to hear minutes before you're taken into the theatre!” “Lucky to get out alive.” “DKA 10 years ago, once back in normal range the consultant insisted I didn't need anymore insulin & refused to let me have any. Obvs within 3 hours I was back in DKA, he wouldn't come see me but had a convo with my husband on the ward phone where hubs explained how T1 works.” “I've been given a full day's bolus, through my iv and then told I was wrong when I said that I only bolused when I ate. Massive hypo followed quickly. I was then told it was my fault and I should have said something.” “After being admitted as an emergency, my own insulin ran out. I was given 2 (2!) of the wrong types of insulin and told that 'it would be okay'.” “They were often confused about T2 versus T1 - lots of emphasis about low fat foods and only being allowed a low fat yoghurt for puddings even though I was on a pump! I had a bag of snacks though as it was a planned hospital stay” “After a major medical issue I was denied insulin in the ICU for over 24 hours but was told I could have some pills to treat my type 1 diabetes” “Last time I went to the hospital, they took my pump (forcefully) and refused to give it back. When I protested, they sedated me. I was in and out of sedation having a panic attack bc I couldn’t breathe. They sedated me again and put me on DKA protocol, even tho I wasn’t in DKA.” “it’s so scary right like you know that you’re the expert on your condition and your needs but that power gets totally taken away” “Handing over your care over to a group of nurses who have no idea what they are doing. It’s super scary. I hate it when they lock it all away and you can’t get to it.” “I didn’t feel safe either. Told them on a few occasions I felt ‘low’. Finally Lucozade got wheeled out but it was almost an inconvenience” “Totally understand why they don’t know much about it if it’s not their specialism BUT some are so arrogant that what they were told one afternoon 10yrs ago is the absolutely way to deal with, and that the person living with it doesn’t know what they’re talking about!” Sarcastic responses “You seem to know a lot about it!” “The neurologist told me I am a terrible diabetic.” “I never feel safe because they don’t allow me to dose my own insulin and last time dropped me from 600 to 40 in three hours and then shot me back up so fast when i specifically told them that i would go low and high from that much insulin” Report of being diagnosed with type 1 diabetes while in hospital, despite telling every healthcare professional she had T1. “I smuggled in my own tester and meds and took care of myself.” “I think the biggest thing for me is them not understanding insulin dose when they’re writing up your chart and how you don’t really have a “typical” insulin dose that fits neatly into their charts because of carb counting or correction doses/reduction dose. It’s strange, when I’ve had DKA admissions and I’m on the sliding scale IV it’s fine because there’s clear guidelines but for just day to day injection management it’s soooo difficult.” "Daughter had food and insulin withheld in a mental hospital." “the ward nurses didn’t even know I had T1 until the more mobile lady opposite me went and fetched a nurse who had been ignoring my call button. I was hypo and couldn’t reach my treatment.” "Taken off insulin for two days as no doctor to prescribe." “Particularly bad experience when a nurse left the glucose drip on but turned off the insulin. It terrifies me to think how bad this could have been.”

Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf

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!

We are looking into introducing a new device to deliver CPAP at ward level into our trust. Currently we use NIPPY machines which can deliver some PEEP when in a selected mode, however the downfall to this is, it can only produce an oxygen concentration of around 50%. Often, the patient groups that require this intervention are on high oxygen requirements and so particularly in the early stages would benefit from a device that could deliver both. I have previously worked with Pulmodyne 02-Max trio which allows up to 90% oxygen and PEEP up to 7.5cmH20. Majority of patients responded very well to this treatment. I wondered whether any other trusts/ team have any other experiences/ devices that they may use and recommend? @Danielle Haupt@Claire Cox@Emma Richardson@Mandy Odell@PatientSafetyLearning Team@Patient Safety Learning@Patient safety Hub@CCOT_Southend

Hi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione

A woman took her own life on a ward after her move to a mental health hospital was not facilitated. Anne Clelland was found unconscious in the toilet of her room in Glasgow's Queen Elizabeth University Hospital and later died of a brain injury. Anne - who had a history of self-harm - was admitted following an overdose. She was due to be moved to a psychiatric hospital three days before her death but this did not take place because of a "failure of communication." NHS Greater Glasgow and Clyde pled guilty today to failing to conduct their undertaking in a way that a person would not be exposed to risks to their health and safety. Glasgow Sheriff Court heard Anne was admitted to Ward 5A at the hospital after overdosing on 7 May 2015. A specialist met with Ann on 11 and 12 May with a plan put in place for her to be transferred to Leverndale hospital once she was medically fit. A psychiatry team was to be contacted at that time for a further review to facilitate the transfer. Prosecutor Catriona Dow said: “There was no suggestion at this time that despite her ongoing treatment following her suicide attempt, that she was at risk of suicide and required special requirements such as the removal of her possessions and enhanced observations such as constant observations.” “There appears there was a breakdown in communication regarding the intention of the psychiatrist that Anne would be transferred that evening due to her assessed risk of self-harm.” Other witnesses recalled a plan for a transfer to Leverndale but it was understood that until a bed was to become available, she would be able to remain at Ward 5A. Other staff appeared not to have been aware of the assessed risk of self-harm and her transfer to Leverndale that evening. Read full story Source: Glasgow Live, 8 November 2021

This survey looks at the experiences of people who stayed at least one night in hospital as an inpatient. The results show that, generally, people’s experiences of inpatient care were positive and overall differences between COVID-19 and non-COVID-19 patients were small, suggesting that care provided was consistent. Most people said they were treated with respect and dignity, had confidence and trust in the doctors and nurses that treated them and observed high levels of cleanliness. Survey findings were less positive, however, for areas of care including people’s experiences of receiving emotional support, information sharing and hospital discharge. For the detailed findings, click here Original source: Care Quality Commission

NHS England has told hospitals to begin planning for the use of Nightingale Hospitals as the numbers of coronavirus patients in hospitals is expected to surge in coming weeks. In a letter sent on Wednesday night hospitals were told to activate all of their emergency capacity to cope with the expected pressures over the coming weeks. This is likely to mean the mass redeployment of staff and designating wards, surgical theatres and recovery areas as makeshift intensive care units for patients. NHS England did not explain how the Nightingale Hospitals would be staffed if the decision was made to activate them. Read full story Source: The Independent, 24 December 2020