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Showing results for tags 'Hospital ward'.
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News Article
Hundreds of sexual assaults each year on mixed-gender wards
Patient Safety Learning posted a news article in News
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- Posted
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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 ArticleAnaphylaxis is a severe and often sudden allergic reaction that occurs when someone with allergies is exposed to something they are allergic to (known as an allergen). Anaphylaxis is potentially life-threatening, and always requires an immediate emergency response. Between 10 May 2017 and 10 May 2019, 55 hospital trusts reported 77 incidents relating to allergens in hospital, three of which involved the patient going into anaphylaxis, a severe and potentially life-threatening condition. This e-learning course is for nurses, healthcare assistants, ward managers, staff educators, directors of nursing, dieticians and anyone else involved in patient care on the ward. It has been designed to equip participants with knowledge and understanding about food allergies so that they can ensure the necessary processes are in place to keep inpatients with food allergies safe.
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- Allergies
- Anaphylaxis
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Content ArticleThis analysis in the Financial Times highlights that in early April 2022, the number of vacant NHS hospital beds in England was 5.4%, the lowest figure since the start of the Covid-19 pandemic. The joint pressures of dealing with the backlog of elective care and ongoing high rates of Covid-19 infections are leaving the health service dangerously close to capacity. The authors highlight that this is likely to cause longer waits in accident and emergency and the potential for patients to be sent to wards that cannot effectively cater for their needs.
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- Lack of resources
- England
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Content ArticleFalls are the most commonly reported patient safety incident in healthcare, with nearly 250,000 reported from hospitals in England and Wales each year. As well as causing injury to patients, the cost of treating falls is estimated to be around £630 million each year in England. This eLearning course is designed to help healthcare workers prevent patient falls in hospital. There are two modules available: Module 1 is aimed at hospital-based nurses. Module 2 is aimed at foundation level doctors and includes interactive information about patient and environmental falls risk factors, the patient assessment and post fall management. Both modules have been designed to complement, not replace, local falls prevention policies and processes.
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Content ArticleThe positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance. This study from Baxter et al. sought to explore how multidisciplinary teams deliver exceptionally safe care on medical wards for older people. Based on identifiable qualitative differences between the positively deviant and comparison wards, 14 characteristics were hypothesised to facilitate exceptionally safe care on medical wards for older people. This paper explores five positively deviant characteristics that healthcare professionals considered to be most salient. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of positively deviant wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented. This study exemplifies that there are no ‘silver bullets’ to achieving exceptionally safe patient care on medical wards for older people. Healthcare leaders should encourage truly integrated multidisciplinary ward teams where staff know each other well and work as a team. Focusing on these underpinning characteristics may facilitate exceptional performances across a broad range of safety outcomes.
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- Organisational Performance
- Organisational culture
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Content ArticleThis study in the Journal of Patient Safety aimed to assess the impact of a pro forma that standardises medical record-keeping on ward rounds. The pro forma was developed by analysing notes entered in patient charts and comparing them with standards set out by the Royal College of Surgeons of Ireland and England, as well as Medical Council guidelines from the two countries. The authors found that the pro forma improved compliance of ward round notes when compared with internationally recognised guidelines, with no additional time required during ward rounds.
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- Hospital ward
- Doctor
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Content ArticleIn this personal blog, an NHS volunteer describes her experience of supporting a patient dying in hospital of Covid-19. She highlights the role that volunteers can play in giving compassion and comfort to patients in an overwhelmed health system. She also draws attention to the lack of training she had before taking on the role, and the mental and emotional toll of volunteering in such environments.
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Content ArticleThe experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. This study in the Journal of Patient Safety aimed to establish whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities. The authors found that participation in EFC activities was associated with higher patient safety culture scores, suggesting that root cause analysis in the team’s routine may improve patient safety culture.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores the prescription of oral paracetamol in adult inpatients who, on admission to hospital, have low bodyweight (less than 50kg). Paracetamol is a common painkiller often used as first-line management for mild to moderate pain. Although it is safe if taken at the right dose, paracetamol in large amounts is toxic to the liver and therefore the maximum dose must never be exceeded. As its 'reference case', the investigation used the case of Dora, an 83-year-old woman who weighed less than 50kg on admission and lost further weight in hospital. While in hospital, Dora was prescribed oral paracetamol 1g four times a day and towards the end of her admission, she developed multiorgan failure due to sepsis and was diagnosed with paracetamol-induced liver toxicity.
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- Medication
- Adminstering medication
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Content Article
It’s time to rename the ‘visitor’: reflections from a relative
Anonymous posted an article in By patients and public
In my first blog, ‘Visiting restrictions and the impact on patients and their families’, I highlighted how the pandemic has shone a stark spotlight on so many inequities and inconsistencies in access to health and social care. I wanted to draw attention to how visiting restrictions can result in worse outcomes for patients and their families. In my second blog I want to focus on the terms ‘visiting’ and ‘visitor’ and discuss what defines a visitor and why, in my opinion, it requires redefining and renaming.- Posted
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- Patient / family involvement
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Content ArticleThe National Comparative Audit of Blood Transfusion (NCABT) is a programme of clinical audits which looks at the use and administration of blood and blood components in NHS and independent hospitals in England. Blood services in Northern Ireland, Scotland and Wales are also invited to take part. The audit aims to provide evidence that blood is being ordered and used appropriately and administered safely, and to highlight where practice is deviating from guidelines and may cause patients harm. The latest audit took place in 2021, and previous audits are also available to download on this page.
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- Blood / blood products
- Audit
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Content ArticleThis report was triggered by the Coroner’s report into the death of Evan Nathan Smith in North Middlesex hospital. Evan was a young man with his whole life in front of him. The mistakes made in his treatment leading to his early and avoidable death brought into sharp focus the lack of understanding of sickle cell, the battles patients have to go through to get proper treatment and the terrible consequences which can come about as a result. Following the publication of the Coroner’s report, the All-Party Parliamentary Group (APPG) on Sickle Cell and Thalassaemia held three evidence sessions, hearing from patients, clinicians and politicians. This report is a result of that evidence. The findings in this report reveal a pattern of many years of sub-standard care, stigmatisation and lack of prioritisation which have resulted in sickle cell patients losing trust in the healthcare system that is there to help them, feeling scared to access hospitals, expecting poor treatment from some of those who are supposed to care for them and fearing that it is only a matter of time until they encounter serious care failings.
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- Investigation
- Medicine - Haematology
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Content ArticleThis document outlines the Royal College of Emergency Medicine’s (RCEM) systemwide plan to improve patient care. The RCEM CARES campaign addresses pressing issues facing emergency departments (EDs) so that staff can deliver safe and timely care for patients. The campaign focuses on five key areas: Crowding, Access, Retention, Experience, and Safety.
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- Emergency medicine
- Accident and Emergency
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Content ArticleThe 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.
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- Workspace design
- Hospital ward
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Content ArticleResearch shows that patient safety walk rounds are an appropriate and common method to improve safety culture. This observational study in The Joint Commission Journal on Quality and Patient Safety combined walk rounds with observations of specific aspects of patient safety and measured the safety and teamwork climate. Healthcare workers were observed in specific aspects of patient safety on walk rounds in eight settings in a Swiss hospital. They were also surveyed using safety and teamwork climate scales before the initial walk rounds and six to nine months later. The authors evaluated the implementation of planned improvement actions following the walk rounds. The authors found that walk rounds with structured in-person observations identified safe care practices and issues in patient safety. However, improvement action plans to address these issues were not fully implemented nine months later, and there were no significant changes in the safety and teamwork climate.
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- Hospital ward
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Content ArticleThis systematic review in Nursing Open synthesises the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute care hospitals. The review included nine studies and found that nurses with positive safety attitudes reported: fewer patient falls and medication errors fewer pressure injuries and healthcare-associated infections fewer mortalities fewer physical restraints and vascular access device reactions higher patient satisfaction. The authors also found that effective teamwork led to a reduction in adverse patient outcomes. They conclude that a positive safety culture results in fewer reported adverse patient outcomes, and that nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
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Content Article1- 7 November 2021 is Occupational Therapy Week. In this blog, Susanna Keenan, occupational therapist and Joanna Gilmore, student occupational therapist at Northumbria Healthcare NHS Foundation Trust, explain what their role involves and the important part occupational therapists play in patient safety.
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- Occupational medicine
- Falls
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Content ArticleThis guide provides guidance for hospital clinical staff and managers in the secondary care of COVID-19 patients, based on the experience of hospital trusts that performed well during the early phase of the pandemic. It summarises the challenges faced by, and responses of, several high performing trusts visited as part of the GIRFT cross-specialty COVID-19 deep dives, as well as identifying successful innovations they implemented.
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Content ArticleThis article in Age & Ageing describes a quality improvement project at Leeds Teaching Hospitals Trust (LTHT) that aimed to achieve timely Parkinson’s disease medication administration.
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- Parkinsons disease
- UK
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Content ArticleWard audit is a specific and common form of audit and feedback used in hospitals around the world. This study in BMC Health Services Research describes the content of ward audits and how they are carried out. The authors found that ward audits can have unintended and sometimes negative consequences, often caused by punitive feedback. They highlight the need to make feedback more constructive, for example, by including suggestions for improvement.
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Content ArticleDouble-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors. The authors found that: most nurses complied with mandated double-checking, but the process was rarely independent when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious. They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.
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- Medication
- Paediatrics
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Content ArticleNew research by the Health Foundation shows that the amount of hospital care received by those living in care homes in England rapidly declined in the first three months of the pandemic in 2020 and was substantially lower than in the same period in 2019. The research, which is due to be peer reviewed, provides the first comprehensive and national analysis of all hospital care provided to care home residents during the first wave of the pandemic. It appears to substantiate concerns that care home residents (including those in nursing homes and residential care) may have faced barriers to accessing hospital treatment as the NHS rapidly reorganised to free up hospital capacity to care for critically ill COVID-19 patients.
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Content ArticleThis directive alert has been issued on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure.
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- Patient harmed
- Anaesthesia
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Content ArticleThis article, published in the BMJ, looks at the declining mental health of staff in ICU during the height of the Covid-19 pandemic, based on research by King's College London in 2020.
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- Staff safety
- Safety culture
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