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Found 126 results
  1. News Article
    The chief executive at a trust behind one of the UK’s first ‘virtual hospitals’ has said this model is the ‘new gold standard’ for care provision and the trust is looking at a significant expansion. West Hertfordshire Teaching Hospitals Trust boss Matthew Coats said the trust aimed to eventually have “hundreds” of virtual beds for patients to be monitored at home. The trust has been at the forefront of NHS England’s programme to significantly expand the use of virtual wards across the NHS. It was also among the first to launch a virtual ward to monitor Covid patients at home during the pandemic. Its virtual ward model has since evolved beyond covid, to what the trust calls its “virtual hospital”, providing remote care for patients across several different pathways and specialties, including heart failure, respiratory and frailty patients, who are admitted from either a hospital bed, the emergency department or by GPs. Mr Coats told HSJ its virtual hospital is not only supporting better flow through the hospital, but is also leading to better patient experience. Read full story (paywalled) Source: HSJ, 25 September 2023
  2. Content Article
    September 2023 - World Patient Safety Day, Patient Safety Partners, Patient Safety Strategy, improving patient safety culture, the International Dysphagia Diet Standardisation Initiative (IDDSI), checking medication. patient-safety-newsletter-september2023.pdf August 2023 - patient safety investigations, managing human & animal bites in UTCs/MUIs, weight settings for mattresses, Bournemouth Guidelines standardised training tool to support safe manual handling, cross system relationships. patient-safety-newsletter-august2023.pdf July 2023 - Medical Devices Roadshow, end of life care audit, SCFT Patient Safety Day, speaking up, Patient Safety Partners. patient-safety-newsletter-july2023.pdf June 2023 - Learning disabilities care bags, Heel Pro boots, Palliative Care for People with Learning Disabilities (PCPLD), “No reply, missed or deferred visits (Adults) procedure” policy, clinical audit and CQUINS. patient-safety-newsletter-june2023.pdf May 2023 - aSSKINg Framework, Freedom To Speak Up update, Patient Safety Partners recruitment, missed fractures, supporting staff with patient handling, staff safety. patient-safety-newsletter-may2023.pdf April 2023 - Intentional non-adherence in the context of ART, PSIRF, Patient Safety Partners, blocked catheters, patient moving and handling training. patient-safety-newsletter-april2023.pdf March 2023 - GripAble for upper limb rehabilitation, Mindray C2 AEDs, recruitment for Patient Safety Partners, Clostridium difficile infection, Bivona tracheostomy tube, therapy dogs. patient-safety-newsletter-march2023.pdf February 2023 - Patient feedback, Trust's Patient and Public Voice Policy, Patient Safety Partners, safe wheelchair risk assessment, referral to prolonged jaundice clinic. patient-safety-newsletter-february2023.pdf January 2023 - Dementia friendly ward, National Audit for Inpatient Falls (NAIF), investigation training, CQUINS, ePMA, Health Visitor teams. patient-safety-newsletter-janaury2023.pdf December 2022 - Supporting hydration (HCSW Innovation Idea project), deteriorating patient thematic review, investigation training, checking the right saline, Professional Nurse Advocacy, Medical Device Safety Lead. patient-safety-newsletter-december2022.pdf November 2022 - Reducing the use of fall alarms, wound photography, defining levels of assistance when moving patients, Duty of Candour. patient-safety-newsletter-november2022.pdf October 2022 - Reminiscence Interactive Therapeutic Activities RITA systems, pressure ulcers on heels, post falls checklist, importance of carers care plans, Datix and LfPSE. patient-safety-newsletter-october2022 (1).pdf September 2022 - World Patient Safety Day, ordering and fitting mattress toppers, PSIRF, Sussex interpreting services, risk assessment to prevent pressure sores. patient-safety-newsletter-september2022.pdf August 2022 - Thematic review to discuss falls on the unit, Duty of Candour requirement, reporting a pressure ulcer on Datix, UTC and learning disability health facilitation team table top, care home matrons. patient-safety-newsletter-august2022.pdf July 2022 - Collaboration with the IC24 Roving GP service, critical limb ischaemia, Genius 2 and 3 thermometers, implementing the Patient Safety Strategy, introducing Professional Nurse Advocates and Patient Safety Learning's hub. patient-safety-newsletter-july2022.pdf June 2022 - New visual fluid chart tool, bruising in children who are not independently mobile, end PJ paralysis campaign, investigation training and the importance of personalised communication. patient-safety-newsletter-june2022 (1).pdf May 2022 - Why frailty matters’ week, audit of unstageable pressure ulcers reported on Datix and risk assessing pressure ulcer equipment. patient-safety-newsletter-may2022 (1).pdf April 2022 - ICUs engaging in recent table tops to discuss the falls prevention on the ward, paraffin fire risk leaflet, improving the environment for patients with dementia and safeguarding babies. patient-safety-newsletter-april2022.pdf March 2022 - Patients leaflet on what to expect from therapy during ICU admission and the aim of rehabilitation on the unit, falls alarm, falls in toilets and bathrooms, food fortification, project to develop better tools to monitor food and fluid intake, new or changing confusion, and the importance of end of life care. patient-safety-newsletter-march2022 (1).pdf February 2022 - Homeless Health Inclusion Team, ensuring an MDT falls review, following the no response policy, End of Life Care plan and alerts on SystmOne. patient-safety-newsletter-february2022 (2).pdf January 2022 - patient-centred care, NEWS2 on paper, ensuring safe use of Smartcards, fluid balance charts and the importance of education. patient-safety-newsletter-january2022.pdf December 2021 - a PCN Quality feedback session, the impact of student projects, safe use of wheelchairs on the ICU, the delirium alert on SystmOne and the Herbert protocol patient-safety-newsletter-december2021 (1).pdf November 2021 - hover jacks, taking photos of pressure ulcers, enhanced care assessments, an update from the deteriorating patient and resuscitation lead, and ensuring effective communication. patient-safety-newsletter-november2021 (1).pdf
  3. News Article
    Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, May Ashford was not offered surgery until five years later. A woman died unnecessarily after doctors failed to operate soon enough on a growing brain tumour, according to the health complaints service. May Ashford, from Blackpool, was diagnosed with a brain tumour in 2010 after experiencing headaches and seizures. Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, she was not offered surgery until five years later. An investigation by the Parliamentary and Health Service Ombudsman (PHSO) said the treatment was too late as medical staff had failed to monitor the scan results properly. Medical experts said Mrs Ashford should have been operated on at least three years earlier, before the tumour had time to grow and affect the surrounding area of the brain. She tragically died aged 71 from a stroke following surgery. Link to full article here
  4. Content Article
    Yellow Card Scheme The Yellow Card Scheme is intended to support the Medicines and Healthcare products Regulatory Agency (MHRA) monitor the safety of all healthcare products in the UK to ensure they are acceptably safe for patients and those who use them.[1] Reports can be made for all medicines, including: side effects (also known as adverse drug reactions or ADRs) medical device adverse incidents defective medicines (those that are not of an acceptable quality) counterfeit or fake medicines or medical devices safety concerns for e-cigarettes or their refill containers (e-liquids). IMMDS Review and incident reporting Published on the 8 July 2020, the Independent Medicines and Medical Devices Safety (IMMDS) Review, led by Baroness Julia Cumberlege, highlighted the need to improve incident reporting in healthcare, specifically in regards to medicines and medical devices.[2] The Review examined the response of the healthcare system in England to the harmful side effects of three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. These interventions have resulted in a truly shocking degree of avoidable harm to patients over a period of decades. One area of particular concern that the Review raised related to the Yellow Scheme, highlighting the need for reform of this system, stating that: it needs to be more user-friendly and accessible that the system was hampered by a lack of awareness among both the public and healthcare professionals. More broadly, the Review recommended that the MHRA needed to revise its approach in relation to adverse event reporting and do more to ensure that it engages with patients and their outcomes. The Government accepted this recommendation in its response to the Review.[3] Questions in the House of Commons Below are details of three written questions tabled by Emma Hardy MP concerning the Yellow Card Scheme. All three questions were answered by Will Quince MP, Minister of State (Minister for Health and Secondary Care). Awareness Question: To ask the Secretary of State for Health and Social Care, what assessment he has made of the level of awareness of (a) health professionals and (b) the general public of the Adverse Events Yellow Card System; and what steps is he taking to increase awareness of that system among those groups. Answer: The Medicines and Healthcare products Regulatory Agency (MHRA) recognises the importance of both public and healthcare professional understanding of, and access to the MHRA Yellow Card scheme, so that they can promptly report any concerns they have about the safety of healthcare products. The MHRA monitors the number of reports it receives from members of the public and healthcare professionals and strives to keep improving understanding and awareness of the reporting system. The MHRA continually works to encourage reporting of any safety concerns to the Yellow Card scheme and help improve the safe use of medicines and medical devices for everyone. A sharp increase in reporting, mainly from patients, has been seen due to better awareness of the scheme following significant communications activity at the start of the COVID-19 vaccination campaign.[4] Data collection Question: To ask the Secretary of State for Health and Social Care, what assessment he has made of the (a) level and (b) adequacy of data collected by (i) mandatory and (ii) voluntary reporting of adverse clinical events by health professionals before the introduction of the Yellow Card reporting system in England compared to that now collected via the Yellow Card system. Answer: The Medicines and Healthcare products Regulatory Agency (MHRA) has reviewed other international mandatory and non-mandatory reporting systems for healthcare professionals and found limited evidence that making reporting mandatory increases the ability to detect safety signals. Very few international mandatory reporting systems have a better reporting rate or a more successful system for detecting safety signals than the United Kingdom. In both medicines and devices legislation there are requirements for manufacturers to report, but there is no legal obligation for healthcare organisations. However, there are professional body standards and guidelines that make reporting a gold standard for healthcare professionals. The MHRA continues to work with partners across the healthcare system to promote and encourage use of the Yellow Card scheme to help detect safety issues. The MHRA has reviewed global approaches to mandatory reporting in other regulatory systems and continues to consider the approach in the UK as we work to improve reporting capability and functionality through systems.[5] Data analysis Question: To ask the Secretary of State for Health and Social Care, which body has responsibility for analysing data collected by the Adverse Events Yellow Card system; and what assessment has he made of the potential merits of collating this data on a publicly accessible database. Answer: The Medicines and Healthcare products Regulatory Agency (MHRA) collects and analyses the data received through the Yellow Card Scheme, and publishes data on medicines and COVID-19 vaccines in a searchable database on the Yellow Card website for transparency purposes. As outlined in the Yellow Card Privacy Policy, the MHRA has responsibilities under both the UK General Data Protection Regulation and the Data Protection Act 2018 to protect confidential data and personal data pertaining to individuals. The content and format of the data is currently being enhanced in line with patient and healthcare professional feedback and will be expanded to include medical devices in due course. The data provided will continue to be aligned to the MHRA’s legal responsibilities to data subjects.[6] References MHRA, Welcome to the Yellow Card reporting site, Last Accessed 6 June 2023. The IMMDS Review, First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020. Department of Health and Social Care (DHSC), Government response to the report of the Independent Medicines and Medical Devices Safety Review, 21 July 2021. House of Commons, Yellow Card Scheme, UIN 186945, tabled on 25 May 2023. House of Commons, Yellow Card Scheme, UIN 186944, tabled on 25 May 2023. House of Commons, Yellow Card Scheme, UIN 186946, tabled on 25 May 2023. Related reading A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021) Response to the Select Committee report on the Independent Medicines and Medical Devices Safety Review (Patient Safety Learning, 20 January 2023) Regulatory flaws: Women were catastrophically failed in the mesh, Primodos and Sodium Valproate tragedies (Kath Sansom, 15 April 2021)
  5. News Article
    Hundreds of children who manage their type 2 diabetes by regularly pricking their finger can now monitor their glucose levels using automated sensors, the government’s expert health advisers have announced. Doctors and nurses in England, Wales and Northern Ireland have been advised they can now give glucose monitoring devices to children with type 2 diabetes who currently use the more intrusive finger-prick testing methods, the National Institute for Health and Care Excellence (NICE) said on Thursday. The health minister Helen Whately said that offering children the devices would relieve a burden and “empower them to manage their condition more easily”. She said: “Type 2 diabetes is increasingly being diagnosed in children, many of whom face the constant stress of needing to monitor their blood glucose levels by finger-prick testing – often multiple times a day – just to stay healthy and avoid complications.” The NICE committee that reached the decision heard that children found finger pricking to check their glucose levels several times a day “burdensome”, “tiring” and “stressful”. The devices, which give a continuous stream of real-time information on a smartphone, have already been recommended for children with type 1 diabetes, a less aggressive form of the disease. Read full story Source: The Guardian, 11 May 2023
  6. News Article
    Maternity services at a trust in Staffordshire have been rated as 'requires significant improvement' by the Care Quality Commission (CQC). University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely. It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be. Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services. The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage. Read full story Source: ITV News, 28 April 2023
  7. News Article
    A team from NHS Ayrshire & Arran has successfully created a system to ensure that people with Parkinson’s get their medication on time while they are in hospital. Parkinson’s nurse specialist Nick Bryden, who led the team, explains: “The timely administration of medication is hugely important in helping to control symptoms in people with Parkinson’s. "Guidance states that Parkinson’s medication should be administered within 30 minutes, either side, of the prescribed time which can be challenging within a busy hospital ward environment." Nick, who works out of Biggart Hospital in Prestwick, added: “When we initially worked with our digital pharmacist, Richard Cottrell, it was to develop a system that would alert us to when a Parkinson’s patient was admitted to hospital. "It then became clear that we could take the system a step further and use it to monitor if people are on the right medication and whether or not it is being administered at the right time.” The team worked to develop a further system of clear visual prompts with NHS Digital services, which appear alongside relevant patient details on wards’ electronic whiteboards. Every patient prescribed Parkinson’s medication has a tulip symbol beside their name which changes colour and flashes when it’s close to the time to administer the medication. The system was initially piloted in a couple of wards and, due to its success, has now been rolled out to almost every ward in Ayrshire and Arran. Read full story Source: The Herald, 19 April 2023 Related reading on the hub: Top picks: Seven resources about Parkinson’s Professionals with Parkinson’s tackle time critical patient safety issue: a blog by Sam Freeman Carney
  8. News Article
    Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023
  9. News Article
    More than 100,000 patients, including children, have been treated in so-called virtual wards over the last year, NHS officials have said. Leading medics said that the use of the system to monitor patients at home has been a “real game changer”. Officials say virtual wards can help patients avoid unnecessary hospital trips altogether, or enable them to be sent home from hospital sooner. Using various equipment and technology, clinicians can monitor vital signs such as a patients’ heart rate, oxygen levels and temperature remotely. NHS England’s national medical director, Professor Sir Stephen Powis, said: “The advantages of virtual wards for both staff and patients have been a real game-changer for the way hospital care is delivered and so it is a huge achievement that more than 100,000 patients have been able to benefit in the last year alone, with the number of beds up by nearly two thirds in less than a year. “With up to a fifth of emergency hospital admissions estimated to be avoided through better supporting vulnerable patients at home and in the community, these world-leading programmes are making a real difference not just to the people they directly benefit but also in reducing pressure on wider services.” Read full story Source: The Independent. 11 March 2023
  10. Content Article
    Risk assessment themes The review identified seven key areas: The language used to discuss and document risk assessments should encourage a dynamic and holistic assessment of the individual pregnant woman/person’s risk (‘dynamic’ means the risk is continually assessed to allow for unknown factors and to handle uncertainty, while ‘holistic’ refers to looking at other factors that might be relevant) that promotes the need for maternity care to be provided by multi-professional teams. Telephone triage services should support 24-hour access to a systematic structured risk assessment of pregnant women/people’s needs. Telephone triage services should be operated by appropriately trained and competent clinicians who are skilled in the specific needs required for effective telephone triage. Face-to-face triage in maternity units should use a structured approach to prioritise pregnant women/people to be seen in order of clinical need. Clinicians should be enabled to proactively monitor and recommend the place of labour care and birth for pregnant women/people based on the individual’s specific care needs during the course of their pregnancy and labour. Each pregnant woman/person should be helped to understand their individualised risk associated with a vaginal or caesarean birth after a previous caesarean birth, based on their specific risk factors and care needs. Pregnant women/people whose labour has been induced need clinical oversight and an individualised plan of care for maternal and fetal monitoring. Prompts for NHS trusts This thematic review also includes prompts for NHS trusts to consider how these risks may be mitigated: Are risk assessment and screening documents designed and presented in a consistent and logical way? Does the language used in risk assessment and screening documents avoid binary definitions of risk, and instead promote dynamic and holistic risk assessments supporting a multi-professional approach? Does risk assessment and screening documentation support a holistic consideration and documentation of risk, or does it focus on only single risk factors? Do telephone triage services facilitate 24-hour support for systematic risk assessment? Are clinicians equipped with the appropriate training, skills and competencies to manage an effective telephone triage service? Is a structured approach used so that pregnant women/people are seen in order of clinical need within your maternity face-to-face triage service? Are there frequent opportunities to revisit and recommend the place of birth based on the pregnant woman/person’s individual needs? Does your risk assessment tool encourage clinicians to think about the most suitable place of birth when a pregnant woman/person in labour is admitted? Do processes support holistic risk assessments to be revisited during labour to proactively assess the most suitable place for fetal monitoring and birth? In antenatal discussions with pregnant woman/people, are structured tools used to support individualised care planning and decision-making when planning a birth after a previous caesarean birth? Is there an opportunity to revisit these discussions when there is a change in circumstance, such as induction of labour? Are clinicians encouraged to make individual plans, taking into consideration a pregnant woman/person’s and baby’s risk during the induction of labour process and including frequency of observations, fetal monitoring and place of induction? Is there a system to prioritise pregnant women/people requiring induction of labour according to clinical need, and to ensure appropriate escalation and action when there are delays?
  11. News Article
    The trust at the centre of a maternity scandal has been ordered to report on urgent improvements in services for women and babies, amid ‘significant concerns’ about the risk of harm. The Care Quality Commission (CQC) used its enforcement powers to issue the conditions on East Kent Hospitals University Foundation Trust, after it carried out an unannounced inspection last month. However, the “section 31” warning letter has just been made public, and the first deadline for the trust to report back to the CQC is Monday (20 February). The CQC said some of the problems it found were due to the labour ward environment – but others involved monitoring of women and babies whose conditions deteriorate and the risk of cross-infection due to poor cleanliness standards. “We have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care,” Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said in a statement today. Read full story (paywalled) Source: HSJ, 17 February 2023
  12. News Article
    A heart failure patient has become the first in the UK to be fitted with an early warning sensor the size of a pen lid which gives off an alert if their condition deteriorates. Consultant cardiologists Dr Andrew Flett and Dr Peter Cowburn have pioneered the procedure to fit the FIRE1 System during trials at University Hospital Southampton (UHS), Hampshire. Dr Flett said: “This innovative new device has the potential to improve patient safety and outcomes in the management of patients with chronic heart failure and we are delighted to be the first site in the UK to implant as part of this ground-breaking study". Read full story Source: The Independent, 12 February 2023
  13. News Article
    East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light. The Care Quality Commission has highlighted: Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup. Read full story (paywalled) Source: HSJ, 6 February 2023
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