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Found 126 results
  1. Event
    This webinar from the Institute of Global Health Innovation explores the safety, effectiveness and global relevance of pulse oximetry for at-home monitoring of Covid-19. Pulse oximeters are being explored as a tool for people with COVID-19 to keep an eye on their health at home, away from healthcare settings. These are widely available, low-cost devices that shine light through a person’s finger to assess their blood oxygen saturation. Evidence has shown that a fall in blood oxygen levels is a critical indicator that a COVID-19 patient’s health is deteriorating and they may need closer monitoring and urgent treatment. But what is the evidence surrounding their effectiveness, and are they a safe way for people to monitor themselves at home? Join our webinar as we explore these important questions while discussing their applications in the UK health system and globally, with particular attention to their relevance in low- and middle-income countries. We will also discuss findings of the ongoing NHS COVID Oximetry at Home (CO@H) programme, which supports people at home who have been diagnosed with coronavirus and are most at risk of becoming seriously unwell. This virtual event will consist of a series of short talks by experts from IGHI followed by a live audience Q&A, giving you the chance to ask any questions you may have. Speakers Professor the Lord Ara Darzi, IGHI co-director Dr Ana Luisa Neves, IGHI Advanced Research Fellow and Associate Director, NIHR Imperial Patient Safety Translational Research Centre, IGHI Dr Jonny Clarke, Sir Henry Wellcome Postdoctoral Research Fellow, IGHI, Imperial College London Dr Ahmed Alboksmaty, IGHI Research Associate Professor Paul Aylin, Professor of Epidemiology and Public Health, IGHI Dr Thomas Beaney, IGHI Clinical Research Fellow Register for the webinar
  2. Event
    This conference focuses on reducing medication errors and the level of severe, avoidable harm related to medications. The conference focuses on prioritising high risk medications and high risk patient groups to enable your interventions to have the highest impact on patient care and reduction in patient harm. The conference which aims to bring together clinicians and pharmacists, managers, and medication safety officers and leads will reflect on medication safety issues that have arisen as a result of the Covid-19 pandemic, help you to understand current national developments, and allow you to debate and discuss key issues and areas in improving and monitoring medication safety, reducing medication errors and harm in hospitals. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/reducing-medication-errors or email kate@hc-uk.org.uk hub members receive a 20% discount. Email infor@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #MedicationErrors
  3. Event
    This Westminister Forum conference will discuss the priorities for NICE within health and social care following the publication of the NICE Strategy 2021 to 2026: Dynamic, Collaborative, Excellent earlier this year, which sets out NICE’s vision and priorities for transformation over the next five years, including: rapid and responsive evaluation of technology, and increasing uptake and access to new treatments flexible and up-to-date guideline recommendations which integrate the latest evidence and innovative practices improving the effective uptake of guidance through collaboration and monitoring providing scientific leadership through driving research and data use to address gaps in the evidence base. It will be an opportunity to discuss the role of NICE in a changing health and social care landscape following the pandemic, as well as the opportunities presented for guidance to keep pace with the development of integrated care, innovative treatments, and data-driven research and technology. Sessions in the agenda include: key priorities for delivering the future vision and transformation of NICE going forward developing evidence-based guidelines in a changing health and social care landscape: flexibility, patient engagement, collaboration, and effective implementation lessons learned from the use of rapid guidelines in response to COVID-19 the opportunities presented for improving the utilisation of data and the future for data-driven evidence and guidelines taking forward new approaches to evaluating health technology - speed, cost-effectiveness, and engagement priorities for industry engagement and improving value and access to innovative health technology supporting the development and adoption of innovative medicines the role of managed access and funding in delivering improved patient access to innovation opportunities for using research and data analytics to meet gaps in the evidence base. Register
  4. Community Post
    I would be interested to know, if overnight, patients who score 0-2 on NEWS which has not changed with no concerns since the last set of observations, what your trust policy is on observation frequency? Does your trust require observations to be carried out 4 hourly minimum regardless of patients NEWS score and stability? Or if there are no concerns and the patient is clinically stable with consecutive NEWS 0-2 that they do not have observations taken overnight? Looking forward to hearing what other trust practices are.
  5. Content Article
    Coroner's concerns Whilst at King’s College Hospital, Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries. The bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to the coroner very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring. The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. Evidence suggests that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments, and to ensure that there is pro-active paediatric intensive care outreach. However, the intended programme has stalled, partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future. Response from King's College Hospital Further reading Sharing her story in the Guardian, Merope, Martha's mother, gives a heart breaking account of how Martha was allowed to die: ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (Guardian article)
  6. Content Article
    HSIB was notified about potential patient safety issues by Sarah, who was concerned about the care she had received when her babies were delivered. The investigation used interviews, observations of the maternity unit and reviews of guidelines and organisational documents in order to understand the system-wide factors that contributed to Sarah’s experience and the decisions made by staff. The evidence suggested that the process of decision making in the context of Sarah’s care was relevant to this investigation, so the investigation has summarised the key factors that appear to have influenced the decision making associated with her care and the delivery of her babies Findings There are currently no proven treatments available to reduce the risk of preterm labour for twin pregnancies. There are gaps in scientific knowledge and challenges to completing research in the field of preterm labour and birth. This creates a challenge for the development of detailed guidelines to support clinical decision making. Guidelines and equipment recommended for managing and monitoring singleton (one baby) and full-term pregnancies are used to assist with clinical decision making about preterm twin pregnancies; some interventions within the guidelines are unproven for use in preterm twin pregnancies. Research and national improvement initiatives, such as the British Association of Perinatal Medicine perinatal optimisation care pathway and NHS England and NHS Improvement ‘Saving babies’ lives care bundle version two’ and the Maternity and Neonatal Safety Improvement Programme are improving the standardisation and implementation of evidence-based interventions. Intelligence from national data gathered by maternity units can support the learning on preterm labour and birth in twin pregnancies. Safety observations It may be beneficial if further research aimed to generate additional knowledge to predict and prevent preterm labour for twin pregnancies among different groups of women/pregnant people. It may be beneficial to increase awareness among the public and healthcare professionals of the limitations of interventions for the prevention of preterm labour of multiple births. It may be beneficial to regularly analyse data on multiple births so the interpretation of this data can inform learning and research. Safety actions Following stakeholder feedback received during an update of the guideline for preterm labour and birth, the National Institute for Health and Care Excellence decided to delete the recommendation relating to milking the cord and amend the subsequent recommendation on clamping of the cord to wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need earlier clamping.
  7. Content Article
    Did you know? Key causes of anti-infective medication error claims: Failure to check allergy status. Failure to cross-check the ingredients of a medication against allergy status. Failure to adjust dose of medication to the patient’s weight. Failure to adjust dose of medication according to renal function. What can you do? When prescribing antibiotics, refer to the British National Formulary (BNF) for guidance on adjusting dosages according to patient weight, kidney function and the frequency of monitoring. Refer to the traffc light system for antibiotics and penicillin allergy. Ensure that the weight of a patient is regularly checked and adjust drug doses accordingly. • Check the allergy status of the patient at each point of the medication process. Review local guidelines to ensure they incorporate national guidance and support clinicians to prescribe, administer and monitor the effects of anti-infectives appropriately. Examples of relevant national guidance include NICE quality standards on on antimicrobial stewardship and sepsis. Access the NICE guidelines on acute kidney injury to fnd information and advice on the prevention, detection, and management of acute kidney injury. Review your organisation’s claims history regarding medication errors and ensure that learning is shared with clinicians.
  8. Content Article
    The vision-based patient monitoring and management system described in this article has been deployed, or scheduled for deployment, in 18 Mental Health Trusts in NHS England (in April 2020). The system is not a replacement for nursing skills. Rather, it provides an enhancement to nursing practice. As with the adoption of any new technology into clinical workflows, it is important for practitioners to learn how to manage the cultural shift required to take advantage of a vision-based patient monitoring and management system. The engineering framework described in this article will help them to understand how the tasks involved in patient care (assess, observe, intervene, and improve) can be optimised through the adoption of a vision-based system, which offers nonintrusive physical and physiological monitoring of quantified patient state. Potential further developments in the vision-based system include metrics of sleep quality, agitation, and more detailed analysis of patterns of behavior. Development of non–contact-sensing of patient temperature at a distance and with affordable technology would also be valuable.
  9. Content Article
    Key findings Patients, their care partners and care providers express that safety is more than the absence of harm. Safe care requires a proactive approach, with ongoing engagement of patients and their care partners. A number of strategies can be used to enable safer care including giving patients and care partners access to information and engaging them in safety discussions (huddles, bedside reporting, etc). Care partners, volunteers, advocates, and/or a point person (provider) is required to improve communication with patients and increase opportunities for them to be meaningfully involved in their care.
  10. Content Article
    ADRe is designed for use by nursing staff (NVQ level 3-5 or above), the professionals closest to patients. By using ADRe complex information on drugs is combined into a checklist providing advice on common problems. This helps nurses recognise and act on adverse drug reaction, including pain, dental pain, aggression, peptic ulcers, and sedation. In doing so, it greatly enhances the administration of medicines, and by capturing this individualised picture of the patients’ health and well-being prompts prescribers to refine dosages. ADRe is very simple to use: Nurses use the Profile to check and record problems that might be related to prescribed medicine. Nurses solve some problems, e.g. dental pain, dehydration, by referrals or paying closer attention to intake. Nurses share the completed ADRe Profile with prescribers (GPs or specialists), who decide prescriptions and doses. Repeating the Profile one month later ensures no new issues have arisen. You can request a copy of the full tool, or even try out part of our digital app by registering.
  11. Content Article
    How do we know we are safe? This is the Holy Grail that has led to many publications and much research. Authors such as Berwick, Dekker and Syed have written insightful and clear reports that detail that safety is about much more than mere compliance to rules, reporting of incidents and monitoring risk. Local context In my previous blog I shared Solent NHS Trust’s staff survey results, which show high confidence in our staff about safety, having a voice and speaking up. The organisation works hard to define how safe we are and uses a variety of measures for this. Incident reporting is high for a trust of our size and is the highest in our group. The levels of harm are consistently low and the structures for scrutiny and investigation are clean and regularly audited. An active risk register is regularly updated and shared. We still have a long way to go on our journey towards truly triangulated data. There is a real commitment to get there. We seek to learn and have a 'Best in Class' Research and QI Academy. We have regular sharing events – the question on all our lips is often “How do we truly learn?” We monitor safe staffing regularly; even more so at times of significant pressures. A Rapid Quality Impact assessment process, which ensures that rapid change can take place but must be monitored for quality with regular post change follow up. Wider context We are not alone – many trusts share these traits. So what do our staff say about this? Our staff survey (68% participation) shows our staff believe we are safe. We have a larger than normal network of Freedom to Speak Up Guardians and consistently perform well nationally in the annual guardians’ survey. So, what’s the problem – our safety climate is good by all agreed measures? But is it as good as it can be? The key players who can comment on whether we are safe are those delivering care and those receiving it – our community. Our wider community are central to what we do. We have a really ground-breaking community and patient engagement programme. It is the belief of our senior team that complaints are a gift of feedback that help us learn and can shine a light on safety concerns. We take these seriously. When a complaint is made our patient experience team will ask the question “How can we make this it better?” as this will help us learn and improve the experience for other people. Again, it is not perfect but comes from a place of positive intent and partnership. Although staff say the organisation is safe, we have never asked them what that means. We have yet to get them to describe what is safe in their team and what is not safe. It is only from this perspective of safety in the ‘work as done' that an organisation can understand what the real issues are. Through this approach we can support staff to be not just the eyes and ears of safety but the mechanism of making their world safer. The learning across teams could truly drive change across our clinical teams. It was from this position that I decided to undertake a series of “Safety Chats” in clinical areas. A brief outline of them is below but these will be covered in the next blog in this series. If you would like to discuss Safety Chats further, please email me at: Gina.Winter-Bates@solent.nhs.uk Other blogs in the Safety Chat series Safety Chats blog series: Part 1 Part 3 - Starting the conversation Part 4 - Talking about safety and creating safer environments
  12. Content Article
    The report highlights the following key findings: The maternity service was offering care to women whose pregnancies represented a high risk, but did not have the necessary systems or staff with the appropriate skills in place to manage such cases. There was a lack of input from consultants at crucial times, and there was an over reliance on junior staff to manage complex and difficult cases with little guidance or support. Consultant obstetricians did not routinely carry out ward rounds when they were responsible for overseeing care in the labour ward and the teamwork between midwives and obstetricians was not as effective as it should have been. Therefore, there was no adequate mechanism in place for staff to discuss concerns that they may have had about the women. There was an excessive reliance on the use of locum and agency staff, who did not always receive the necessary guidance or support. Deficiencies in the management structures also contributed to the poor quality of care the women received, for example midwives were expected to manage a busy delivery suite that was reliant on agency and locum staff, with at times, little professional or managerial support. Around the time of the first deaths the midwives received little professional support from the supervisors of midwives. In the majority of cases the women attended their hospital and GP antenatal appointments and sought help when they felt unwell. Yet despite this, in a number of the cases, clinical staff failed to recognise and respond to the severity of the condition of the women, thereby reducing the chances of survival of the women. In some of the cases there were minor deficiencies in care which, in isolation, may not have had such a dramatic impact, but when occurring together had serious consequences for the health of the women concerned. The anaesthetic staff involved in the care of the women responded well, often in difficult circumstances. The haematology department responded efficiently in providing the necessary, and at times large, volumes of blood and blood products. In two of the cases there was an absence of documentation for surgical procedures that were carried out by the obstetric staff and in one case there was an absence of contemporaneous documentation. Related reading An independent review of serious untoward incidents and clinical governance systems within maternity services at Northwick Park Hospital (16 September 2008)
  13. Content Article
    The objectives of this study protocol is to establish baseline data related to the types and frequency of infusion pump alarms from the B. Braun Outlook 400ES Safety Infusion System with the accompanying DoseTrac Infusion Management Software. This exploratory study will analyse the aggregate alarm data for each hospital by care area, drug infused, time of day, and day of week, including overall infusion pump alarm frequency (number of alarms per active infusion), duration of alarms (average, range, median), and type and frequency of alarms distributed by care area. Infusion pump alarm data collected and analyzed in this study will be used to help establish a baseline of infusion pump alarm types and relative frequencies. Understanding the incidences and characteristics of infusion pump alarms will result in more informed quality improvement recommendations to decrease and/or modify infusion
  14. Content Article
    This guideline includes recommendations on: information for patients measuring temperature warming patients before their operation, including transfer to the operating theatre keeping patients warm during their operation, including ambient temperature in the operating theatre and temperature of intravenous fluids keeping patients warm after their operation
  15. Community Post
    Hello I would be interested in hearing from anyone who has done any work on how we monitor patient deterioration overnight? I am currently working on am improvement project looking at patient surveillance of deterioration during night shifts. I have chosen this project as part of a Clinical Improvement Scholarship Program I am on. The program is combined with my day job as a Critical Care Outreach Sister as well as enabling me to develop my research and leadership skills alongside implementing improvements in clinical care. I am in the early stages of my work, however I have some literature and local research around deficiencies in how we monitor patients for deterioration overnight (as well as personal experiences as a CCOT nurse) which is why this topic is so important to me. I would be interested in hearing from anyone who has worked on anything similar, or can point me in the direction of anyone who maybe able to help. Thank you ?
  16. Content Article
    Recommendation 1: There should be an urgent review of pulse oximetry medical products used in the United Kingdom Recommendation 2: Identification of suitable parameters to identify hypoxia need to be verified Recommendation 3: Review of all medical equipment and devices Recommendation 4: Further research To read the full report and detailed recommendations, follow the link below.
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