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Showing results for tags 'Monitoring'.
Found 136 results
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Content ArticleThis article looks at an incident of unsafe prescribing of haloperidol that resulted in overdose and the death of an elderly patient.
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Content ArticleThe Health System Response Monitor (HSRM) has been designed in response to the COVID-19 outbreak to collect and organise up-to-date information on how countries are responding to the crisis. It focuses primarily on the responses of health systems but also captures wider public health initiatives. This is a joint undertaking of the WHO Regional Office for Europe, the European Commission, and the European Observatory on Health Systems and Policies.
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Content ArticleThis independent external quality assurance review looks at the independent investigation into the care and treatment of mental health service user Mr M at Greater Manchester Mental Health NHS Foundation Trust.
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News Article
CQC threatens to suspend licence of ‘large scale’ GP provider
Patient Safety Learning posted a news article in News
A major GP group in Plymouth covering tens of thousands of patients could have its licence removed after failing to make ‘substantial improvements’ ordered by the Care Quality Commission (CQC). In August, the CQC rated the Mayflower Medical Group “inadequate” and last month the regulator said it had served a “letter of intent” on the group after another inspection. Such a letter is the last step the CQC takes before a provider’s licence is suspended. Licence suspension would affect around 40,000 people (a sixth of Plymouth’s population), who live in one of the highest areas of deprivation in the country – according to Public Health England (now the UK Health Security Agency). Among the CQC’s concerns were safety fears about the way medicines were prescribed, poor management of high-risk patients, coding issues, limited monitoring of the outcomes of care and treatment, and patients experiencing difficulties accessing care and treatment. Read full story (paywalled) Source: HSJ, 2 December 2021 -
News Article
GPs in England may stop monitoring vulnerable patients
Patient Safety Learning posted a news article in News
Ministers may allow GPs in England to halt regular monitoring of millions of patients with underlying health problems as part of the urgent new blitz on delivering Covid booster jabs. Sajid Javid and NHS bosses are locked in talks with GP representatives at the British Medical Association (BMA) about relaxing rules which mean family doctors undertake checks on people with diabetes, high blood pressure and other conditions that mean they are at higher risk of having a heart attack or stroke. It came as the health secretary announced the government has secured contracts to buy 114m more vaccine doses for next year and 2023. The deals, accelerated in the wake of the Omicron variant, will see the UK purchase 54m more Pfizer/BioNTech jabs and 60m from Moderna to “future-proof” the inoculation programme, Javid said. The BMA, the doctors’ union, has been lobbying Javid for months to suspend or scrap the Quality Outcomes Framework (QOF), which it says is “bureaucratic” and interferes with GPs’ right to judge how they care for patients. Officials with knowledge of the talks told the Guardian that those involved spent much of Tuesday discussing the suspension of part or all of the requirements under QOF. “They’re talking about a partial suspension of QOF. But they may well just bin it,” one said. However, sources stressed that ministers are nervous about approving a move that could lead to claims that vulnerable patients could see any deterioration in their condition go undetected by GPs. Read full story Source: The Guardian, 1 December 2021 -
Event
Priorities for NICE in health & social care
Patient Safety Learning posted an event in Community Calendar
untilThis 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 -
Content ArticleIn this article in the Anesthesia Patient Safety Foundation Newsletter, Katsuyuki Miyasaka talks about the history of the pulse oximeter in Japan and celebrates one of it's earliest developers, Takuo Aoyagi. The author recognises the life-saving impact of pulse oximeters, but talks about the need for more education and regulation around the use of this readily available device. Miyasaka highlights that the quality of devices is variable and that when patients attempt to interpret the numbers they see, it may lead to harm.
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Content ArticleThis is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user David at North West Boroughs Healthcare NHS Foundation Trust, published in June 2020.
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Content ArticleThe authors of this research study, published in BMJ Quality & Safety looked at the issues of hazardous prescribing and inadequate monitoring in patients with mental health issues being managed in primary care. They identified a lack of data in this area, despite most patients with mental illness receiving treatment in a primary care setting. The study found that: 9.4% of patients ‘at risk’ triggered at least one indicator for potentially hazardous prescribing. The risk was greatest for patients aged 35–44, females and those receiving more than 10 repeat prescriptions. 90.2% of patients ‘at risk’ triggered at least one indicator for inadequate monitoring. The risk was particularly high in people under the age of 25, females and those with one or no repeat prescription. The authors of the study hope their findings will support providers to reduce risk and improve care for patients who receive mental health treatment in primary care.
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Content ArticleIn this editorial for BMJ Quality & Safety, Dr Tamasine Grimes makes the case for greater patient involvement in managing medication, particularly at points of transition in care. She comments on a recent report on the effects of MARQUIS2, an evidence-based toolkit trialled in North American hospitals to help manage complex medication. The report found that interventions that involved patients in managing their medication had a significant effect in decreasing medication discrepancies, while purely system-level interventions did not.
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Content Article
Avoiding Brain Injury in Childbirth (ABC)
PatientSafetyLearning Team posted an article in Maternity
Preventable harm during labour can be catastrophic for parents, babies and families, as well as for the staff involved. Reducing avoidable brain injury in childbirth means building on everyone’s experiences and expertise, working together to improve care in labour for all. THIS Institute, in partnership with The Royal College of Midwives and The Royal College of Obstetricians & Gynaecologists, is inviting maternity staff, parents and birth partners from across the UK to contribute their views to their Avoiding Brain Injury in Childbirth (ABC) campaign. The focus is on monitoring and responding to babies’ wellbeing during labour and on managing the emergency complication at caesarean section known as impacted fetal head. The ABC campaign aims to give maternity staff tools and support to be able to provide the highest quality of care when there are concerns about the baby’s wellbeing during labour. It also aims to improve communication with everyone using maternity services and make sure they are listened to and involved in decisions about their care. -
Content ArticleThis document describes and sets out the NHS Delivery Framework 2018-2019, Reporting Guidance, NHS Delivery Measures, Summary of Revisions to Measures, Reporting Templates and Measures from 2017-18 that have not been carried forward into the 2018-19 NHS Delivery Framework.
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Content ArticleThe purpose of this document from the Medicines and Healthcare products Regulatory Agency (MHRA) is to provide information and guidance to all involved with the purchase, management and use of non-invasive blood pressure measurement devices. It reviews the advantages and disadvantages of mercury, aneroid, electronic manual sphygmomanometers and automated blood pressure measuring devices. This should help to ensure the most appropriate technology is selected for use.
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Content ArticleUK guidelines recommend that assessment and monitoring of breathless, unwell, or high risk patients with suspected COVID-19 should include pulse oximetry. Guidance published in January 2021 by the World Health Organization includes a provisional recommendation for “use of pulse oximetry monitoring at home as part of a package of care, including patient and provider education and appropriate follow-up. In this BMJ Practice article, Tricia Greenhalgh and colleagues discuss the remote management of COVID-19 using home pulse oximetry.
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Content ArticleThis report from the NHS Race and Health Observatory, acknowledges the growing evidence suggesting there may be drawbacks when using pulse oximetry on darker skin. Whilst the picture on racial bias in pulse oximetry is still mixed, as a worst-case scenario, the application of this intervention can potentially have negative outcomes for patients with more pigmentation in their skin. To help counter potential health inequalities in this area, the report outlines a number of recommendations for healthcare, regulatory and research bodies.
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Content ArticleIn conditions of intensive therapy, where the patients treated are in a critical condition, alarms are omnipresent. Nurses, as they spend most of their time with patients, monitoring their condition 24 h, are particularly exposed to so-called alarm fatigue. The purpose of this study from Lewandowska et al. is to review the literature available on the perception of clinical alarms by nursing personnel and its impact on work in the ICU environment.
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Content ArticleThis review in the Journal of Clinical and Diagnostic Research explains the basics of audit and describes in detail how a clinical audit should be performed and monitored. It includes information on the 'Audit Cycle' and 'Ten Tips for Successful Audits'.
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Content ArticleTelemetry monitoring of heart rates and rhythms was introduced in intensive care units in the 1960s, and since then it has expanded into patient rooms and units in noncritical care settings. It allows healthcare workers to watch the condition of many patients all at once and intervene quickly when their condition changes; however, if the technology is not used appropriately or the equipment malfunctions, relying on telemetry monitoring also risks patient harm. This study from Kukielka et al. looked at real-life cases of breakdowns in the processes and procedures regarding telemetry monitoring, such as user errors and miscommunication, and equipment failures, including broken transmitters and dead batteries. The lessons learned can help improve training and best practices to improve the safety of patients being monitored.
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Content ArticleFrequent and wide ‘swings’ in blood glucose levels are common in the hospital setting, for both diabetic and non-diabetic patients, due to factors including, but not limited to, physiologic stress, certain medications and procedures. However, these uncontrolled swings in glucose levels can be detrimental to patients and can compromise wound healing, increase risk of infection, and delay surgical procedures and discharge. Early recognition and anticipation of blood sugar swings have proven to be effective in improving outcomes but require significant infrastructural changes within the organisation. Many healthcare organisations have successfully implemented and sustained blood glucose management initiatives.These organisations have focused on projects that included education around and trigger tools for early recognition and anticipation of blood sugar “swings”. This document provides a blueprint that outlines the actionable steps organisations should take to successfully improve blood glucose management and summarises the available evidence-based practice protocols.
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Content ArticleIdentifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk.
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Content ArticleThis alert, from the National Institute for Health Research, provides a synopsis of a new study which suggests that many early warning scores are based on flawed research. It looks at the issue and the next steps in terms of patient safety.
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Content ArticleThe aim of this systematic review in the Journal of Patient Safety was to determine the impact of automated patient monitoring systems (PMSs) on sepsis recognition and outcomes. Authors Gale and Hall found that automated sepsis PMSs have the potential to improve sepsis recognition and outcomes, but current evidence is mixed on their effectiveness. More high-quality studies are needed to understand the effects of PMSs on important sepsis-related process and outcome measures in different hospital units.
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Content ArticleCare Quality Commission (CQC) Chief Executive, Ian Trenholm, discusses the immediate priorities for CQC, what’s coming next with their Transitional Regulatory Approach, and further ahead to CQC's future strategy.
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Content ArticleThis investigation, published in Anesthesiology, was specifically designed to determine whether errors at low saturation correlate with skin colour.
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Content ArticleThis report, from the Healthcare Safety Investigation Branch (HSIB), provides insight into a current safety risk that was identified on a referral. The referral was about difficulties in identifying clinical deterioration in patients with COVID-19 on general wards. The Royal College of Physicians (RCP) highlighted the issue of rapid deterioration in oxygenation in patients with COVID-19 and how this might relate to the use of early warning scores.
