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Found 136 results
  1. Content Article
    After babies are born they have to breathe, suck, feed, wee, poo and stay warm. This NHS leaflet (April 2020) will tell you how to keep your baby safe and healthy. Do not delay seeking help if you have any concerns. Content includes: What is jaundice? Breathing, colour and movement. Feeding.
  2. Content Article
    This is a series of three articles written by Kirsten Small, a specialist obstetrician and gynaecologist in Australia, exploring the risks that flow from the use of intrapartum monitoring. Part 1 Examines evidence of short and long-term physical harms to birthing women relating to higher rates of surgical birth when intrapartum Cardiotocography (CTG) monitoring is used. Part 2 Focuses on possible psychological harms which have been reported relating to CTG use. Part 3 Looks at the possibility that CTG use might cause harm to the baby, while the two previous posts have examined the risk to birthing women.
  3. Content Article
    Unknown to its hypertension specialists, a major teaching hospital changed the cuffs on its sphygmomanometers from manufacturer-validated to a uniform washable alternative, in line with ‘Health and Safety’ concerns surrounding potential cross-contamination between patients. When clinic doctors suspected serious under-reading with the new cuffs, a systematic comparison was undertaken in 54 patients using two UM-101 sphygmomanometers: one using the original, manufacturer-supplied cuff and the other with the washable replacement. The study confirmed an average under-reading of 8±10/5±5 mm Hg using the washable cuff, and a third of patients with poorly controlled hypertension were considered normotensive, after using this cuff. The UM-101 sphygmomanometers have now been re-fitted with the original cuffs. Sphygmomanometer cuffs are not interchangeable between devices and a modicum of common sense should be shown to prevent changes made in the name of Health and Safety from having the opposite effect to that intended.
  4. Content Article
    Blood pressure (BP) has been measured with a cuff for over a 100 years. Recently, ‘tricorders’ and smartwatches that measure BP without a cuff using pulse transit time (PTT) have become available. These BP measurements are based on the inverse relationship between BP and PTT. PTT can be measured as the timing delay in a QRS complex on an EKG and the onset of a photoplethysmography wave, for example measured from a finger. Since these measurements are relatively more user‐friendly than conventional cuff‐based measurements they may aid in more frequent BP monitoring. Using a guidelines‐based protocol, Bard et al. investigated the accuracy and precision of two popular PTT‐based BP measuring devices: the Everlast TR10 fitness watch (Everlast, New York City, NY) and the BodiMetrics tricorder (BodiMetrics, Manhattan Beach, CA).
  5. Content Article
    Since the severity of disease is closely related to the prognosis, the basic and essential strategies to improve outcomes that we should adhere to remain the early detection of high-risk and critically ill patients  This retrospective analysis of casein Jiangsu Province proved a good consistency between early screening of SpO2, RR, HR and early warning model. Therefore, a flowchart integrating early warning model and early screening procedure is recommended for high risk patients recognition and all patients’ screening to make it possible for early intervention. This article includes flow charts for: early recognition of high-risk and critically ill patients management of critically ill patients.
  6. Content Article
    The Specialist Pharmacy Service (SPS) is supporting healthcare professionals with the COVID-19 Vaccination Programme in England. Read about how they are helping and the resources available.
  7. Content Article
    The Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. These data have been used to compute indicators of care quality. Use of the quality indicators to inform quality improvement initiatives is contingent upon the validity and reliability of the indicators.
  8. Content Article
    Maybe your blood pressure has been creeping up over time, or you’re starting treatment for hypertension. So your doctor suggests you buy a home blood pressure monitor to help keep track between office visits. Simple enough, right? But a quick check online reveals hundreds of different models — and even a bunch of apps for your smartphone. How do you even start to sort through all that without, well, spiking your blood pressure? This article highlights six things you need to know.
  9. Content Article
    Steve Turner's blog discusses the use of psychotropic medicines for people with learning disabilities who show symptoms of distress. Steve offers a useful guide to help those prescribing these drugs consider all of the relevant factors so they can keep patients safe.
  10. Content Article
    Dr Hein Le Roux is Primary Care Patient Safety GP Lead at the West of England Academic Health Science Network. Here Hein interviews Dr Emma Redfern on their programme to encourage the use of the National Early Warning Score (NEWS), followed by a conversation with Dr Sheena Yerburgh on a standardised admission sheet they have helped to develop, which is being used by GPs in the Gloucestershire area when referring patients to emergency departments.
  11. Content Article
    The objective of this study, published in the Journal of Clinical Nursing, was to determine the predictive value of individual and combined dutch-early-nurse-worry-indicator-score indicators at various Early Warning Score levels, differentiating between Early Warning Scores reaching the trigger threshold to call a rapid response team and Early Warning Score levels not reaching this point.
  12. Content Article
    The reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery. The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
  13. Content Article
    Understanding Patient Data has produced a series of animations to explain how data saves lives. Following the journeys of patients with cancer, a heart attack, diabetes, dementia and asthma, they show the huge range of ways data is used to improve care, and the safeguards that are in place to protect confidentiality. 
  14. Content Article
    The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level across the NHS in England using a standard and transparent methodology. It is produced and published monthly as a National Statistic by NHS Digital. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
  15. Content Article
    The UKONS Telephone Triage Tool Kit outlines a clear symptom based, RAG rated ( RED, AMBER, GREEN) risk assessment process. It is used for telephone triage of patients who: have received or are receiving systemic anticancer therapy have received any other type of anticancer treatment, including radiotherapy and bone marrow graft/transplant may be suffering from disease-/treatment-related immunosuppression. The UKONS tool is evidence based and has been piloted and evaluated positively. It can be used by almost all, regardless of skill level or experience, and identifies patients at risk and advises action according to the level of risk.
  16. Content Article
    CQUIN stands for Commissioning for Quality and Innovation. This is a system introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care. This means that a proportion of a Trusts income depends on achieving quality improvement and innovation goals, agreed between the Trust and its commissioners. The sum attached to the CQUINs is variable each year based on a percentage of the contract value and depends on achieving quality improvement and goals.
  17. Content Article
    In this presentation on improving patient safety and reducing alarm fatigue, the panellists discuss the right and wrong way to use continuous surveillance monitoring. 
  18. Content Article
    According to the National Institutes of Health (January 2019), more than 130 people in the United States die after overdosing on opioids every day. Among these deaths are patients in the hospital setting, recovering from surgical procedures or undergoing sedation, who are often prescribed opioids such as morphine and oxycodone to manage pain – a necessity for healthy and comfortable recovery. But at certain doses, these drugs can also cause respiratory failure, and, because each patient is different, there is no one dose that is 'right' or 'wrong'. Hospitals must take action to ensure their staff are aware of these risks, and put protocols in place to prevent patient deaths. The authors of this US article, published by Medium, offer recommendations for improving patient safety in this area.
  19. Content Article
    In this article published in the British Columbia Medical Journal, Drs Richard Merchant and Matt Kurrek encourage the use of capnographic monitoring to improve the safety of patients undergoing procedural sedation.
  20. 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.
  21. Content Article
    The Young Epilepsy app is a free information and support tool designed primarily for young people with epilepsy, their parents and carers. The app includes a seizure video function, symptom log and diary to help keep track of seizures and aid diagnosis. It also features key emergency and contact details, an information library tailored for either adults or young people, and provides data in both email and chart format that can be easily shared with a school, carer or medical professional.
  22. Content Article
    Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring.
  23. Content Article
    This was one of Q Exhange's 2018 winning ideas. Testing the use of a tool to support domiciliary care staff in recognising the softer signs of deterioration. Improving response and communication to colleagues/health professionals (incorporating SBAR). The aim of this work is to reduce avoidable harm, enhance clinical outcomes and improve the experience of deteriorating individuals in the community.To achieve this, focus will be placed on improving recognition (softer signs and NEWS where appropriate), response and communication by domiciliary carers. 
  24. 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 ?
  25. Content Article
    The Yellow Card Scheme helps 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. On the Yellow Card Scheme website you can report a suspected incident or problem. 
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