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Found 137 results
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. Content Article
    In this video, Leah Coufal’s mother, Lenore Alexander, recounts the tragic story of her 12-year-old daughter’s preventable death in hospital in December 2002. Leah died from opioid-induced respiratory depression due to a lack of continuous postoperative monitoring which could have saved her life. Lenore now campaigns for the legal requirement to monitor patients on opioids after surgery.
  8. Content Article
    This report provides an overview of the findings of Ireland's Health Information and Quality Authority (HIQA)’s monitoring programme against the national standards in emergency departments in 2022.  Throughout 2022, HIQA commenced a new monitoring programme of inspections in healthcare services against the National Standards for Safer Better Healthcare. As part of the initial phase, HIQA’s core assessment in emergency departments focused on key standards relating to governance, leadership and management, workforce, person-centred care and safe and effective care. The report highlights, HIQA has identified key areas for both immediate and longer-term attention to address safety issues in our emergency departments. 
  9. Content Article
    This article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
  10. Content Article
    This study in the Annals of Surgery aimed to characterise errors, events and distractions in the operating theatre, and measure the technical skills of surgeons in minimally invasive surgery practice. The authors of the study implemented the use of an operating room (OR) Black Box, a multiport data capture system that identifies intraoperative errors, events and distractions. The study found that the OR Black Box identified frequent intraoperative errors and events, variation in surgeons’ technical skills and a high number of environmental distractions during elective laparoscopic operations.
  11. Content Article
    Vision-based patient monitoring systems (VBPMS) are assistive tools that enable staff to enhance and support patient safety in inpatient services by delivering non-contact measurement of physiological parameters such as pulse and breathing rate, some estimate of patient location, activity or behaviour data and some form of contextual video information (which may be blurred) either in real-time or through subsequent reviews. In some cases, a VBPMS can be classified as a medical device regulated by the Medicines and Healthcare products Regulatory Agency and have specific indications for use. Providers adopting the technology need to ensure users are appropriately trained.
  12. Content Article
    This blog by Dr Anna Bayes from Altera Digital Health looks at the benefits of closed-loop medication administration (CLMA) in preventing avoidable medication errors. CLMA provides an extra validation at the point of drug administration by using barcode technology to positively identify the patient and validate their prescribed medications against the physical medication product (for example, pills, infusions or creams) at the point of care. Anna also considers CLMA's role in advancing digital maturity.
  13. News Article
    Norfolk Community Health and Care it is using a remote monitoring service from Inhealthcare which allows patients to monitor their vital signs at home and relay readings via a choice of communication channels to clinicians who monitor trends and intervene if readings provide any cause for concern. Analysis of the six months before and after introduction showed a significant reduction in hospital bed days, A&E attendances, GP visits and out-of-hours appointments. Lead heart failure nurse at the trust, Rhona Macpherson, spoke to Digital Health News about the impact of the services on patients and nurses. For Macpherson, the service has helped promote self-management. “We give each of the patients a set of scales, blood pressure monitor and pulse oximeter and we get them to do their observations,” she said. “So we’re promoting self-management and looking at things but also it means that we can get accurate information on what’s happening with their observations. “We then set parameters to alert if they go outside of the parameters, and it just means we can intervene much more quickly than we would do, and we can see what’s going on between our visits as well as what’s happening when we’re actually there.” The service has transformed working practices for nurses, increasing efficiency and saving valuable time. Macpherson said: “We’re using the technology to try and make ourselves a little bit more efficient, so it’s saving on the travel time and face to face visits. “We can do a lot more with telephone. We’ve got the option of using video, but telephone is actually quite useful. So it’s less face to face visits, less travel and also, we’re trying to empower the patients to do their own observations and monitor themselves, rather than us just doing it for them.”
  14. Content Article
    Near misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED). This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED. It was published in the Journal of Patient Safety. Authors conclude that near-miss events are relatively common (22.7% of their sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.
  15. Content Article
    Risk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway. This thematic review draws on findings from the Healthcare Safety Investigation Branch's (HSIB's) maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’). It examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included. The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.
  16. Content Article
    Remote, at-home patient monitoring was widely used during the Covid-19 pandemic due to lack of hospital beds. This article in JAMA Network looks at the benefits of remote monitoring and how it can be used safely. Studies have shown that the use of remote telemonitoring reduced length of hospitalisation for Covid patients requiring oxygen, and the number of patient visits to emergency departments. The authors look at how the combined use of telehealth, home health and remote monitoring could bring hospital-level–monitoring services to patients in their home, and what barriers need to be overcome to achieve this.
  17. Content Article
    This investigation by the Healthcare Commission examined the cases of ten women who died during pregnancy or within 42 days of delivery at Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005. This number of maternal deaths was significantly higher statistically when compared with other trusts that serve similar populations.
  18. Content Article
    Annie Hunningher highlights the difficulties in measuring an organisation's safety culture and the lack of validated measurement tools available.
  19. Content Article
    'Virtual wards' have existed for a number of years, but Covid-19 has led to further research and pilot schemes exploring their use. How have they been used during the pandemic and what does the future hold? This explainer by Holly Walton and Naomi Fulop provides some answers.
  20. Content Article
    This 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.
  21. Content Article
    This 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.
  22. Content Article
    This article details the case and findings of an investigation by the Parliamentary and Health Service Ombudsman (PHSO) into the death of Stephen Durkin. Stephen died after suffering organ failure from sepsis, while under the care of Wye Valley NHS Trust. His wife, Michelle Durkin, subsequently made a complaint that delays in the diagnosis and treatment of sepsis led to her husband’s death.
  23. Content Article
    In 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.
  24. Content Article
    This 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'.
  25. Content Article
    In 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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