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Found 51 results
  1. News Article
    The proportion of newborn babies receiving a timely health visitor check-in has fallen sharply, with one in five missing out in the most recent statistics available. Official data reveals that only 82.6% of babies received a new birth visit within their first fortnight in 2021-22, as is recommended, and in the fourth quarter of the year it dropped as low as 79.3%. This is the lowest proportion recorded in recent years in the annual dataset on health visitor service delivery metrics, published by the Office for Health Improvements and Disparities. According to the NHS website, a health visitor new birth visit is supposed to take place between 10 and 14 days after birth and is designed to offer advice on issues including safe sleeping, vaccinations, infant feeding, infant development, and adjusting to life as a parent. Kate Holmes, head of support and information at charity The Lullaby Trust, said: “Safer sleep saves babies’ lives and all families should be given advice on how to reduce the risk of sudden infant death syndrome for their baby. The new birth visit is a key opportunity for health visitors to talk to families about safer sleep and to provide them with information and support that takes their individual and family circumstances into account.” Read full story (paywalled) Source: HSJ, 7 November 2022
  2. News Article
    Brain complications, including stroke and psychosis, have been linked to COVID-19 in a study that raises concerns about the potentially extensive impact of the disease in some patients. The study, published in Lancet Psychiatry, is small and based on doctors’ observations, so cannot provide a clear overall picture about the rate of such complications. However, medical experts say the findings highlight the need to investigate the possible effects of COVID-19 in the brain and studies to explore potential treatments. “There have been growing reports of an association between COVID-19 infection and possible neurological or psychiatric complications, but until now these have typically been limited to studies of 10 patients or fewer,” said Benedict Michael, the lead author of the study, from the University of Liverpool. “Ours is the first nationwide study of neurological complications associated with Covid-19, but it is important to note that it is focused on cases that are severe enough to require hospitalisation.” Scientists said the findings were an important snapshot of potential complications, but should be treated with caution as it is not possible to draw any conclusions from the data about the prevalence of such complications. Read full story Source: The Guardian, 26 June 2020
  3. Content Article
    On 11 June 2019 an investigation into the death of Brooke Martin aged 19 started. Brooke was a patient at Isla House, Chadwick Lodge, Milton Keynes and was detained under the Mental Health Act. She had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder. Brooke was found hanging in her room and was taken to Milton Keynes University Hospital where she died on 11 June 2019.
  4. Content Article
    A strong focus on systems thinking and an encouragement to apply insights and expertise from human factors and ergonomics is paramount in how we plan, design and deliver healthcare safely. It’s central to the WHO Global Patient Safety Action Plan, the NHS Patient Safety Strategy, new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care and the National Patient Safety Syllabus.[1-3] It’s something Patient Safety Learning emphasise in our report A Blueprint for Action and is central to the organisational standards for patient safety that we’ve developed.[4] But how should we ‘do’ human factors? How do we apply the concepts, methodologies, tools and techniques in healthcare? What training do we need? How can patient safety managers embed human factors in all of their work, not just a reactive response to incidents of harm? These are some of the questions that patient safety managers have been asking and discussing in the recent Patient Safety Manager Network (PSMN) meetings. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance, providing information, peer support and safe space for discussion. You can find out more about the network here.
  5. Content Article
    This case story about placental abruption, published by NHS Resolution, highlights the importance of regular risk assessments throughout labour to help prevent harm to mother and baby. It provides learning points and considerations that can be applied across all maternity units.
  6. Content Article
    This article, published in Simulation and Gaming proposes a strategy for ensuing simulation training following the implementation of a thorough Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) training initiative. The strategies include observing Teams in the workplace to facilitate the construction of organisation-wide, follow-on simulation training.
  7. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the HSIB Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #DeterioratingPatient
  8. 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.
  9. Community Post
    Lets talks NEWS... Nurse and carer worry, I like to think that Critical Care outreach teams take this very seriously and that the 'worry' has a heavy influence in our management. Many of our patients may score 0, but warrant a trip to the ITU (AKI patients for instance). However, as part of our escalation policy it states that staff should alert the doctor and or the Outreach team when NEWS is 5 or 3 in one parameter. This causes the 'radar referral effect'. We often have a group of these patients on our list. Personally, I find them difficult to prioritise as they are often receiving frequent observations and have a plan. By concentrating on this group and make sure they have everything in place can take time, but... what about those not scoring in this threshold? Do they get pushed to the bottom of the list? Should nurses follow this protocol to safeguard themselves as well as the patient or are we not looking for sick patients in the right place? Don't get me wrong, the NEWS has been revolutionary in the way we deal with deterioration, but as a tool to prioritise this may not be the case. There are softer signs at play here....has anyone got any solutions to deal with the 'radar referals' Lots to discuss @Ron Daniels @Emma Richardson @LIz Staveacre @Danielle Haupt @Kirsty Wood
  10. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient
  11. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 not only in an acute setting but also in the community and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk Follow on Twitter @HCUK_Clare #deterioratingpatient hub members can receive a 20% discount. Email info@pslhub.org discount code.
  12. Event
    This Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the Covid-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. Attending this conference will enable you to: Network with colleagues who are working to improve Hospital at Night Practice Learn from developments as a results of Covid-19 Improve your skills in the recognition management and escalation of deteriorating patients at night Understand and evaluate different models for Hospital at Night Examine the role of task management solutions for Hospital at Night, including handover and eObservations Ensuring effective and safe staffing at night, including adequate breaks Examine Hospital at Night team roles, competence and improve team working Improving safety through the reduction of falls at night Supporting staff and reducing fatigue at night Develop the role of Clinical Practitioner and Advanced Nursing Practice at night Identify key strategies to change practice and ways of working in Hospital at Night Understand how hospitals can improve conditions for night workers and support Junior Doctors Improve the management of pain at night Work across whole systems to improve support for patients out of hours Self assess and reflect on your own practice Gain CPD accreditation points contributing to professional development and revalidation Evidence Register There are a limited number of free places for hub members. Email: info@pslhuborg if interested. Follow on Twitter @HCUK_Clare #hospitalatnight
  13. Content Article
    In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents.
  14. Content Article
    From 28 June 2022, courts and tribunals will have new powers to allow reporters and other members of the public to observe hearings remotely. The purpose of this practice guidance is to help judicial office holders understand and apply the new law.
  15. Content Article
    Investigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
  16. Content Article
    An investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life. Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information. Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.
  17. Content Article
    This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here
  18. Content Article
    On 23 April 2020 Jaqueline Lake commenced an investigation into the death of Eliot Harris aged 48. Eliot had schizophrenia and diabetes. Eliot had not been taking medication for several days and his condition deteriorated. He was admitted to Northgate under the Mental Health Act after assessment on 5 April. He was initially in seclusion then on the ward from 6 April, he spent a lot of time in his room and only ate cheese sandwiches. He only accepted medication in intramuscular form and on 9 April by depot injection. His physical observations were recorded as being normal, and a blood test on 7 April showed he did not have diabetes. His intake of food and fluid remained minimal but he was not put on a chart to monitor this. Staff last entered his room at 17:46 on 9 April. He was last seen conscious at 18:10 on 9 April. He was found unresponsive at 01:33 and declared dead at 02:00.  The investigation concluded at the end of the inquest on 8 August 2022. Medical cause of death: 1a) Unascertained Conclusion: Open – the evidence does not reveal the means by which Eliot Harris came by his death.
  19. Content Article
    Responding to abnormalities in patients’ vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study from Smith et al., in the journal Resuscitation, aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and the failure to respond promptly to patients’ abnormal physiology. The authors found that RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.
  20. Content Article
    This article from Delaveris et al. outlines one health system's experience implementing a bundle to reduce sepsis-related mortality and the observed connection between adherence to the bundle and improved sepsis care.
  21. Content Article
    Implementation of high reliability principles in healthcare delivery is recognized as an effective strategy for reducing harm to patients and healthcare workers. With the coronavirus disease 2019 (COVID-19) pandemic upon us, our emergency departments (EDs) are facing an unprecedented safety threat. How does a high reliability ED function during a pandemic, and what are the most important strategies for keeping ourselves and our patients safe? Thull-Freedman et al. discuss this in a commentary in the Canadian Journal of Emergency Medicine.
  22. Content Article
    A Pareto chart is a type of bar chart in which the factors that contribute to an overall effect are arranged in order from most frequent to least. This ordering helps identify the "vital few" — the factors that warrant the most attention. It also includes a line showing the cumulative % (so you can see easily for example that the top three causes account for 80% of incidents). According to the "Pareto Principle," in any group of things that contribute to a common effect, relatively few account for the majority of the effect.
  23. Content Article
    An honest account from a junior doctor on moving from paper to electronic observation charts and why user testing should be done before rolling it out in hospitals.
  24. 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.
  25. Content Article
    In this blog, Claire discusses the use of NEWS2 in coronavirus patients and the importance of recognising, tracking and alerting the appropriate team that your patient has an increasing oxygen demand to ensure that the risk of more people being exposed to the virus is minimal.
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