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Found 272 results
  1. Content Article
    Medication errors are a common issue within the care home sector, impacting on the health and wellbeing of residents as well as creating challenges for care home staff and managers. This report addresses the issue of medication safety in care homes in England. Through intense engagement with a representative sample of care homes and stakeholders involving an electronic survey, workshops and conversations, Patient Safety Collaboratives have sought to understand the reasons for medication errors and how these could be avoided in the future.
  2. Content Article
    Medication safety has long been a major issue in long-term social care due to the number of medications taken by many older people. This editorial in BMJ Quality & Safety looks at why managing medications in care homes is so complex and highlights potential interventions to improve medication safety in long-term care settings.
  3. Content Article
    Issues with medication management and errors in medication administration are major threats to patient safety. This article for the US Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network takes a look at the AHRQ's current areas of focus for medication safety. The authors look at evidence-based solutions to improve medication safety in three areas: High-risk medication use and polypharmacy in older adults Reducing opioid overprescribing, increasing naloxone access and use and other interventions for opioid medication safety Nursing-sensitive medication safety The article also explores future research directions in medication safety and highlights that these will advance patient safety overall.
  4. Content Article
    Adverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study from St Clair et al. used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs.
  5. Content Article
    Fracture liaison services (FLSs) check if people who have recently broken a bone after falling from a standing height or less (a fragility fracture) might also have osteoporosis – a disease that weakens bones. They then advise on treatments to reduce the risk of another fracture, helping to improve patient outcomes. The Royal College of Physicians (RCP) estimates that at least 90,000 patients in England and Wales who should have anti-osteoporosis therapy are not receiving it. This guide by the RCP's Fracture Liaison Service Database (FLS-DB) aims to help patients and their families and carers understand what to expect following a fragility fracture. It outlines three key findings and the actions that individuals can take to ensure they receive the care and treatment they need from health services.
  6. Content Article
    The National Audit of Inpatient Falls (NAIF) has published its latest report into the care given to patients who fell while they were in hospital and sustained a hip fracture. Based on data from 1,394 patients in 2021, the report presents information on post-fall management and tracks performance against National Institute for Health and Care Excellence (NICE) Quality Standard 86, which includes checking the patient for injury before moving, using safe lifting equipment and prompt medical assessment after the fall.
  7. Content Article
    Safety conversations are an important step in building a proactive patient safety culture. They’re a respectful discussion about safety between two or more people involved in organising, delivering, and seeking or receiving care. This collection of tools and resources, from quick tip sheets to comprehensive reports and frameworks, aims to help healthcare professionals to have effective safety conversations and support safer care of older adults.
  8. Content Article
    We need urgent radical solutions for the crisis in social care, to prevent the collapse not just of the NHS but of the entire UK economy. Social care is facing extreme difficulties with funding and workforce shortages. Staff are poorly paid, and 10% of posts are vacant. The situation is about to get worse: 19% of the UK population is over 65. In Northern Ireland the number of people over 65 more than doubled between the censuses in 2011 and 2021. Projections show that each person will need an average of 10 years of social care. We must, then, focus on prevention. The need for social care is not inevitable. Ageing does not have to be associated with a loss of fitness. Exercise and strength training can restore muscle and balance and are proved to reduce the impact of falls and fractures. 
  9. Content Article
    This article tells the story of Mr K, who died following a misdiagnosis of tension pneumothorax. Mr K was 81 and had a history of chronic obstructive pulmonary disease (COPD) and bullous emphysema. He had been diagnosed with a bulla, a large air pocket, in his right lung. The medical team treating Mr K after his admission to hospital with shortness of breath failed to review his previous x-ray and medical notes, and did not involve the respiratory team in his treatment. This led to his misdiagnosis, after which he was fitted with an unnecessary chest drain. The drain collapsed the bulla and ruptured a blood vessel leading to progressive bleeding. The medical team did not recognise their error or Mr K's bleeding and he died two days following the insertion of the drain. At his inquest, the Coroner found that the unnecessary chest drain led to Mr K's death, and that there was a missed opportunity to reassess the situation at a review the next day. They ordered that a prevention of future death report be made as the evidence heard at the inquest revealed a number of matters that gave rise to concern.
  10. Content Article
    Richard von Abendorff's elderly mother died an avoidable, painful death in hospital due to being inappropriately prescribed Nalaxone. In this article, Richard outlines the steps he has taken to try and ensure lessons are learned from his mother's experience. Eventually, in 2014 NHS England published a patient safety alert relating to inappropriate doses of naloxone in patients on long-term opioid treatment. A coroner’s palliative expert report identified issues contributing to Richard's mother's poor end of life care, noting that purely advisory palliative services in an acute hospital setting are ‘not fit for purpose’ to meet the needs of more complex dying patients. Richard expresses his frustration at an ongoing lack of interest and action related to substandard end of life care.
  11. Content Article
    These resource lists compiled by US insurance company MedPro Group, highlight a number of expert and evidence-based sources that can be used to increase awareness of safety issues, identify areas of risk and determine mitigation strategies. They cover a wide range of healthcare safety topics: Advanced practice providers Anaesthesia and surgery Artificial Intelligence Bed safety and entrapment in senior care Behavioural health Behavioural health in senior care Burnout in healthcare Culture of safety Cybersecurity Disclosure of unanticipated outcomes Disruptive behaviour Elder abuse Electronic Health Records Emergency medical Treatment and Labour Act Emergency preparedness and response Emergency preparedness and response in senior care organisations Ergonomics and safe patient handling Falls and fall risk in older adults Handoffs and care transitions Health equity and social determinants of health Health literacy and cultural competence Healthcare-associated infections Healthcare compliance HIPAA Human trafficking and trauma-informed care Infection prevention and control in ambulatory care settings Infection prevention and control in dentistry Infection prevention and control in senior care organisations Informed consent LGBT+-inclusive care Maternal morbidity and mortality Medical marijuana Medication safety during care transitions Obstetrics and gynaecology Opioid prescribing and pain management Patient engagement Pressure injuries in older adults Sepsis Social media in healthcare Staff shortages and workforce issues Suicide screening in primary care Telehealth/telemedicine Violence prevention in home healthcare Violence prevention in the Emergency Department Wrong-site procedures
  12. Content Article
    When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.
  13. Content Article
    The National Institute for Health and Care Excellence (NICE) is developing an update to the guideline on assessment and prevention of falls in older people and people 50 and over at higher risk. It has published the final scope for the update alongside consultation comments and responses, an equality impact assessment and the stakeholder list. The final guidance is expected to be published on 13 June 2024.
  14. Content Article
    A broken hip or ‘hip fracture’ is a serious injury, which each year in the UK leads to around 75,000 people needing hospital admission, surgery and anaesthesia, followed by weeks of rehabilitation in hospital and the community. The National Hip Fracture Database (NHFD) is an online platform that uses real-time data to drive Quality Improvement (QI) across all 163 hospitals that look after patients with hip fractures in England and Wales. This report highlights key research carried out using data from the NHFD in 2021, and makes a number of recommendations to improve treatment and outcomes for patients with hip fractures.
  15. Content Article
    These reports by the Pharmaceutical Society of Australia look at different aspects of medication safety. Medicine safety: Take care This report details the extent of harms in Australia as a result of medicine use. It highlights that 250,000 Australians are hospitalised each year, with another 400,000 presenting to emergency departments, as a result of medication errors, inappropriate use, misadventure and interactions. At least half of these incidents could have been prevented. Medicine safety: Aged care This report provides data about the real and current medication safety problems affecting older care residents across Australia. Medicine safety: Rural and remote care This report highlights the extreme challenges patients in rural and remote Australia have in accessing health care and the impact that this has on the safe and appropriate use of medicines. Medicine safety: Disability care This report focuses on the challenges that people with disability face in using medicines safely and effectively. The report found that people with disability face challenges at all stages of medicine use–prescribing, dispensing, administration and adherence and monitoring. Medicine safety forum: Informing Australia’s 10th National Health priority area This report presents a summary of views and experiences shared at a stakeholder workshop in December 2019.
  16. Event
    until
    The COVID-19 pandemic has put a spotlight on the rights and needs of older persons. While everyone has been affected, evidence shows that older people are among those most at risk of complications from the disease, with fatality rates for those over 80 years of age five times the global average. They are also at greater risk of poverty, discrimination and isolation. Older persons have been hit particularly hard by the virus itself but it has been the failure to protect their rights in the response that has led to unnecessary deaths, unmet health and care needs, increased isolation, discrimination and stigma. This webinar will: Recognise the impact of COVID-19 on the wellbeing and dignity of older persons across the Commonwealth. Raise awareness of ageism, stigma and discrimination against older people in the COVID-19 response and the need to foster intergenerational connections across the Commonwealth. Reflect on how The Commonwealth needs to adapt to ensure the rights of its citizens of all ages are respected. Register
  17. Content Article
    The goal of this virtual discussion is to explore practical solutions for keeping seniors safe. The ideas are drawn from real life experiences noting how COVID-19 impacted seniors, their loved ones as well as healthcare workers and leaders.  The focus of the discussion is on identifying safety risks together with practical solutions for seniors who live at home, in residences and long-term care facilities. Watch the webinar on demand and download the slides.
  18. Content Article
    The Centre for Ageing Community of Practice resource library brings together a catalogue of reports, studies and infographics on areas of interest to Community members and others interested in evidence around ageing better. From designing age-friendly homes to maintaining physical activity and supporting social connections, browse the library by theme to access a wide range of relevant resources.
  19. Content Article
    The Cornwall and Isles of Scilly Safeguarding Adults Review into The Morleigh Group has found elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated. The Morleigh Group operated seven homes in Cornwall and has since shut down. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  20. Content Article
    Elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  21. Content Article
    An open letter has been published in the Nursing Times from infection prevention and control experts, together with interested and concerned individuals and organisations, about the restrictions enforced in nursing, care and residential homes. Restrictions are being imposed in relation to COVID-19 across too many nursing, care and residential homes in the UK and beyond, in the name of infection prevention and control. A number of experts in this field, led by Jules Storr, independent global health consultant and former Infection Prevention Society (IPS) president, summarise in an open letter why infection prevention and control should be an enabler not a barrier to safe, compassionate human interaction in nursing, care and residential homes. By adding their voice their intention is to accelerate action to end this uncompassionate treatment of people in homes as well as for their families and other loved ones.
  22. Content Article
    Published by the Older People's Commissioner for Wales, Care Home Voices: A snapshot of life in care homes in Wales during Covid-19, gives a voice to people living and working in Welsh care homes and provides a snapshot of their experiences during the COVID-19 pandemic.  The responses from older people and their families and friends highlight just how difficult lockdown has been for many people. Many older people had not seen their family and friends at all for prolonged periods and had concerns about the impact that lockdown could be having on their wellbeing. 
  23. Content Article
    Loneliness and social networks may influence onset of Alzheimer's disease, but little is known about this relationship in people with Alzheimer's disease. This study, published in Geriatric Psychology, aimed to explore the relationship between loneliness and social networks (social measures) and cognitive and psychopathology decline in people with Alzheimer's disease. The authors concluded that maintaining or developing a close friendship network could be beneficial for cognition in people with Alzheimer's disease.
  24. Content Article
    The report, As if expendable: The UK Government's failure to protect older people in care homes during the COVID-19 pandemic, was published by Amnesty International in 2020. It argues that the UK government, national agencies, and local-level bodies have taken decisions and adopted policies during the COVID-19 pandemic that have directly violated the human rights of older residents of care homes in England – notably their right to life, their right to health, and their right to non-discrimination. The report states that decisions and policies have also impacted the rights of care home residents to private and family life, and may have violated their right not to be subjected to inhuman or degrading treatment.
  25. Content Article
    Older people and people with an intellectual disability who receive long-term care are considered particularly vulnerable to infection outbreaks, such as the current coronavirus pandemic. The combination of healthcare concerns and infection-related restrictions may result in specific challenges for long-term care staff serving these populations during infection outbreaks. This review from Embregts et al. aimed to: (1) provide insight about the potential impact of infection outbreaks on the psychological state of healthcare staff and (2) explore suggestions to support and protect their psychological well-being. They found that research into support for long-term care staff during an infection outbreak is scarce. Without conscious management, policy and research focus, the needs of this professional group may remain underexposed in current and future infection outbreaks. The content synthesis and reflection on it in this article provide starting points for new research and contribute to the preparation for future infection outbreaks.
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