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Found 272 results
  1. Content Article
    This is the first study, published in Age and Ageing, demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium.
  2. Content Article
    This Healthcare Safety Investigation Branch (HSIB) report sets out a case where a medication error with warfarin contributed to the death of a 79-year-old man. The patient had suffered a fall at home and had been admitted to hospital. An error on his chart whilst he was on the ward led to him receiving four or five doses of warfarin, which he did not normally take, before the error was spotted by a ward-based clinical pharmacist. The patient developed internal bleeding and deteriorated (due to several health reasons) and died 21 days after his first admission. Research published this year suggests that medication errors may directly cause around 712 deaths per year and indirectly contribute to 1,708. The report highlights the growing ageing population and that pharmaceutical care of older people can be complex. They are often taking multiple medications and are at the greatest risk of harm due to medicine-related errors.
  3. Content Article
    The COGER study is collecting data to gain insight into the course of functional and medical recovery in older people affected by COVID-19 participating in rehabilitation across Europe.
  4. Content Article
    The objective of this study was to to report the frequency of adverse events (AEs) that occurred during the months when SARS-CoV-2 spreading rate was at its highest in the Italian nursing homes, and to identify which conditions and attributes were most associated with the occurrence of AEs. Authors note that future recommendations for the management and care of residents in nursing homes during the COVID-19 pandemic should include specific statements for the most vulnerable populations, such as people with dementia. This research paper can be viewed in full via the link below to the Frontiers in Psychiatry website.
  5. Content Article
    A fundamental shift is underway in care provision for older populations, with long-term care (LTC) increasingly taking on care provision that was traditionally delivered in hospitals. As OECD populations are rapidly aging, there has been increasing demand on the LTC sector to provide care for more, and older people, with complex conditions and heightened needs for expert care. Currently, 58% of adults aged 65 or over report living with two or more chronic diseases, with this figure rising over 70% in many OECD countries. Simultaneously, trends in LTC focus on substitution of care settings from nursing homes and residential care towards home care and supporting older persons to live on their own or with family as long as possible. The total cost of avoidable admissions to hospitals from LTC facilities in 2016 was almost USD 18 Billion, equivalent to 2.5% of all spending on hospital inpatient care or 4.4% of all spending on LTC. Research shows that over half of the harm that occurs in LTC is preventable, and over 40% of admissions to hospitals from LTC are avoidable. The root causes of these events can be addressed through improved prevention and safety practices and workforce development—including skill-mix and education. Targeted investments in a number of key areas can have a significant impact by mitigating the main cost drivers of adverse events in LTC.
  6. Content Article
    The OSIRIS programme is a major project of research, to understand and improve the shared decision making process for patients at high risk of medical complications as they contemplate major surgery. Led by Barts Health NHS Trust & Queen Mary University London and funded by the National Institute for Health Research (NIHR), research will be conducted with patients, doctors and carers to understand the surgical decision making process. The OSIRIS team aim to understand the values and beliefs about long-term outcomes amongst high-risk patients contemplating major surgery, how these differ from doctors’ opinions, how these affect decisions about surgical treatments, and whether patients’ opinions change once they experience surgery. They will co-design with patients and doctors, a decision support intervention, to provide an accurate and individualised forecast of the risks and benefits of surgery for each high-risk patient. You can find out more about the research methodology and the aims of the project through the link below. 
  7. Content Article
    Despite the increasing policy focus on integrated dementia care in the UK, this paper published in Health and Social Care in the Community, argues that little is known about the opportunities and challenges encountered by practitioners charged with implementing these policies on the ground.
  8. Content Article
    According to experts, older adults with or without pre-existing chronic conditions are at higher risk of COVID-19 infection and are also more likely to have severe cases requiring intubation, ventilator support, and intensive care. In fact, the CDC reports that about 8 of 10 COVID-19 deaths in the U.S. have been adults over the age of 65 years, with the majority over 85 years of age. The risk of contracting and dying from COVID-19 is an even greater problem in the almost 16,000 U.S. nursing homes, where there are concentrated numbers of older adults with chronic disease and frailty. This PSNet Patient Safety Primer looks at the patient safety problems for older adults.
  9. Content Article
    Frailty is increasingly recognised as a critically important policy and quality of care issue in healthcare systems. There is clear evidence that frail older people are at increased risk of acute illness. These heightened risks mean that frailty is associated with high mortality and high healthcare utilisation. It is a key consideration in clinical decision-making. However, frailty is a contested concept, both in definition and measurement terms. Identification of frailty is complex and issues of over-diagnosis and over-treatment are increasingly garnering attention.
  10. Content Article
    ADASS, is a charity that provides a national voice and leadership for adult social care. In 2019, they published a report, Sort out social care, for all, once and for all, setting out what they believe needs to be done by the Government to tackle the crisis. The report called for: Short-term funding, including continuation of the Better Care Fund and Improved Better Care Fund, to prevent the further breakdown of essential care and support over the course of the next financial year. Long-term funding and reform following, to enable us to build care and support for the millions who need it and create a social care system that is truly fit for the 21st century. A long-term plan for adult social care which means a support system in place that links with other public services including the NHS and supports resilient individuals, families and communities. 
  11. Content Article
    Due to the high morbidity and disability level among diabetes patients in nursing homes, the conditions for caregivers are exceedingly complex and challenging. The patient safety culture in nursing homes should be evaluated in order to improve patient safety and the quality of care. Thus, the aim of this study was to examine the perceptions of patient safety culture of nursing personnel in nursing homes, and its associations with the participants’ (i) profession, (ii) education, (iii) specific knowledge related to their own residents with diabetes, and (iv) familiarity with clinical diabetes guidelines for older people.
  12. Content Article
    In recent years, there has been an increasing focus on the role of safety culture in preventing incidents such as medication errors and falls. However, research and developments in safety culture has predominantly taken place in hospital settings, with relatively less attention given to establishing a safety culture in care homes. Despite safety culture being accepted as an important quality indicator across all health and social care settings, the understanding of culture within social care settings remains far less developed than within hospitals. It is therefore important that the existing evidence base is gathered and reviewed in order to understand safety culture in care homes.
  13. Content Article
    HomeLink Healthcare (HLHC) has been providing clinical care in the home with Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUHT) since January 2019, to release in-patient bed capacity and improve patient choice. The two organisations have co-created the service, NNUH at Home, creating additional capacity and promoting improvements in patient flow from hospital to home. A key feature of NNUH at Home is that it compliments and integrates with existing services, rather than replicating those already in place.
  14. Content Article
    This film features frontline staff from Salford Royal NHS Foundation Trust explaining how they are using technology to improve the quality of care they provide their patients. The team talk about an electronic assessment tool for delirium which has increased screening of people aged 65 years and over from 800 to more than 5,600 in 12 months. They also explain how the tool has helped them increase the number of identified cases per year and reduce the length of stay for these patients. They also talk about the Global Digital Exemplar 'blueprint' they have created of this project, which is now available for other NHS organisations to use as a guide for their own local implementation of similar projects. The GDE blueprints can be found on the FutureNHS platform. To register, email: gdeblueprints@nhsx.nhs.uk
  15. Content Article
    An extensive governance review of the events leading to the closure of Tawel Fan ward in December 2013 and a review of the current governance arrangements in older people’s mental health in Betsi Cadwaldr University Health Board.
  16. Content Article
    Harold Fredrick Shipman was convicted at Preston Crown Court on 31 January 2000 of the murder of 15 of his patients while he was a General Practitioner at Market Street, Hyde, near Manchester and of one count of forging a will. He was sentenced to life imprisonment. On 1 February 2000, the Secretary of State for Health announced that an independent private inquiry would take place to establish what changes to current systems should be made in order to safeguard patients in the future. The Inquiry's First Report was published on 19 July 2002 and its Final Report on 27 January 2005.
  17. Content Article
    Reducing emergency admissions from care homes has the potential to reduce pressure on hospitals. This is a significant national policy focus, as demonstrated by a strong commitment to improve support in care homes in the NHS Long Term Plan. 
  18. Content Article
    In this briefing, the Improvement Analytics Unit (a partnership between the Health Foundation and NHS England) identifies some early signals of changes in hospital use by vanguard care home residents in Wakefield, in order to inform local learning and improvement.
  19. Content Article
    Adverse events and poor health outcomes are continuing challenges for nursing home residents and staff. Research has shown that many resident harms are avoidable and may be caused by situations in which residents do not receive needed care, often called omissions of care. Omissions of care research in nursing home settings is limited and definitions of omissions of care vary. Therefore, the US Agency of Healthcare Research and Quality (AHRQ) has developed a definition of omissions of care for nursing homes intended to be meaningful to stakeholders, including residents and caregivers, and actionable for research or improving quality of care. They developed the definition through a literature review and feedback from subject matter experts and stakeholders in the US. To develop and describe the definition, project staff produced an environmental scan and final report, including resources to help nursing homes operationalise and apply the definition of omissions of care.
  20. Content Article
    The RCNi (the publishing company of the Royal College of Nursing) have brought together a selection of their most popular articles on the topic of sepsis from across their journals to inform your practice. Sepsis remains a significant cause of death – it is estimated that 44,000 people die from ‘the silent killer’ every year. RCNi has a wide range of resources available to help nurses improve diagnosis and early management of the condition.
  21. Content Article
    A thought-provoking blog about what it's like nursing in the emergency department (ED) when there are no beds. 
  22. Content Article
    This blog has been written by a healthcare worker and demonstrates the reality of what it is like caring for patients and families while being chronically low on staff. They describe the impact this has on staff morale and the impact it has on patients, patients family members and the relationship between staff and patients.
  23. Content Article
    An insightful blog from a nurse on the frontline. The author of this blog has requested to stay anonymous.
  24. Content Article
    Patient Safety Learning speaks to sepsis survivor, Dave Carson, and his wife, Margaret Carson, who tell us how things have improved and what more still needs to be done for sepsis.
  25. Content Article
    Sepsis is the immune system’s overreaction to an infection. Normally, our immune system helps fight infections – but sometimes it attacks our body’s own organs and tissues. We do not yet know why the body reacts this way, which is what makes sepsis so dangerous; if Sepsis isn’t treated immediately, it can result in organ failure and death. Yet with early diagnosis, it can be treated with antibiotics.
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