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Found 140 results
  1. News Article
    The authors of a new study in Australia, published in the Emergency Medicine Journal, have said moving emergency care patients to other hospital departments by wheelchair or trolley is prone to a high rate of mishaps, with nearly 40% leading to incidents. The study, which took place at Austin Hospital, a teaching hospital in the Melbourne suburb of Heidelberg, also found endotracheal tubes, ventilator hoses, and arterial lines were also associated with high mishap rates. “Risk events are common and some result in harm. Risk factors include a high equipment number, transport to a ward and some abnormal vital signs. As many risk events are likely preventable, our identified predisposing factors may inform preventative strategies that may benefit other emergency departments.” The authors have said. Read full story. Source: Nursing Times, 24 August 2021
  2. News Article
    BBC News Research has revealed disabled and vulnerable adults in England will face a steep rise in the amount they have to pay towards their care, with Directors of council services blaming years of government funding cuts. One woman, Saskia Granville earlier this year was shocked when she found her care charges had increased from £92 to £515 per month. A sum of almost £1,500 was also taken out of Saskia's bank account as a backdated payment, in March, leaving her in debt. Her mother, Bobbie, says: "Without my intervention, she wouldn't have had any food that week. She wouldn't have been able to pay her gas, electricity or water bills." Read full story. Source: BBC News, 24 August 2021
  3. News Article
    Midwives at Suffolk Hospital have spoken out in a whistleblowing letter describing problems in their department as ‘demoralising and heartbreaking’. In the letter, written by midwives who declined to give their names "for fear of retribution", describe constant staff shortages, a culture of blame and fear, a high pressure environment and substandard care, saying " We entered midwifery to be able to give women centred, holistic care. Instead it feels like we are being overwhelmed by the unmanageable and relentless workload, and as a result are giving substandard care which is demoralising and heartbreaking. We are all feeling like we are now desperate for change. This change is beyond what we can achieve ourselves so we urge you to please help us to generate it. It should not be accepted or tolerated for us to be forced into giving unsafe care entirely due to unsafe staffing". In response, Karen Newbury, head of midwifery at the trust, said: “We are working exceptionally hard to recruit additional midwives and we are very grateful for the flexibility and dedication of our staff in ensuring that we provide a safe and caring service – this was recognised by our Care Quality Commission inspection in April which found we managed safety well. We have recently completed recruitment so there will be at least two senior midwives on every shift to provide flexible and experienced support to our maternity teams, and we are working with colleagues regionally to recruit staff both locally and internationally as well as running a full student training programme.” Read full story. Source: Suffolk News, 20 August 2021
  4. News Article
    Almost 100 members of the army have been brought in to help four ambulance trusts amid staff shortages in the South Central, South West, North East and East areas of England, with Unison saying it was a sign "things were not right". Vicky Court, assistant chief operating officer at North East Ambulance Services has said "It will ensure everyone continues to get the care they need by freeing up paramedics to be more available to attend potentially life-threatening incidents." Read full story. Source: BBC News, 21 August 2021
  5. Content Article
    This document by the National Institute for Clinical Excellence sets out the principles for best practice in clinical audit and includes; preparing for audit, selecting criteria, measuring level of performance, making improvements and sustaining improvement.
  6. Content Article
    This patient-centred report from the Regulatory Horizons Council discusses a route to more effective safety assurance through mechanisms that consider the whole product lifecycle, how adverse events are detected or a long time after use of the device and how to trace and recall patients when needed. In addition, this report also considers a number of ways in which use of data and technology can be smarter and to join up digital systems.
  7. News Article
    Ashford and St Peter’s Hospitals Foundation Trust, has apologised after nearly 1,000 patients faced delays due to a breakdown of referral systems. It was found 175 of these patients were considered urgent cases by their GPs and are now being reviewed for clinical harm. When the error was discovered, the patients were added to the referral tacker by 9 July, however until that point, they had not been on any patient waiting list, nor were they visible to either operational management or clinical teams. Trust chief executive Suzanne Rankin said in a statement: “We are very sorry for any inconvenience these delays may have caused patients and we contacted all concerned and issued appointments where necessary.” Read full story (paywalled). Source: HSJ, 19 August 2021
  8. News Article
    According to recent reports, the number of patients on waiting lists for non-urgent hospital treatment in Wales has again hit record levels. Data has revealed there were 624,909 people waiting in June, and those waiting the longest, more than nine months, rose again to 233,210. A Welsh government spokesperson said: "Waiting times for treatment continue to grow. However, it is encouraging to see progress being made with the number of patients waiting over 52 weeks falling for the third month in a row. We also saw the largest number of specialist consultations completed and treatments started in any month since the start of the pandemic." A&E time performance has been at its worst on record, with 94,176 attendances to emergency units over the month. Health spokesman Russell George said: "To record the worst ever A&E waiting times and the longest NHS treatment waiting list in the same month shows a complete lack of leadership." Read full story. Source: BBC News, 19 August 2021 Related Reading Patient Safety Learning blog: Tackling the care and treatment backlog safely (19 August 2021)
  9. Content Article
    Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. This article considers the results of a review that compared knee replacement with use of a tourniquet versus without use of a tourniquet and non‐randomised studies with more than 1000 participants. It highlights the risks of complications such as blood clots and infections associated with this, and indicates that changing surgical practice to avoid using tourniquets could avoid nearly 2,000 serious complications in the UK each year.
  10. News Article
    According to public health reports, there has been a sharp rise in drug overdoses, particularly heroin, over the past 10-14 days with the synthetic opioid isotonitazene implicated in some cases. In several areas of the country including five London boroughs, Hampshire, Essex, West Sussex, Dorset and Thames Valley, there has been 46 poisonings, resulting in 16 deaths, although currently, investigations are still ongoing. In a National Patient Safety alert issued on 18 August 2021, Public Health England (PHE) have instructed all NHS organisations to ensure staff are made aware of the risk of severe toxicity resulting from the synthetic opioid, and that all organisations that treat emergency cases should ensure staff are able to treat suspected cases “using naloxone and appropriate supportive care”. Roz Gittins, director of pharmacy at the charity Humankind, said "People also need to know where they can get hold of naloxone, as well as being reminded to carry it with them and to let people know where they keep it. If advice and support is required then the local substance misuse service should be contacted for specialist support. We hope that the current consultation to widen naloxone provision will be successful and that improved funding will lead to naloxone being distributed more widely to help reduce the risk of accidental opioid overdoses." Read full story. Source: The Pharmaceutical Journal, 18 August 2021
  11. Content Article
    This article discusses the prevalence and cost of hospital-acquired conditions (HACs) and patient safety events (PSIs) associated with procedures that may below value, and reports on the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. 
  12. Content Article
    This article examines the challenges in regulating patient safety during hospital discharges in England through the lens of liminality. In addition, this article proposes that by positioning the new role of Patient Safety Commissioner (PSC) as that of a ‘Representative of Order’, it could be a means by which this poorly regulated space could be navigated more successfully.
  13. Content Article
    This article describes what to be expect when coming off of antidepressants, withdrawal problems, the importance of safely tapering off medication and the need for extreme care and support for patients coming off prescribed antidepressants and benzodiazepines.
  14. Content Article
    The present research conducted a prospective observational study in 21 UK critical care units (CCU's) from 5-18 November 2012 with the aim to describe clinical pharmacist interventions. Data was collected via a web portal where specialist critical care pharmacists could make their reports, with each intervention classified as medication error, optimization or consult. A total of 20, 517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. Results demonstrated that both medication error resolution and pharmacist-led optimisation rates were substantial.
  15. News Article
    Providers fear 'fragmentation' of specialised services as NHS England begins delegating specialised services budgets to integrated care systems under reform plans. One leader of a specialist trust told HSJ: “There is a real risk of fragmentation. You can already see some of the conversations around various services around how people want to keep patients within their own ICS. There is the potential there for systems to buck the trend of centralising specialist services. Rather than bringing expertise and quality together, systems looking after budgets will look to set up their own specialist services.” Read full story (paywalled). Source: HSJ, 17 August 2021
  16. Content Article
    This article discusses what advocacy actually entails and what values it ought to embody. The paper considers whether advocates are necessary since not only can they be dangerously paternalistic, but the salutary values advocacy embodies are already part of good professional health care.
  17. Content Article
    This article by Dean K Wright describes the definition of 'advocate' and discusses how a doctor can best support their patient, particularly in regards to advocating for their patients rights and/or needs and in cases of child abuse and barriers to effective patient care.
  18. News Article
    According to reports, Barts Health Trust and most other providers in the north east London health system may run out of blood tube collection products by the end of August. Though, according to notes seen by HSJ, a “mitigation plan with demand management in place this may extend into September”. After warning colleagues in north east London that the shortage of blood collection tubes made by Becton Dickinson affects “all NEL areas” except acute trust Barking, Havering and Redbridge University Hospitals Trust, Diane Jones, chief nurse of the NEL integrated care system has said “NHSE are looking at mitigations, but nothing confirmed as yet, and [they] may take a few weeks to come on stream. The mitigation may get us up to 50 per cent of usual supply in the short term.” Read full story (paywalled). Source: HSJ, 13 August 2021
  19. News Article
    A hospital in Yorkshire has suspended all routine inpatient surgeries amid overcrowding in A&E caused by a lack of beds. Staff at the Mid Yorkshire Hospitals NHS Trust were told in an email that this had been a "critical issue for too long." “It is with regret that this decision has had to be made given that it will result in less patients receiving surgical treatment, slowing down our progress on reducing waiting times. However, the extreme pressure on beds has to be reduced and quickly. The trust consistently has between 25 and 50 patients waiting for a bed at any one time at Pinderfields emergency department, causing serious overcrowding and long delays [and] contributing to an unacceptable patient and staff experience.” Martin Barkley, chief executive of the trust, told staff. Read full story. Source: The Independent, 14 August 2021
  20. News Article
    New figures show a record number of 5.45 million people are waiting for NHS hospital treatment in England, with many more joining the waiting list who also need treatment, and those who came back to the NHS for healthcare having not done so during the worst periods of the pandemic. Sajid Javid, the Health Secretary has said, "We estimate there's probably some seven million people that ordinarily would have come forward to the NHS that stayed away, understandably, during the height of the pandemic. We want those people to come back. I don't know how many will come back but, even if half of them came to the NHS - and can I just stress I really want people that need to be seen by the NHS to know the NHS is there for them and they should come forward - but as they do I think waiting lists will rise because there will be a huge increase in demand." Read full story. Source: BBC News, 12 August 2021
  21. Content Article
    This guide, published by WHO, consolidates COVID-19 guidance for human resources for health managers and policy-makers to design, manage and preserve the workforce necessary to manage the COVID-19 pandemic and maintain essential health services. The guide identifies recommendations at individual, management, organisational and system levels.
  22. Content Article
    This article by Robin Aldwinckle discusses the case study of a 61-year-old male patient with severe knee osteoarthritis and hypertension who was admitted for surgery under subarachnoid regional anesthesia. However at the end of the procedure, the patient remained unresponsive and was subsequently diagnosed with Local Anesthetic Systemic Toxicity (LAST). Whilst the patient recovered, this case highlights a lack of communication between the operating room team members concerning the safe dosing of local anesthetics and that the correct diagnosis and treatment of LAST in the operating room is critically important.
  23. Content Article
    This research article focuses on the patient safety aspects of handling and recognising allergic reactions and severe perioperative anaphylaxis, and discusses the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.
  24. Content Article
    This article on sex and gender differences discusses the definitions, general and perioperative implications and how acknowledging differences between men and women relevant to anesthesia is of paramount importance to ensuring perioperative patient safety.
  25. Content Article
    This article describes the case studies of a 65-year-old woman with a history of acute myeloid lymphoma called her oncology physician's office with symptoms of chemotherapy-induced nausea and a 66-year-old woman was prescribed estradiol vaginal tablets for post-menopausal symptoms. Cynthia Li and Katrina Marquez discuss how both patient cases resulted from human error by pharmacy staff and how although most medication errors can be directly attributed to human error, human error is often a result of poor system design and recommend 'The 8 R's' approach to reduce the risk for errors includes development of safeguards at every level of the medication use process.
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