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Showing results for tags 'Policies / Protocols / Procedures'.
Found 110 results
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Content ArticleThe World Health Organization (WHO) is in the process of establishing a Roster of consultants in the area of patient safety with the main objective of identifying experts from all over the world in different patient safety areas who may support the implementation of the Global Patient Safety Action Plan (GPSAP) 2021-2030 at global, regional, country and institutional levels. The experts with the successful outcome of their application will be placed on the Roster and subsequently may be selected for consultancy assignments in the specified area of work, primarily across the seven strategic objectives of the GPSAP 2021-2030. More information can be found in the link below. Closing date for applicants: 3 April 2024.
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Content Article
Antibiotic underdosing is a widespread issue in the healthcare system. The use of modern infusion pumps to deliver intravenous (IV) medications has resulted in the practice of flushing IV lines being lost in some specialties. Failure to give full doses of IV antibiotics poses significant risks to individual patients as well as adding to the problem of antimicrobial resistance (AMR). In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT. A transcript is available below the video. -
Content ArticleIn this open letter to Steve Brine, Chair of the Health and Social Committee, The Association of Ambulance Chief Executives say they believe the “spirit” of national agreement on how to implement the Right Care, Right Person model is not being followed by police, raising “significant safety concerns”. It outlines key concerns, including the timescales for implementation, the consistency of application and failure by the police to attend when required.
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News Article
Trust CEOs accuse police of ‘high stakes game of chicken’
Patient Safety Learning posted a news article in News
Ambulance chiefs have warned that patients are coming to harm, paramedics are being assaulted and control room staff reporting a “high stakes game of chicken” with police during the implementation of a controversial new national care model. The Association of Ambulance Chief Executives say in a newly published letter they believe the “spirit” of national agreement on how to implement the Right Care, Right Person model is not being followed by police, raising “significant safety concerns”. The membership body set out multiple concerns about the rollout of the model, under which the police refuse to attend mental health calls unless there is a risk to life or of serious harm. In the letter to Commons health and social care committee chair Steve Brine, AACE chair Daren Mochrie says timescales for introducing it were often “set by the police rather than “agreed” following meaningful engagement with partners”, meaning demand was shifting before health systems had built capacity. They also flag a lack of NHS funding to meet the new asks. Mr Mochrie, also CEO of North West Ambulance Service Trust, described a “grey area” relating to what he called “concern for welfare” calls, which meet neither the police nor attendance services’ threshold for attendance. “To date this is the single biggest feedback theme we have heard from ambulance services, with some control room staff describing feeling like they’re in a ‘high-stakes game of chicken’ where the police have refused to attend and told the caller to hang up, redial 999 and ask for an ambulance,” he wrote. Read full story (paywalled) Source: HSJ, 20 February 2024 -
News ArticleThe head of the NHS has today announced the rollout of ‘Martha’s Rule’ in hospitals across England from April, enabling patients and families to seek an urgent review if their condition deteriorates. The patient safety initiative is set to be rolled out to at least 100 NHS sites and will give patients and their families round-the-clock access to a rapid review from an independent critical care team if they are worried about their or a loved one’s condition. This escalation process will be available 24/7 to patients, families and NHS staff, and will be advertised throughout hospitals, making it quickly and easily accessible. NHS chief Amanda Pritchard said the programme had the potential to “save many lives in the future” and thanked Martha’s family for their important campaigning and collaboration to help the NHS improve the care of patients experiencing acute deterioration. Thirteen-year-old Martha Mills died from sepsis at King’s College Hospital, London, in 2021, due to a failure to escalate her to intensive care and after her family’s concerns about her deteriorating condition were not responded to promptly. Extensive campaigning by her parents Merope and Paul, supported by the cross-party think tank Demos, has seen widespread support for a single system that allows patients or their families to trigger an urgent clinical review from a different team in the hospital if the patient’s condition is rapidly worsening and they feel they are not getting the care they need. Merope Mills and Paul Laity, Martha’s parents, said: “We are pleased that the implementation of Martha’s Rule will begin in April. We want it to be in place as quickly and as widely as possible, to prevent what happened to our daughter from happening to other patients in hospital. “We believe Martha’s Rule will save lives. In cases of deterioration, families and carers by the bedside can be aware of changes busy clinicians can’t; their knowledge should be recognised as a resource. We also look to Martha’s Rule to alter medical culture: to give patients a little more power, to encourage listening on the part of medical professionals, and to normalise the idea that even the grandest of doctors should welcome being challenged. We call on all NHS clinicians to back the initiative: we know that the large majority do listen, are open with patients and never complacent – but Martha’s doctors worked in a different culture, so some situations need to change. “Our daughter was quite something: fun and determined, with a vast appetite for life and so many plans and ambitions – we’ll never know what she would have achieved with all her talents. Hers was a preventable death, but Martha’s Rule will mean that she didn’t die completely in vain.” Read full story Source: NHS England, 21 February 2024
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Content ArticleThis is an independent review commissioned by NHS England, chaired by Siobhan Melia, Chief Executive, Sussex Community NHS Foundation Trust, to support the improvement of the culture within the ambulance service. The review considers the prevailing culture within ambulance trusts in England. It considers the core factors impacting cultural norms and offers actionable recommendations for improvement. Based on insights from key stakeholders, this review has identified six key recommendations to improve the culture in ambulance trusts.
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News Article
Hundreds of rheumatology patients wrongly prescribed drugs or misdiagnosed
Patient Safety Learning posted a news article in News
Hundreds of rheumatology patients have stopped receiving drugs they did not need or had their diagnosis changed after a damning review of the service found the standard of care was “well below” what would be considered acceptable. Jersey’s Health and Community services department has said it will be contacting some of the affected patients “over the coming weeks” and would also be seeking legal advice on “an appropriate approach to compensation”. The independent review by the Royal College of Physicians also noted there was “no evidence” of standard operating procedures for most aspects of routine rheumatological care and, in some cases, “no evidence of clinical examinations”. It also found that there had been incorrect diagnosis and wrongly prescribed drugs, describing the standard of care as “well below what the review team would consider acceptable” for a contemporary rheumatological service. The review was commissioned by HCS medical director Patrick Armstrong, following concerns raised by a junior doctor in January 2022. Read full story Source: Jersey Evening Post, 22 January 2024 -
News Article
David Fuller: NHS failures enabled killer to abuse bodies
Patient Safety Learning posted a news article in News
Mortuary abuser David Fuller was able to offend without being caught because of "serious failings" at the hospitals where he worked, an inquiry has found. Between 2007 and 2020, Fuller abused the bodies of at least 101 women and girls in Kent hospitals. Inquiry chair Sir Jonathan Michael said "there were missed opportunities to question Fuller's working practices". He added the abuse "had caused shock and horror across our country and beyond". The inquiry has made 17 recommendations to prevent "similar atrocities". Read full story Source: BBC News, 28 November 2023 -
Content ArticleThis is the phase 1 report by the independent inquiry into the issues raised by the David Fuller case. The inquiry has been established to investigate how David Fuller was able to carry out inappropriate and unlawful actions in the mortuary of Maidstone and Tunbridge Wells NHS Trust and why they went apparently unnoticed, for so long. A phase 2 report, looking at the broader national picture and the practices and procedures in place to protect the deceased in the NHS and other settings, is planned for publication at a later date.
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Content Article
Duty of Candour for Wales
Gethin posted an article in NHS Wales (Gig Cymru)
The Duty of Candour for Wales statutory guidance. -
Community Post
Better use of data for medication safety in hospitals
Kenny Fraser posted a topic in Medicine management
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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks- Posted
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Content ArticleThis report by Healthcare Inspectorate Wales (HIW) relates to vascular services provided by Betsi Cadwaladr University Health Board following the de-escalation of these services as a Service Requiring Significant Improvement (SRSI). The review outlines that while progress has been made against all nine recommendations made by the Royal College of Surgeons, the health board still has improvements to make.
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Content ArticleThese templates were developed by Liverpool Heart and Chest Hospital for use in After Action Review, SWARM and Rapid Review toolkit responses.
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Content ArticleFailure to be aware of and to follow clinical guidelines and protocols could constitute clinical negligence, but not in all cases, and much will depend on the facts of each case. John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses aspects of the law on clinical guidelines and other care management tools.
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News Article
Leak shows NHSE ‘sorry’ for endorsing service which ‘hurt patients’
Patient Safety Learning posted a news article in News
NHS England is ‘sorry’ for backing a mental healthcare model which it now admits has caused hurt to patients, according to a leaked draft policy document. The serenity integrated mentoring model was launched in 2013 in the Isle of Wight and Hampshire. It quickly became viewed by mental health trusts as an “innovative approach” to helping support frequent users of the emergency services. A core element of the scheme involves placing a local community police officer within the healthcare team charged with supporting those patients. In 2021, the pressure group StopSIM raised concerns about the model, which included a belief that police involvement was potentially coercive, criminalised mental health crises, and could result in withholding healthcare from people, which would breach human rights legislation. The group also argued the SIM programme had not been robustly and clinically evaluated. As a result, NHSE committed to co-producing policy guidance on SIM with StopSIM. The draft document states: “NHS England did not apply sufficient scrutiny to the decision [to endorse SIM] and involve the voice of lived experience sufficiently. This compromised the safety and quality of care for service users and has caused hurt to patients. For this, NHS England is sorry.” Read full story (paywalled) Source: HSJ, 19 May 2023 Further reading on the hub: The High Intensity Network (HIN) approach and SIM model for mental health care and 'high intensity users' – what are your views? -
News Article
NHS 'hamstrung by red tape' as it takes 50 steps to release patients
Patient Safety Learning posted a news article in News
Britain is hamstrung by red tape in the NHS and workers are blighted by regulation, Boris Johnson’s former cabinet secretary has said. Lord Sedwill, who was head of the civil service for two years, said that the UK was “failing to fulfil its great potential” because of excessive regulation. He made the comments in a foreword to a report by the Policy Exchange think-tank which also highlights examples of regulation “passing on significant costs” to customers. Examples in the report include NHS rules instructing hospital staff to go through 50 separate steps to discharge patients, “leading to severe delays”. Read full story (paywalled) Source: The Telegraph, 23 April 2023 -
Content ArticleThis systematic review in BMJ Open synthesised evidence on the impacts of insufficient sleep and fatigue on health and performance of physicians in independent practice, as well as on patient safety. The authors also assessed the effectiveness of interventions targeting insufficient sleep and fatigue. The authors found that fatigue and insufficient sleep may be associated with negative physician health outcomes, but concluded that current evidence is inadequate to inform practice recommendations.
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Content ArticleThis poster produced by researchers at Warwick Medical School summarises a qualitative research project that examined attitudes and behaviours related to patient safety culture at a single West Midlands Trust. The study's objective was to gain an understanding of staff’s views regarding the culture within the Trust and of their attitudes and behaviours when reviewing clinical incidents and mortality and morbidity. The poster was a winner at the HSJ Patient Safety Congress 2022 in the category 'A just culture for learning and change'. Read the full research paper.
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Content ArticleOn 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
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Content ArticleThis report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
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Content ArticleVision-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.
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Content ArticleRacism is unacceptable and it has no place in health and care. But we know that it exists and that the impact on staff can be devastating. All registered professionals have responsibility under the Nursing and Midwifery Council (NMC) Code to challenge discriminatory behaviour, creating an environment where people are treated as individuals and with dignity and respect. This resource is firmly rooted in our professional Code and it is designed to support nurses, midwives and nursing associates, providing advice on the action you can take if you witness or experience racism. It also supports those in leadership roles to be inclusive leaders. This document provides practical examples of how, as nursing and midwifery professionals, you can recognise, and challenge racial discrimination, harassment, and abuse. It also highlights other useful resources and training materials that will support you to care with confidence. This document is a resource for individuals at all levels. This resource does not replace existing NHS England policies and procedures for speaking up and managing racism. It is a resource to support best practice in line with organisational policies and procedures.
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Content ArticleThis document by the World Health Organization (WHO) outlines an easy to follow country approach to developing or adapting an infection prevention and control guideline. It gives guidance on five steps countries can take: Prepare for action Baseline assessment Develop/adapt and execute Evaluate impact Sustain over the long term
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Content ArticlePerioperative practitioners in the UK are universally concerned about the risk surgical smoke plume poses to their health. Yet less than a fifth are aware of any policy being in place to manage this risk within their organisation. The majority of hospitals have plume evacuation equipment in place, but it is only used in the minority of surgical procedures. Almost three-quarters of theatre staff have experienced symptoms associated with exposure to surgical smoke plume. But these symptoms are rarely reported and, when they are, no action is generally taken. These are the findings of a new report published by the Surgical Plume Alliance (SPA), a joint advocacy initiative between the Association for Perioperative Practice (AfPP) and the International Council on Surgical Plume (ICSP). They aimed to gain a greater understanding of the awareness levels, training, management and policy surrounding surgical smoke plume in the UK.
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Content ArticleThe NHS England National Patient Safety Team has produced two podcasts to provide an overview of the background and development of the new National Maternity Early Warning Score (MEWS) tool. In the first podcast, Professor Marian Knight, University of Oxford; Professor Peter Watkinson, Oxford University Hospitals NHS Foundation Trust; and Tony Kelly, National Clinical Advisor, Maternity & Neonatal Safety Improvement Programme NHS England, discuss the development of a new national Maternity Early Warning Score (MEWS) tool. In the second podcast, Tony Kelly, Hannah Rutter, Senior Improvement Manager at MatNeoSIP NHS England, Louise Page, Consultant Obstetrician and Gynaecologist, West Middlesex University Hospital and Chelsea and Westminster Hospital NHS Foundation Trust, Anita Banerjee, Consultant Obstetric Physician, Guys and St Thomas’s NHS Foundation Trust and Katherine Edwards, Director of Patient Safety and Clinical Improvement, Oxford Academic Health Science Network discuss the the benefits of implementing the new national MEWS tool.
