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Showing results for tags 'Recommendations'.
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Content ArticleProbiotics are used for both generally healthy consumers and in clinical settings, but there have been adverse events as a result of their consumption. Concise and actionable recommendations on how to use probiotics safely and effectively are therefore needed, especially as increasing numbers of new strains and products come to market, and probiotic use increases in vulnerable populations. The International Scientific Association for Probiotics and Prebiotics convened a meeting to discuss and produce evidence-based recommendations on potential acute and long-term risks, risks to vulnerable populations, the importance for probiotic product quality to match the needs of vulnerable populations and the need for adverse event reporting related to probiotic use. This paper presents these recommendations to guide the scientific and medical community on judging probiotic safety.
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Content ArticleIn February 2023, the government commissioned an independent review to offer recommendations on how to resolve key challenges in conducting commercial clinical trials in the UK and transform the UK commercial clinical trial environment. The review sets out 27 recommendations, including both priority actions to progress in 2023 and longer-term ambitions for UK commercial clinical trials. The review was conducted by Lord James O’Shaughnessy, Senior Partner at consultancy firm Newmarket Strategy, Board Member of Health Data Research UK (HDR UK) and former Health Minister, who was appointed as review Chair. During the review, Lord O’Shaughnessy consulted closely with industry and a wide range of stakeholders across the UK clinical trials sector. The government response welcomes all recommendations from the review, in principle, and makes 5 headline commitments backed by £121 million. An implementation update, setting out progress made against these commitments and a comprehensive response to the remaining recommendations, will be published in the autumn.
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Content ArticleThis policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS.
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Content ArticleIn healthcare, telling stories brings benefits to both storytellers and audience members, but also presents risks of harm. A reflective storytelling practice aims to honour stories and storytellers by ensuring there is time to prepare, reflect, learn, ask questions, and engage in dialogue with the storyteller to explore what went well and where there are learning and improvement opportunities. Healthcare Excellence Canada (HEC) is a pan-Canadian health organisation focused on improving the quality and safety of care in Canada. The HEC Patient Engagement and Partnerships team have co-developed these recommendations on how best to meaningfully share stories from those leading, providing and receiving care at Board meetings. This Case Study outlines the process HEC used to co-develop storytelling recommendations, focusing on a trauma-informed approach to create safe spaces for preparing, learning from and reflecting on stories, to clearly articulate their purpose, and to ensure the locus of control for storytelling rests with the storytellers.
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News Article
Players told to 'sit it out' under new concussion guidance
Patient Safety Learning posted a news article in News
Anyone with suspected concussion must be immediately removed from football, rugby and other sports and rest for at least 24 hours, under new guidance for grassroots clubs. It says the NHS 111 help-line should be called and players should not return to competitive sport for at least 21 days. The UK-wide guidelines are aimed at parents, coaches, referees and players. Its authors say a "culture change" in the way head injuries are dealt with is needed. "We know that exercise is good for both mental and physical health, so we don't want to put people off sport," Prof James Calder, the surgeon who led the work for the government, said. "But we need to recognise that if you've got a head injury, it must be managed and you need to be protected, so that it doesn't get worse." Read full story Source: BBC News, 2 May 2023 -
Content ArticleThis report is the Falls and Fragility Fractures Audit Programme's (FFFAP's) State of the Nation Report 2022 for Wales. It examines how the care of inpatient falls and fragility fractures has changed since 2020, highlighting what the audit reveals about the quality of patient care and the impact of the Covid-19 pandemic. The report used three sources of data and concludes with a number of recommendations around the care of people with hip fracture, preventing inpatient falls, and preventing future fractures.
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Content ArticleBased on data from January 2019 to December 2021, this report by the Paediatric Intensive Care Audit Network (PICANet) catalogues comprehensive information on referral, transport and admission events. This enables the monitoring of delivery and quality of care in relation to agreed standards, and the evaluation of clinical outcomes to inform national policy in paediatric critical care. It reports on five key metrics relevant to Paediatric Intensive Care services: case ascertainment including timeliness of data submission retrieval mobilisation times emergency readmissions within 48 hours of discharge unplanned extubation in PICU mortality in PICU
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Content ArticleThis report by the World Health Organization (WHO) identifies major global gaps in water, sanitation and hygiene (WASH) services. It outlines that: one third of health care facilities do not have what is needed to clean hands where care is provided one in four facilities have no water services 10% have no sanitation services. This means that 1.8 billion people use facilities that lack basic water services and 800 million use facilities with no toilets. Across the world’s 47 least-developed countries, the problem is even greater, with half of health care facilities lacking basic water services. In addition, the extent of the problem remains hidden because major gaps in data persist, especially on environmental cleaning. The report describes the global and national responses to the 2019 World Health Assembly resolution on WASH in health care facilities. More than 70% of countries have conducted related situation analyses, 86% have updated and are implementing standards and 60% are working to incrementally improve infrastructure and operation and maintenance of WASH services. Case studies from 30 countries demonstrate that progress is being propelled by strong national leadership and coordination, use of data to direct resources and action, and the mutual benefits of empowering health workers and communities to develop solutions together. The report includes four recommendations to all countries and partners to accelerate investments and improvements in WASH services in health care facilities: Implement costed national roadmaps with appropriate financing. Monitor and regularly review progress in improving WASH services, practices and the enabling environment. Develop capacities of the health workforce to sustain WASH services and promote and practice good hygiene. Integrate WASH into regular health sector planning, budgeting and programming to deliver quality services, including Covid-19 response and recovery efforts.
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Content ArticleOn the 20 January 2023 the Health and Social Care Select Committee published a reported with reviewed the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. This paper sets out the UK Government’s response to the recommendations set out in this report. Related reading: Health and Social Care Select Committee: Follow-up on the IMMDS report and the Government’s response (20 January 2023) Patient Safety Learning: Response to the Select Committee report on the Independent Medicines and Medical Devices Safety Review (20 January 2023)
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Content ArticlePatient safety in oncology should remain a standard indicator of quality of care and a critical objective on the EU health policy agenda as all European citizens deserve the same level of safeguarding and protection at all stages of their healthcare. Patient safety is also a critical indicator of life overall, as any irreversible or reversible patient safety issue potentially affects the quality of life. This report from the European Network for Safer Healthcare calls for 10 actions for European policy makers and national health authorities.
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Content ArticleOn 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
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Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the work of community mental health teams (CMHTs). Specifically, the investigation looked at the following four areas: assessing a patient’s risk of self-harm or suicide considering menopause as a risk factor for mental health conditions engaging with families caring for people with a first episode of psychosis. Reference event Ms A was 56 years old when she came into contact with mental health services for the first time in September 2019, following a suicide attempt. Ms A spent a month in hospital, and was then discharged home under the care of a community mental health team (CMHT) with a diagnosis of psychotic depression. At the end of May 2020, Ms A was again admitted to hospital following a second suicide attempt. She again stayed in the hospital for about four weeks before being discharged home under the care of a CMHT. Ms A was seen by CMHT workers regularly throughout July, and had a telephone review with a consultant psychiatrist. At the end of July, Ms A’s family became increasingly concerned about her mental state and were unable to make contact with her. On 2 August, Ms A was found deceased at home having died by suicide.
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News Article
Ministers blasted by scandal inquiry chair
Patient Safety Learning posted a news article in News
The government’s response to the East Kent maternity scandal inquiry has been condemned as ‘very disappointing’ by its chair. More than four months on from the inquiry report, ministers this morning issued what they called an “initial response” to it, as a brief written statement to Parliament. It contained few specific proposals, instead saying government was kicking off a series of other reviews, and “working” with various other agencies. Inquiry chair Bill Kirkup, the well-regarded former medic and expert in care failures, told HSJ the response was poor and should have been “wider and deeper”. Dr Kirkup said the response showed government had “not grasped how fundamental” some of the issues outlined in his report were, and “what sort of initiative” was needed to address them. Read full story (paywalled) Source: HSJ, 7 March 2023 -
Content ArticleStatement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
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Content ArticleThis study from Jones et al. identified wide variability in the implementation of the Guardian role and concluded that optimal implementation has six components.
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News Article
Eating disorder patients ‘repeatedly failed’, says England watchdog
Patient Safety Learning posted a news article in News
Urgent action is needed to prevent people dying from eating disorders, the parliamentary and health service ombudsman for England has warned, as he said those affected are being “repeatedly failed”. The NHS needs a “complete culture change” in how it approaches the condition, while ministers must make it a “key priority”, according to Rob Behrens. Little progress has been made since the publication of a devastating report by his office in 2017, which highlighted “serious failings” in eating disorder services, he said. Lives continue to be lost because of “the lack of parity between child and adult services”, and “poor coordination” between NHS staff involved in treating patients. There remain issues with the training of medical professionals, Behrens added. “We raised concerns six years ago in our ignoring the alarms report, so it’s extremely disappointing to see the same issues still occurring,” he said. “Small steps in improvements have been taken, but progress has been slow, and we need to see a much bigger shift in the way eating disorder services are delivered." Read full story Source: The Guardian, 27 February 2023 -
Content ArticleThis report details the findings of a thematic review of Safe and wellbeing reviews (SWRs) between October 2021 and May 2022. SWRs are undertaken for children, young people and adults that are autistic and/or have a learning disability who are being cared for in a mental health inpatient setting. SWRs are part of the NHS response to the safeguarding adults review concerning the tragic deaths of Joanna, Jon, and Ben at Cawston Park Hospital, who were each detained for a long period of time and did not receive appropriate care.
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Content ArticleThis practice recommendation offers practical recommendations to assist acute-care hospitals in prioritising and implementing strategies to prevent healthcare-associated infections (HAIs) through hand hygiene. It updates Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals through Hand Hygiene, published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association and The Joint Commission.
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News Article
Derby maternity deaths may have been prevented
Patient Safety Learning posted a news article in News
Three women who died under the care of a hospital's maternity unit may have survived if earlier recommendations had been implemented, a report has said. The cases occurred at University Hospitals of Derby and Burton (UHDB) NHS Foundation Trust over 16 months. A review by the Healthcare Safety Investigation Branch (HSIB) also found a culture of intimidation and bullying. The report found that although there was no common theme to the deaths - and four other life-threatening cases that occurred in the same period - processes and leadership had been inconsistent and fragmented. HSIB said "robust action planning and prompt addressing of the learning" from previous recommendations from other investigations "may have had an impact on the outcome for the women who received care during the seven events included in this thematic review". Read full story Source: BBC News, 22 February 2023 -
News Article
Millions with mental health needs not seeking NHS help, watchdog says
Patient Safety Learning posted a news article in News
Millions of people in England with mental ill-health are not seeking NHS help, and many who get it face long delays and a “poor experience”, a report says. Long waits for care will persist for years because soaring demand, exacerbated by Covid, will continue to outstrip the ability of severely understaffed mental health services to provide speedy treatment, the National Audit Office (NAO) found. The report found that “NHS mental health services are under continued and increasing pressure and many people using services are reporting poor experiences”. Under-18s, the LGBT+ community, minority ethnic groups and people with more complex needs are most likely to find the system inadequate. “While funding and the workforce for mental health services have increased and more people have been treated, many people still cannot access services or have lengthy waits for treatment,” the NAO said. It found: An estimated 8 million people with mental health needs are not in contact with NHS services. There are 1.2 million people waiting for help from community-based mental health services. While the mental health workforce grew by 22% between 2016-17 and 2021-22, the NHS recorded a 44% increase in referrals over the same period. In 2021-22, 13% of mental health staff quit. Read full story Source: The Guardian, 9 February 2023 -
Content ArticleThis guidance from the Office of Rail and Road outlines how to manage the risk of fatigue that may arise from a working pattern. It defines 'fatigue factors', highlighting that the more a working pattern features these fatigue factors, the greater the likely need to assess, avoid and control potential fatigue risks.
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Content ArticleTen years ago today, a public inquiry concluded that patients were subject to shocking levels of neglect at Stafford Hospital - putting it among the worst care scandals in NHS history. A young local reporter, Shaun Lintern – now The Sunday Times' health editor – helped expose the scandal. With the NHS again under huge pressure, can we be sure the same failings won't happen again? In this podcast, part of the Stories of our Times podcast series, Shaun speaks to the barrister who chaired the inquiry.
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Content ArticleLast year, the independent NHS Race and Health Observatory commissioned consultancy, Public Digital, to undertake a ‘digital discovery’ project to explore the lived experience of people undergoing acute emergency hospital admissions for sickle cell and managing crisis episodes at home. The NHS Race and Health Observatory’s January 2023 publication – ‘Sickle cell digital discovery report – Designing better acute painful sickle cell care’ – sets out to understand the broad availability of digital products and services that currently exist. The report explores the range of technology that is in place for Accident and Emergency clinicians, red-cell specialists, and ambulance care, to aid timely support to sufferers on their emergency hospital arrival. A number of focus groups and interviews were carried out with those that have lived experience of the disease, including patients who have suffered acute, painful sickle cell episodes during NHS A&E admissions. Research found a lack of individual care plans in place and, more broadly, no clear definition of what constitutes an actual care plan. A number of recommendations are set out in the report for the NHS and the wider healthcare system.
