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Showing results for tags 'Behaviour'.
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An encounter with an error trap by Steve Highley (6 August 2015)
Sam posted an article in Error traps
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Content Article2020 National Patient Safety Goals (NPSGs) for specific programmes include chapters on: ambulatory healthcare behavioural healthcare critical access hospital home care hospital laboratory nursing care centre office-based surgery.
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Further serious patient safety incidents: why are staff still not being listened to when concerns are raised?
Anonymous posted an article in Whistle blowing
Complaints from staff are not being heeded. Why is it that healthcare staff's opinions and pleas for their safety and the safety of patients do not matter? Here are just some examples of where safety has been compromised: Disposable gowns are being reused by keeping them in a room and then reusing after 3 days. There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fit tests were given. I queried about fit checks only to discover that it was not part of the training and, therefore, staff were wearing masks without seals for three months before fit tests were introduced and even after fit tests! I taught my colleagues how to do fit checks via telephone. There was no processes in place at the hospital to aid staff navigation through the pandemic (no red or green areas, no donning or doffing stations, no system for ordering PPE if it ran out); it was very much carry on as normal. A hospital pathway was made one week ago, unsigned and not referenced by governance, and with no instructions on how to don and doff. Guidelines from the Association for Perioperative Practice (AFPP) and Public Health England (PHE) for induction and extubation are not being followed – only 5 minutes instead of 20 minutes. Guidelines state 5 minutes is only for laminar flow theatres. None of the theatres in this hospital have laminar flow. One of my colleagues said she was not happy to cover an ENT list because she is BAME and at moderate/high risk with underlying conditions. She had not been risk assessed and she felt that someone with lower or no risk could do the list. She was removed from the ENT list, told she would be reprimanded on return to work and asked to write a report on her unwillingness to help in treating patients. The list had delays and she was told if she had done the list it would not have suffered from delays. Just goes to show, management only care about the work and not the staff. It was only after the list, she was then risk assessed. Diathermy smoke evacuation is not being used as recommended. Diathermy is a surgical technique which uses heat from an electric current to cut tissue or seal bleeding vessels. Diathermy emissions can contain numerous toxic gases, particles and vapours and are usually invisible to the naked eye. Inhalation can adversely affect surgeons’ and theatre staff’s respiratory system. If staff get COVID-19 and die, they become a statistic and work goes on as usual. The examples listed above are all safety issues for patients and staff but, like me, my colleagues are being ignored and informed "it's a business!" when these safety concerns are raised at the hospital. The only difference is they are permanent staff and their shifts cannot be blocked whereas I was a locum nurse who found my shifts blocked after I spoke up. Why has it been allowed to carry on? Why is there no Freedom To Speak Up Guardian at the hospital? Why has nothing been done? We can all learn from each other and we all have a voice. Sir Francis said we need to "Speak Up For Change", but management continues to be reactive when we try to be proactive and initiate change. This has to stop! Actions needed We need unannounced inspections from the Care Quality Commission (CQC) and HSE when we make reports to them. Every private hospital must have an infection control team and Freedom To Speak Up Guardian in post. -
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Patient restraint spikes as covid measures spark ‘frustration’
Patient Safety Learning posted a news article in News
Several mental health trusts have reported spikes in incidents of physical restraint or seclusion on patients, driven by COVID-19 restrictions, HSJ has learned. Concerns have been raised nationally about the potential for incidents to increase during the pandemic, due to temporary measures which have had to be introduced such as visiting restrictions and communication difficulties due to personal protective equipment. Read full story Source: HSJ, 5 June 2020 -
Content ArticlePodcast 1 – Interview with Chris Frerk Podcast 2 – Interview with Mark Stacey Podcast 3 – Interview with Stephen Hearns Podcast 4 – Interview with Claire Cox
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Coronavirus: UK changes course amid death toll fears
Patient Safety Learning posted a news article in News
Change course or a quarter of a million people will die in a "catastrophic epidemic" of coronavirus – warnings do not come much starker than that. The message came from researchers modelling how the disease will spread, how the NHS would be overwhelmed and how many would die. The situation has shifted dramatically and as a result we are now facing the most profound changes to our daily lives in peacetime. This realisation has happened only in the past few days. However, it is long after other scientists and the World Health Organization had warned of the risks of not going all-out to stop the virus. Read full story Source: BBC News, 18 March 2020 -
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Hundreds of social care residents allegedly sexually assaulted, watchdog reveals
Patient Safety Learning posted a news article in News
Hundreds of elderly and vulnerable social care residents have allegedly been sexually assaulted in just three months, a shock new report from the care regulator has revealed. According to the Care Quality Commission there were 899 sexual incidents reported by social care homes between March and May 2018. Almost half were categorised as sexual assault. In 16% of the cases members of staff or visiting workers were accused of carrying out the abuse. The watchdog said it was notified of 47 cases of rape and told The Independent local authorities were informed and 37 cases were referred to police for investigation. Kate Terroni, Chief Inspector of adult social care at the regulator, said: “Supporting people as individuals means considering all aspects of a person’s needs, including sexuality and relationships. However, our report also shows all too starkly the other side of this – the times when people are harmed in the very place they should be kept safe. This is utterly devastating, both for the people directly affected and their loved ones." “It is not good enough to put this issue in a ‘too difficult to discuss’ box. It is particularly because these topics are sensitive and complex that they should not be ignored.” Read full story Source: The Independent, 27 February 2020 -
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My experience of speaking up as a healthcare assistant in a care home
Anonymous posted an article in By health and care staff
I was employed as a healthcare assistant in a care home, where I worked for about three months. During this time, I found out that patient safety and quality of care were undermined by healthcare assistants, and the management and the nurses did not seem to realise it. Examples included: Carers were given a box of gloves each and they were expected to use them for up to two weeks. When asked for more gloves, the manager would check the last time they took a box of gloves and would question what they had done with the last ones they collected. In order to save the gloves, carers used one pair of gloves to deliver personal care to three to five residents before changing them. They would take the rest of the gloves home and bring them back to work in the next shift. Genital care was totally neglected. Residents’ genitals were not cleaned. I spoke to a nurse in another unit about this and all she said was she thought it was being done. When carrying out personal care to one lady, I found dried faeces wrapped in her pubic hair which took me a good number of minutes to clean. When I finally finished doing it, the lady pointed at her private part and said to me “it can breathe now” and when I asked why, she said “because it has been washed”. Infection control. One of the problems was that there was never any soap in the bathrooms and places where there were wash hand basins. So, after personal care, especially after caring for residents who had opened their bowels, we could only wash our hands with clear water. Hand sanitiser dispensers were hanging empty with no sanitising gel, so no opportunity for either visitors or staff to sanitise their hands whilst in the care home. Healthcare assistants apparently had no clue about catheter care, even those working at the nursing unit where there were a few residents that had catheters. I never saw any of them doing catheter care and one day when I was doing it, my colleague was really frightened, held my hand back and said I was going to pull the catheter out. Most of the times when residents opened their bowels, carers would either clean it very shallowly, or they would only take out the soiled pads and replace them with clean ones without cleaning the area at all. As such, when you took over the shift, during the first checks you would think that a resident had opened bowels but find out that the pad was dry and clean at that moment, but the faeces on it and on their skin was dried up. Oral and nail care was another issue. Carers never did oral care, and those who bothered to document would say “resident denied oral care”. Some of the residents’ beds were not functioning, especially in the nursing unit where most of the residents were bed-ridden. This meant that healthcare assistant staff had to bend and strain their backs each time they were giving personal care, which would lead to backaches. After trying to share my concerns on the above issues with three nurses to no avail, I was only left with the choice of talking to the management. I wrote a letter of observation, accompanied by some recommendations. I ended my letter by letting the management know that I was ready to discuss my concerns with them at any time. They did not call me up for any discussion. A change in behaviour... A few days later I started noticing a change of behaviour from all staff towards me. Most of them did not talk to me, many times I found out that people were whispering things about me as when they saw me approaching them they would stop talking. One unit reported that I was very slow, and I was never assigned to work there anymore. People ignored me when I tried to join in a conversation. Each time I was working, nobody would let me do personal care. I was only allowed to work as an assistant to fellow healthcare assistants. In some rooms where I went in first and started doing personal care, they would tell me that I was taking too much time. My opinion on anything did not count. One day when I came to work, there was a small problem which needed to be fixed between one of the nurses and myself, but she refused to listen to me and insisted that I should go back home. I went home as she had asked, and the next day I called and told the manager that I was sent home last night. He started blaming me based on what the nurse had told him, which was not true, without listening to my own side of the story. I insisted that he should call a meeting where he could listen to both of us, because what the nurse had said was untrue. His response to me was that I would need a reference from him so I should be careful about the way I did things. However, he finally accepted and we agreed on a date for the meeting. But when it came to the day of the meeting, the nurse was not there. I explained myself to my manager, in the presence of the secretary. His response to the letter I wrote with my concerns in was that he appreciated it, but he thought that the care home was not the right place for me, and that he thought that I was too qualified for the job. He suggested that everybody felt threatened with my presence. I told him that that it sounded to me like he wanted to remove me from my job; a job which I very much wanted to do. When I came back for the next shift, I discovered that my shift had been cancelled and I had been replaced by someone else. I spoke to a senior carer who called my manager and he told me that he was not expecting me to come to work because of what had happened the other night. I went back home. The next day he called and told me that after due consideration, he had decided to extend my probation time to a further three months, and that I should compose myself, come to work and do only what I was expected to do. Psychologically tortured As I continued working, things got worse each day. I experienced colleagues laughing at me, talking about me, not talking to me, ignoring me; the list could go on and on. I was psychologically tortured. I developed a violent headache. Each time I thought I was going back to work I felt sick, got palpitations, felt so hot as if I had fever, at times shivering, with painful nerves. I kept asking myself whether I was wrong to have done what I did. I did a lot of self-counselling and told myself that I was going to stay at the workplace if I was not dismissed. This was because I was planning to write more letters. I had only highlighted a few of the many issues in my first letter. My hope was that one day someone was going to understand me and things would improve. One night I stopped a colleague from putting a pad on a resident she had not cleaned properly. I cleaned the resident and did vaginal and catheter care, before putting on the pad. There was another resident who was very wet, from their pyjamas to the bedding; my colleague wanted us to only change the pad and let the resident lay with the wet clothes on the wet bed “since they were going to wash her in the morning anyway”. This was the 1am check, and I argued that I could not imagine her being able to fall asleep in that condition. We ended up changing the resident’s pyjamas and putting a towel and an extra pad on the bed to make her feel comfortable. Forced into resigning My colleague became angry with me. I was surprised because I had done nothing wrong. There was altercation and she confronted me. I couldn’t tell anyone as no one would believe me. I felt excluded and alone and the only thing that came to my mind was that I should resign. When I finished work in the morning I went and told my manager that I was resigning. He told me that I was expected to give two weeks’ notice and that I should write my resignation letter that day, which I did. He told me it was rather unfortunate that it hadn’t worked out for me in the care home… Did I do the right thing? What would you do?- Posted
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Connor Sparrowhawk: The tale of laughing boy (2015)
Claire Cox posted an article in Patient stories
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'Storm in a Checklist'
Kathy Nabbie posted an article in Surgery
Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time! -
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Human factors and ergonomics in practice (2017)
Claire Cox posted an article in Recommended books and literature
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Community PostCall 4 Concern is an initiative started by Critical Care Outreach Nurse Consultant, Mandy Odell. Relatives/carers know our patients best - they notice the subtle signs of deterioration in their loved one. Families and carers are now able to refer straight to the Critical care outreach team directly if they feel that care has not been escalated. Want to set up a call for concern initiative in your Trust? Need some support? Are you a relative that would like it in your Trust? Leave comments below -
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