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Found 93 results
  1. Content Article
    Patients that I care for remain the same. Medically they are the same as they ever were. They have bowel obstructions, they have heart attacks, they have infections, they break bones, and there will always be a constant flow of patients that need the services of the NHS. One day it will be you and it will be me, at some point we will rely on NHS care. However, the way that care is organised and delivered around us will change. We have no idea what it will look like in the future, but it will be different to what we knew before the pandemic hit. At the moment we are all working in a state of flux. I work part time as a critical care outreach nurse, so there are times when I am not at the hospital for a few days in a row. When I am due back at work, I get what I call the ‘Sunday night fear’. I used to get this every Sunday night before I had to go to school. I would worry about fitting in, had I done my homework, have I got all my books together and whether I was going to have a good hair day. Now I find myself worrying about what new protocols I need to follow, what briefings have I missed, which wards are green, which are red. Now I have a new habit of looking through work emails to find out if I need to do anything different when I come to work. I’m not enjoying this habit one bit. I feel like I am starting a new job every time I turn up after two or three days. One of the roles of the critical care outreach nurse is to provide role modelling and support to staff on the wards. More often than not I have no idea what the ‘rules’ are now. Every decision is difficult. My patient needs to go to theatre urgently; they are slowly occluding their airway. Before the theatre will take them, they need a covid swab result. How do I get a swab result quickly? A new rapid test is now available (I only find this out by someone telling me this as they were passing). How do I get this swab? Does it look different? How do you perform the swab? How do I send it? How quick does it come back? How do I find the result? How reliable is it (at this point, I’m not bothered – just get it done, tick that box). Next call – cardiac arrest on one of the wards. Pre-covid we have been taught "Good chest compressions are linked with better outcomes for patients. Keep time off the chest to a minimum". This has been drummed in to us for years. It is now second nature to make sure that chest compressions are given as soon as we confirm cardiac arrest. But now we are advised by our Trust resuscitation team and the Resuscitation Council UK that performing chest compressions is an aerosol generating procedure (AGP), despite the advice from Public Health England who state that chest compressions is not classed as an AGP. There are a few issues here... As frontline healthcare staff we want to do the best for our patients, and we want to be kept safe by our employers. We need clarity on what we are supposed to be doing; this lack of clarity and standard guidance leads us into different interpretations of the rules and a lack of trust in our leaders. I recently taught on an Advanced Life Support Course. Here, I was teaching a range of healthcare professionals from differing hospitals from inner and outer London. I was amazed at the different practices that were going on. Some were wearing full personal protective equipment (PPE) for cardiac arrests despite covid status, some were not. The lack of clarity here made teaching very difficult as they were not sure who was right and who was wrong. They were then worrying if they had been exposed and are now losing trust in their leaders. In the NHS we use guidance that is evidence based. At present we have such a small evidence base, if any, on how we should treat patients during the pandemic. This is leading to differing local policies of which no one knows which is best. This lack of clarity and guidance also has an impact on the patient. If we are to wear full PPE for AGPs (in the cardiac arrest situation) there will be a delay in performing chest compressions; this has a negative impact on patient outcomes. Cardiac arrests are stressful; donning PPE at breakneck speed so that you can treat your patient is compounding the anxiety. It made me question – if covid is here to stay, should we be rewriting the resuscitation guidelines? Then I thought, how can you rewrite guidance in a time of flux? Things change all the time; nothing is the same from 48 hours ago – so how can meaningful standards and guidance be written if they will be out of date before they get uploaded? And re-writing guidance with consensus from experts and professional bodies takes time. What do we do in the meantime? At this stage we need guidance, we need clarity and we need to feel we can trust in those that lead us through. Call for action We need evidenced-based guidance, we need clarity and we need to feel we can trust in those that lead us through. How are leaders communicating best practice and updated relevant guidance to staff and instilling trust that patient and staff safety is a core priority?
  2. Content Article
    “After he died, the little plastic ID band that was around his tiny wrist should have been slipped onto mine. There was nothing more that could have been done for him, but there was plenty that needed to be done for me. I needed an infusion of truth and compassion. And the nurses and doctors who took care of him, they needed it too." Leilani Schweitzer[1] When someone is hurt, it is reasonable to expect the healthcare system to provide care to alleviate symptoms or to cure. It is also reasonable to expect those providing the care to be adequately trained and supported to do so. Yet, when harm is caused by healthcare, the spectrum of harm suffered is not well understood, care needs are not fully recognised and, therefore, the care needed to facilitate optimum recovery is not being provided.[2] In fact, with outrageous frequency, at a time when exceptional care is so desperately needed, those hurting describe how they are further harmed from ‘uncaring’ careless and injurious responses. Healthcare harm is a ‘double whammy’ for patients Healthcare harm is a ‘double whammy’. There’s the primary harm itself – to the patient and/or to those left bereaved – but there is also the separate emotional harm caused specifically by being let down by the healthcare professionals/system in which trust had to be placed.[3] This additional emotional harm has been described as being the damage caused to the trust, confidence and hope of the patient and/or their family.[4] Trust – you rely on professionals to take responsibility for what you cannot do yourself. Confidence - you believe that the system will protect you from harm. Hope – you have the conviction that things will turn out well. Anderson-Wallace and Shale[4] For the patient and family to be able to heal from healthcare harm, appropriate care must be provided not only for the primary injury and any fall out from this, but also this additional emotional injury (being let down by healthcare) and any fall out from that. For example, a parent who loses a child as a result of failures in care will need help to cope with the loss of their child and all of the processes that occur as a result. But they will also need support to cope with having had to hand over responsibility for their child’s safety to healthcare professionals, only to be let down, and all the feelings and processes associated with that. Much needs to happen to restore that parent’s trust, confidence and hope in our healthcare system and the staff within it. This is different to the parent of a child who has passed away from an incurable illness despite exemplary healthcare. A parent let down by healthcare has specific additional care and support needs that need to be met to help them cope and work towards recovery. Healthcare harm also causes emotional harm to the staff involved In 2000, Albert Wu introduced the phrase ‘second victim’ in an attempt to highlight the emotional effects for staff involved in a medical error and the need for emotional support to help their recovery.[5] The term has recently been criticised, since families should be considered the second victim,[6] and the word victim is believed “incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers.”[7] While the term itself may be antagonistic, or misrepresentative, the sentiment – that staff involved in incidents need support to cope with what has happened, and to give them the confidence to do what is needed to help the patient/family heal – certainly stands. When staff are involved in an incident of patient harm, they may lose trust in their own ability and the systems they work in to keep patients safe, and they may worry about their future.[5],[8] They need care and support in order to recover themselves and, crucially, so that they feel psychologically safe and are fully supported to be open and honest about what has happened. They need to feel able to do this without fearing personal detrimental consequences for being honest, such as unfair blame or a risk to their career. This is essential to the injured patient/family receiving the full and truthful explanations and apologies they need in order to regain trust, confidence and hope, and, ultimately, to heal as best they can. So, in addition to patients and families there should be a ‘care pathway’ for staff involved in incidents of harm. A google search on ‘second victim’ reveals a wealth of research on the emotional effects of medical error for staff involved and the best ways to provide support for this, and this is resulting in the emergence of staff support provision to aid recovery.[9] In contrast, very little research has been done into the emotional effects and support needs of families and patients. How is ‘care’ for emotional harm given? The ‘treatment’ of the emotional harm has been described as ‘making amends’ – by restoring trust, confidence and hope.[4] Once a patient has been harmed by healthcare, every interaction (physical, verbal or written) they have with healthcare after that will either serve to help them heal or to compound the emotional harm already suffered. Trew et al.[10] describe harm from healthcare as a “significant loss” and conclude that “coping after harm in healthcare is a form of grieving and coping with loss”. In their model, harmed patients and families proceed through a ‘trajectory of grief’ before reaching a state of normalisation. Some can move further into a deeper stage of grief and seemingly become stuck in what is referred to as complicated grief. They can display signs of psychiatric conditions "if there are substantial unresolved issues, or where there is unsupportive action on the part of individuals associated with the healthcare system and the harm experience”. At the point of the harmful event, the patient/family experiences losses, including a drop in psychological wellbeing. From this point on, healthcare staff and organisations have opportunities to respond. If the response is supportive it may be helpful for the patient/family in coping with the losses. If the response is not supportive, this may cause ‘second harm’ complicating the healing process, leaving the patient/family with unresolved questions, emotions, anger and trust issues. The patient’s psychological wellbeing and ability to return to normal functioning are severely affected. “Most healthcare organizations have proved, in the past at least, extraordinarily bad at dealing with injured patients, resorting at times, particularly during litigation, to deeply unpleasant tactics of delay and manipulation which seriously compounded the initial problems. My phrase ‘second trauma’ is not just a linguistic device, but an accurate description of what some patients experience.” Charles Vincent[11] There is no shortage of individuals who have suffered extensive ‘second harm’ sharing their experiences in the hope this will lead to better experiences for others and some help for themselves to recover. Many are, wrongly, being ‘written off’ as historical cases that can no longer be looked at. This cannot be right – when these people are suffering and need appropriate responses to heal their wounds. The extent of suffering that exists now, in people who have been affected by both primary trauma and then second harm from uncaring defensive responses, or responses that have not taken into account the information patients and families themselves have, or relevant questions they ask, is no doubt nothing short of scandalous. There is a pressing urgency for the NHS to stop causing secondary trauma to affected patients and families. ‘Patient safety’ has to start applying to the harmed patient and their family members’ safety after an adverse event, and not just focus on preventing a repeat of the event in the future. Yes, future occurrences must be prevented, learning is crucial, but so is holistically ‘looking after’ all those affected by this incident. If they are not looked after, their safety is at risk as their ability to heal is severely compromised; in fact they are in danger of further psychological trauma. These same principles apply to affected staff. Avoiding second harm: what happens now and what is needed? This series of blogs will highlight that every interaction a harmed patient or family member has with staff in healthcare organisations (not just clinical staff) after a safety incident should be considered as ‘delivery of care’. With this view, the ‘care interaction’ should be carried out by someone trained and skilled and supported to do so, with the genuine intention of meeting the patient/families’ needs and aiding the patient/family to recover and heal (restore trust, hope and confidence). The interaction / response must not cause further harm. Stress or suffering, and the content of the interaction, for example a letter, should not have been compromised, as often occurs, by competing priorities of the organisation to the detriment of the patient/family. Thus, these blogs will look at: The processes that occur after an incident of harm (Duty of Candour, incident investigation, complaint, inquest) with the aforementioned focus. The care the patient and family need and the obligation (that ought to exist) to meet that need. Processes that are core to the package of ‘care’ to be provided to the harmed or bereaved and to be delivered by skilled and supported ‘care providers’. The blog series will seek to show that meaningful patient engagement in all of these processes is crucial for restoring trust, confidence and hope; therefore, aiding healing of all groups in the aftermath of harm. “It is important to respect and support the active involvement of patients and their families in seeking explanations and deciding how best they can be helped. Indeed at a time which is often characterised by a breakdown of trust between clinician and patient, the principle of actively involving patients and families becomes even more important.” Vincent and Coulter, 2002[3] It will also consider the additional care and support needs that might need to be met alongside these processes in a holistic package of care, such as peer support, specialist medical harm psychological support and good quality specialist advice and advocacy. It will describe what is currently available and what more is needed if healthcare is to provide adequate care for those affected by medical error in order to give them the best chance of recovery. Alongside this, the needs of the staff involved will also be considered. We welcome opinion and comments from patients, relatives, staff, researchers and patient safety experts on what should be considered when designing three harmed patient care pathways: for patients, families and staff. What is the right approach? What actions should be taken? How can these actions be implemented? What more needs to be done? Join in the discussion and give us your feedback so we can inform the work to design a harmed patient care pathway that, when implemented, will reduce the extra suffering currently (and avoidably) experienced by so many. Comment on this blog below, email us your feedback or start a conversation in the Community. References 1. Leilani Schweitzer. Transparency, compassion, and truth in medical errors. TEDxUniversityofNevada. 12 Feb 2013. 2. Bell SK, Etchegaray JM, Gaufberg E, et al. A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families. J Comm J Qual Patient Saf 2018;44(7):424-435. 3. Vincent CA, Coulter A. Patient safety: what about the patient? BMJ Qual Saf 2002;11(1):76-80. 4. Anderson-Wallace M, Shale S. Restoring trust: What is ‘quality’ in the aftermath of healthcare harm? Clin Risk 2014;20(1-2):16-18. 5. Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726-727. 6. Shorrock S. The real second victims. Humanistic Systems website. 7. Clarkson M, Haskell H, Hemmelgarn C, Skolnik PJ. Editorial: Abandon the term “second victim”. BMJ 2019; 364:l1233. 8. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18(5):325-330. 9. Second victim support for managers website. Yorkshire Quality and Safety Research Group and the Improvement Academy. 10. Trew M, Nettleton S, Flemons W. Harm to Healing – Partnering with Patients Who Have Been Harmed. Canadian Patient Safety Institute 2012. 11. Vincent C. Patient Safety. Second Edition. BMJ Books 2010.
  3. Content Article
    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.
  4. Content Article
    The outpatient appointment Attending an outpatient appointment, in my experience, is daunting at the best of times. First, there is the appointment date. Often you have had to wait an exceptionally long time for this appointment (providing the referral letter hasn’t been lost). The date and time are chosen by the Trust. There are some Trusts and specialities that will allow you to choose a time and place, but more often than not you are not able to choose and changing the date and time can prove tricky. There are many reasons for a patient not to turn up for an appointment. These reasons and how to mitigate them are looked at by Trusts. The 'Did not attend' (DNA) rate is looked at by Trusts. DNAs have an enormous impact on the healthcare system in terms of increasing both costs and waiting times. Trusts often want to reduce these to: reduce costs improve clinic or service efficiency enable more effective booking of slots reduce mismatch between demand and capacity increase productivity. Then there is getting there. Getting time off work or college, making childcare arrangements, getting transport… finding parking! Before patients even get to the appointment, they have often been up a while planning this trip. Imagine what this must be like for a patient with learning disabilities. This poses even more planning. What medication might we meed to take with us? Are there changing facilities for adults? Can we get access? Is there space to wait? Will anyone understand me? How long will we be there for? Do they have all my information? Services need to be designed with patients' needs at the forefront: the ability to change appointment dates, the location in where the appointment is held, parking facilities, length of appointment, type of appointment, is a virtual appointment or telephone appointment more appropriate? If you have a learning disability, you may have a family member or carer with you. If you have transitioned out of children’s services you will be seeing someone new, in a new environment. You may not have had the time to discuss the fine nuances to your care that is really important to you. You have now left the comfort bubble of paediatrics where you and your family had built up trust with the previous consultant and care team, and you are now having to build up new relationships. What is in place for you to feel comfortable? Has anyone asked what would help? The consultation Reasonable adjustments such as a double-length consultation is a great way of ensuring people with learning disabilities have enough time to process information and are given time to answer questions. Extra time is only one of many reasonable adjustments that can be made. An example... I would like to reflect on a recent time when I cared for a patient with autism and I didn’t have all the information to enable me to plan care for them at this particular time. This patient had spinal surgery and spent a very brief period on the intensive care unit. As part of my role as a critical care outreach nurse, I see patients who have been in the intensive care unit to check that they are doing well, that ongoing plans of care are in place and that they understand what has happened to them. I read that this patient had autism, but I had no other information. I was unaware of how the autism affected her, if she needed a carer, what she likes, dislikes, how to approach conversations or anything that was important to her. There is a health passport that can be used to aid exactly this information, this is filled out by the patient with their family or carer. Unfortunately, I could not locate the passport. I read the medical notes and went in armed with my usual questions and proforma that we use for all patients. Usual visits like this last from around 10 minutes (for a quick check) to an hour if they are a complex long stay. With the operation that this patient had, I was expecting to be with the patient for around 20 minutes. After introducing myself to the patient, it was clear that the proforma I was going to use wasn’t going to work. Tick boxes and quick fire questions were not the right way of going about this consultation. This patient was scared. More scared than a patient without autism. Their usual routine was gone, they were unable to ask as many questions as they normally would as the nurses and doctors were busy, their surroundings were different, the food was different, new medications, new faces everyday – there was no consistency. The ward round had just happened, the patient had a good plan in place and was due to go home the following day. Normally, this would mean that my visit would be a quick one as the clinical needs of the patient are less complex. This visit took me 90 minutes. Not only did I not have the care passport to hand, due to the coronavirus pandemic I had a face mask on. I felt completely ill-equipped for this consultation. I knew I was missing vital pieces of information which would help me communicate with this patent more effectively. So much of our communication is from facial expressions. A smile for reassurance makes a huge difference. I now have yet another barrier to overcome to communicate with my patient in a way that they can understand and feel comfortable. This particular patient asked many questions. This I had not factored into my day. I have a list of 12 patients to see, in between answering calls from staff on wards who have unwell patients for me to review. It’s too late to abandon the consultation or leave it for a less busy time. I’m at the patient’s bedside and I’m already committed to giving this patient my full attention. After we spent around 20 minutes discussing why I had to wear a mask, what the mask was made of, how many I had to wear in a day, why patients were not wearing masks, we then got onto the subject of food. Where the food is made, how does it get here, who heats it up? Then it came to the other patients in the bay. She knew all of them by name and proceeded to tell me the goings on that happened during the night. I’m clearly not going to get my proforma completed here. This is because my proforma is not important to my patient. "What matters to you?" During my Darzi Fellowship I had the opportunity to visit the Royal Free. Here I met an amazing physiotherapist called Karen Turner. She introduced me to asking the question ‘What matters to you?’ Simple – but so very effective and empowering for your patient to be asked this. The food, my mask and the people around her were of greatest importance to my patient at this time – not what she thought of her stay or if she wanted me to go through the intensive care unit steps booklet; these were important for me to know, these were questions that gave the Trust insight of what is important to them. It dawned on me that we had designed our follow-up service to suit us and not involved families or the patient. I feel a quality improvement project coming on! Reasonable adjustments take planning, as clinicians we need to know about them. We need to factor them into our work. The NHS has just enough capacity to run if all patients followed the NHS pathways, if all patients grasped everything and followed all instructions, took their medications on time, turned up for their appointments – there wouldn’t be a problem. It takes me back to the clip from the BBC programme ‘Yes Minister’ of the fully functioning hospital with no patients and that services run very well without patients! Currently systems within the NHS are designed around the building, the staff within it and the targets that are set out by NHS England and the Department of Health and Social Care. If we started designing care and access around patient need and ask them what would make it easier – what helps? what matters to you? – what would healthcare look like? During this time of uncertainty and change, I see exciting opportunities to take stock and see what’s working and what isn’t – and lets start involving patients at every stage. Call to action What are you doing to ensure reasonable adjustments are made for people with learning disabilities where you work? What more needs to be done to ensure that people with learning disabilities feel part of the conversation and play an active role in their care? Are you a patient, carer or relative? What has your experience been like? Have you any experiences in designing services with patients? Perhaps you are a patient and have been a part of the process. Add your comments below, start a conversation in the Community area or contact us. We'd love to hear your thoughts and experiences.
  5. News Article
    Pregnancy support helplines are experiencing a massive spike in distressed pregnant women asking for urgent help as charities warn coronavirus upheaval is placing pregnant women at risk. Frontline service providers warn mothers-to-be are anxious about whether they will be denied pain relief options and be separated from their newborn babies due to them being put in neonatal units. Birthrights, a maternity care charity, found enquiries to its advice line in March were up by 464 per cent in comparison to March last year. Women getting in touch also raised concerns about home birth services being withdrawn, midwifery-led birth centres shutting their doors and elective caesareans being discontinued due to the COVID-19 crisis. Baby charity Tommy’s experienced a 71% surge in demand for advice from midwives on its pregnancy helpline last month. The organisation warned coronavirus turmoil is placing pregnant women at risk after their midwives answered 514 urgent calls for help in April which is a sizeable rise from the 300 enquiries they would generally get. Jane Brewin, the charity’s chief executive, said: “Antenatal care is vital for the wellbeing of mother and baby – but the coronavirus outbreak means that many don’t know who they can ask for help, or don’t want to bother our busy and beloved NHS." “Although services are adapting, they are still running, so pregnant women should not hesitate to raise concerns with their midwife and go to appointments when invited. The large increase in people contacting us demonstrates that coronavirus is creating extra confusion and anxiety for parents-to-be, making midwives’ expert advice and support even more important at this time.” Read full story Source: The Independent, 5 May 2020
  6. News Article
    GPs are having end of life conversations with their patients because of concerns over a lack of intensive care beds during the coronavirus crisis. Multiple GPs have told HSJ they are talking to patients who are older or in very high risk groups about signing “do not attempt to resuscitate” forms in case these patients were to go on to contract the virus. Some practices have also sent letters to patients requesting they complete the forms, it is understood. One leader of a primary care network, who asked not to be named, told HSJ: “Those in the severe at-risk group and those over 80 are being told they won’t necessarily be admitted to hospital if they catch coronavirus.” Read full story Source: HSJ, 1 April 2020
  7. Content Article
    During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution of fizz, unaware of the hazards. I believe it is still being used to colour hair, remove blood stains, as a mouthwash gargle and also to whiten teeth. Then suddenly a breakthrough! In 2014, in my email inbox, a yellow sticker warning appeared from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the use of hydrogen peroxide in deep cavities. So why did the MHRA ban the use of hydrogen peroxide in deep cavities? Hydrogen peroxide is contraindicated for use in closed body cavities or on deep or large wounds due to the risk of gas embolism. Hydrogen peroxide breaks down rapidly to water and oxygen on contact with tissues. If this reaction occurs in an enclosed space, the large amount of oxygen produced can cause gas embolism.[1] There has been several case reports that have been published from around the world of life threatening or fatal gas embolism with use of hydrogen peroxide in surgery, of which five were from the UK. Most of the global reports describe cardiorespiratory collapse occurring within seconds to minutes of instillation of hydrogen peroxide as wound irrigation or when used to soak swabs for wound packing. This was sometimes accompanied by features associated with excess gas generation such as surgical emphysema, pneumocephalus, aspiration of gas from central venous lines, or the presence of gas bubbles on transoesophageal echocardiography. Non-fatal events were sometimes associated with permanent neurological damage such as neuro-vegetative state and hypoxic encephalopathy.[1] As the Practice Development Lead for the theatre department where I worked it was my role to pass on and act on the information received from the MHRA, so I discussed it with my very supportive theatre manager and then escalated to the theatre staff. But some consultants still ask for it today; it is always refused. So why do consultants request it when they are aware of the hazards? One theatre never event describes a syringe of hydrogen peroxide given to a consultant and injected into a joint instead of the required local anaesthetic![2] The patient survived but required care in the intensive care unit. As a scrub nurse practitioner this scares me. What about you? Would you now research this yellow sticker alert further, implement best practice and speak up, or would you just keep quiet and go "with the flow?" We all make mistakes, but learning from our errors will always be the ultimate key to improvement in healthcare and best practice and safety for our patients. References 1. Medicines and Healthcare products Regulatory Agency. Hydrogen peroxide: reminder of risk of gas embolism when used in surgery. 19 December 2014. 2. Chung J and Jeong M. Oxygen embolism caused by accidental subcutaneous injection of hydrogen peroxide during orthopedic surgery. A case report. Medicine (Baltimore) 2017; 96(43): e8342.
  8. News Article
    Hundreds of women have said they’ve undergone “distressing” diagnostic tests at NHS hospitals which were not carried out in line with recommended practice. Around 520 women who attended NHS hospitals in England to undergo hysteroscopies — a procedure which uses narrow telescopes to examine the womb to diagnose the cause of heavy or abnormal bleeding — have told a survey their doctors carried on with their procedures even when they were in severe pain. This is despite the Royal College of Obstetricians and Gynaecologists advising clinicians should offer to reschedule with the use of general anaesthetic, epidural or sedation if the pain becomes unbearable. The Campaign Against Painful Hysteroscopy patient group has surveyed 860 women who had had the procedure at an English NHS hospital, and shared the results with HSJ. Of them, 750 said they were left distressed, tearful or shaken by the procedure, with around 466 of them saying that feeling remained for longer than a day. Many of the women said their painful hysteroscopies damaged their trust in healthcare professionals, had made cervical smears more painful and had a negative impact on sexual relationships. Patient Safety Learning have connected with the campaigning group 'Hysteroscopy Action' on this issue. We have seen stories and comments posted on the hub from patients who have suffered similar distressing experiences. We are using this feedback and evidence to help campaign for safer, harm-free care. We welcome others to join in the conversation. Read full story (paywalled) Source: HSJ, 2 March 2020
  9. Content Article
    The second edition takes a more practical approach with coverage of methods, interventions and applications and a greater range of domains such as medication safety, surgery, anaesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management. Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.
  10. News Article
    Dozens of women who thought they were having a "complete mesh removal" have discovered material has been left behind, the BBC's Victoria Derbyshire programme has been told. Some women have been left unable to walk, work or have sex after having the initial vaginal-mesh implants. Specialist surgeons say in some cases total or partial mesh removal can be beneficial. But some women said their symptoms had become worse. One was left suicidal. Vaginal-mesh implants remain available on the NHS in England but only when certain conditions are met. In Scotland, the use of mesh was halted in 2018. One paitent said her surgeon had promised her a "full mesh removal", but she has now been told more than 10cm (4in) could have been left behind. She had the mesh implanted several years ago to treat urinary incontinence and said she had woken after the surgery with "chronic pain in my legs, my groin and my hips". It is believed she suffered nerve damage. A year later – after being told by one expert a mesh removal would be unlikely to resolve her pain – she found a surgeon who told her the implant could be completely removed. She had two operations, each taking her half a year to recover from, and was told there had been a full removal. But "within a few months" the pain began to return and her health deteriorated and she found out that only 5–8cm had been removed. "My whole world turned upside down," she said, breaking into tears. She has since been told by a separate specialist her form of mesh was one of the most difficult to remove and could cause significant nerve damage if not removed properly. She said she had never been told this by her surgeon. The number of women affected is unknown but the Victoria Derbyshire programme understands there are at least dozens of such cases. The Royal College of Obstetricians and Gynaecologists said in a statement that it took "each and every complication caused by mesh very seriously". It said: "Women must be informed of all options available and the benefits and risks of each so they can make the best decision about their care." Read full story Source: BBC News, 6 February 2020
  11. Content Article
    Key learning points If the patient had been more closely observed it is likely cardio-respiratory arrest and subsequent hypoxic brain injury could have been avoided. Effective procedures for nurse communication, effective handover and observation of critically unwell patients in intensive care and high dependency units are very important to safe patient care. Bedside and remote monitoring equipment provide vital information to staff and should be properly maintained and replaced where necessary.
  12. Content Article
    From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
  13. Content Article
    The group’s conclusions are that six domains of care communication warrant attention and improvement: the care environment information exchange attitude and listening aligning and responding team communication communicating with unique groups. Together, these domains expand the definition of healthcare communication from communication as information transaction to communication as complex social and local dynamic. The report outlines the consequences of this expanded definition for healthcare communication improvement and improvement research.
  14. Content Article
    This document outlines the seven Caldicott Principles to be adhered to with in all sectors of the NHS: Principle 1 - Justify the purpose(s) for using confidential information. Principle 2 - Don't use personal confidential data unless it is absolutely necessary. Principle 3 - Use the minimum necessary personal confidential data. Principle 4 - Access to personal confidential data should be on a strict need-to-know basis. Principle 5 - Everyone with access to personal confidential data should be aware of their responsibilities. Principle 6 - Comply with the law. Principle 7 - The duty to share information can be as important as the duty to protect patient confidentiality.
  15. News Article
    Mother Natalie Deviren was concerned when her two-year-old daughter Myla awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless. She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice. She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit. Myla died from an intestinal blockage the next day and could have survived with treatment. The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times. In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.” Read full story Source: The Times, 5 January 2020
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