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Found 131 results
  1. News Article
    Major progress made in sepsis care during the previous decade has been significantly reversed amid repeated failures in recognising and treating the condition. HSJ has identified 31 deaths in the last five years where coroners have warned of systemic problems with diagnosing and treating sepsis, including nine cases relating to children. Many of the deaths were deemed avoidable. Meanwhile, investigations suggest a majority of acute trusts are failing to record their treatment rates for sepsis, which is deemed a crucial aspect of driving improvements. Repeated shortcomings raised by coroners, including 10 separate cases in 2023, include delays or failures to administer antibiotics, not following protocols for identifying sepsis, and inaccurate, missed or skipped observations. Health ombudsman Rob Behrens, who issued a report on sepsis failures last year, said the same mistakes were “clearly being repeated time and time again”. He added: “What is chilling to me is that these [coroners’ reports] fit in almost exactly with the issues we raised in our sepsis report… and even the 2013 sepsis report issued by my predecessor, including unnecessary delays, wrong diagnosis, and failure to provide adequate plans for sepsis.” Read full story (paywalled) Source: HSJ, 27 February 2024
  2. Content Article
    Corridor nursing is increasingly being used in the NHS as demand for emergency care grows and A&E departments struggle with patient numbers. In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury.  Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes.
  3. News Article
    Doctors tore down posters offering patients a secondary care review if they were worried about their condition in hospital, the mother of a teenager who died of sepsis claimed. Merope Mills, who has campaigned for a similar policy called “Martha’s Rule” named after her 13-year-old daughter, claimed a small minority of “bad actors” in hospitals risked slowing down the initiative. It comes as NHS England announced 100 hospitals with critical care units will be invited to sign up for the policy, which will be rolled out from April this year. Martha died from sepsis in 2021 after staff at King’s College Hospital failed to move her to intensive care despite her family warning them her condition had deteriorated. “When something similar to Martha’s Rule was introduced to Royal Berkshire Hospital, doctors actually pulled down the posters advertising the service to patients because they hated the idea of giving patients this kind of power,” Mrs Mills told the Today Programme. “A small minority of bad actors whose arrogance, complacency or pride stops them listening and doing the right thing and that is what we are trying to challenge with Martha’s Rule. There are pockets of damaging cultures in hospitals around the country. Sometimes it is not a whole hospital, sometimes it is just a ward in a hospital, sometimes it is just a particular individual on a ward in a hospital.” Read full story Source: The Independent, 21 February 2024
  4. News Article
    The 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
  5. Content Article
    NHS England’s Worry and Concern Collaborative is looking into how hospitals can make sure the worries and concerns of patients, their family and friends about a patient in hospital are taken into account by doctors, nurses and other health professionals.  This webinar, hosted by the Patients Association explored: The role of the National Worry and Concern Collaborative and its seven pilot sites the experiences of both clinicians and patients how these services need to be designed and delivered.
  6. Content Article
    This NICE guideline covers the recognition, diagnosis and early management of suspected sepsis. It includes recommendations on recognition and early assessment, initial treatment, escalating care, finding the source of infection, early monitoring, information and support, and training and education.   In January 2024,, the evidence was reviewed and NICE has made new recommendations on risk evaluation and management of suspected sepsis for people aged 16 or over who are not and have not recently been pregnant, in mental health, ambulance and acute hospital settings. This covers the population and settings in which the national early warning score (NEWS2) applies.
  7. News Article
    People who are severely ill with suspected sepsis should promptly be given life-saving access to antibiotics to prevent unnecessary deaths, according to updated guidance from the National Institute for Health and Care Excellence (NICE.) The guidelines state that the national early warning score should be used to assess people with suspected sepsis aged 16 and over, who are not and have not recently been pregnant, and are in an acute hospital setting or ambulance. The updated guidance also recommends that doctors are more considerate as to who is given antibiotics, in order to reduce the risk of antibiotic resistance in people being prescribed them for less severe cases of sepsis. With the update, NICE says that more people will be categorised at a lower risk level where a sepsis diagnosis should be confirmed before being given antibiotics. Prof Jonathan Benger, Nice’s chief medical officer, said: “This useful and usable guidance will help ensure antibiotics are targeted to those at the greatest risk of severe sepsis, so they get rapid and effective treatment. It also supports clinicians to make informed, balanced decisions when prescribing antibiotics. “We know that sepsis can be difficult to diagnose so it is vital there is clear guidance on the updated [national early warning score] so it can be used to identify illness, ensure people receive the right treatment in the right clinical setting and save lives." Read full story Source: The Guardian, 31 January 2024
  8. Content Article
    The early recognition and treatment of deterioration in patients in clinical settings can help reduce avoidable deaths. NHS England commissioned Florence Nightingale Foundation (FNF) to examine the barriers which prevent worries and concerns being raised about a deteriorating patient. Evidence suggests that organisational culture, professional hierarchies, and the nature of leadership in healthcare environments are the three key factors behind this reluctance. The findings highlight the importance of psychological safety which is highly influenced by authentic leadership in overcoming these barriers.
  9. Content Article
    Appropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study from Ede et al. were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process.
  10. Event
    until
    NHS England’s Worry and Concern Group is looking into how hospitals can make sure the worries and concerns of patients, their family and friends are taken into account by doctors, nurses and other health professionals. This webinar will explore: The work done during the worry and concern pilots The experience of patients and clinicians who took part in the pilot studies How to ensure patient involvement in the design of a nationwide worry and concern programme. Panellists: John Bamford, Patient Safety Partner Kayleigh Griffiths MBE, member of National Worry and Concern Steering Group Jane Murkin, Deputy Director Safety & Improvement – Nursing, NHS England Prof Damian Roland , Honorary Professor of Paediatric Emergency Medicine, University of Leicester John Welch, Consultant Nurse, Critical Care & Critical Care Outreach, University College London Hospitals NHS Foundation Trust. Chief Executive of the Patients Association, Rachel Power, will chair the webinar. This webinar is being held on Zoom and is free to join. Register for the webinar
  11. Event
    This conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. The Recording of NEWS2 score, escalation time and response time for unplanned critical care admissions is now an NHS CQUIN goal. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/deteriorating-patient-summit or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #DeterioratingPatient
  12. Event
    This conference brings together leading experts at the forefront of Martha’s Rule implementation and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/marthas-rule-patient-safety or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code.
  13. Content Article
    NEWS is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. In December 2017, an updated version of NEWS, NEWS2 was published. NEWS2 has been endorsed by NHS England and NHS Improvement – for use in acute and ambulance settings. NEWS2 has seen widespread uptake across the NHS in England – at present 100% of ambulance trusts and 76% of acute trusts are using NEWS2, with other early warning scores in place in other areas. However, confusion caused by the current variation in practice can compromise patient safety, something that would be eliminated by use of a common tool. Through standardisation of NEWS2, we can reduce the number of patients whose conditions deteriorate whilst in hospital, and potentially save over 1,800 lives a year.
  14. Content Article
    The aim of this project was to introduce and evaluate the Call 4 Concern© (C4C) service, which provides patients and relatives with direct access to critical care outreach services (CCOS). This allows patients and relatives an additional platform to raise concerns related to the clinical condition and facilitate early recognition of a deteriorating patient. The introduction of Call 4 Concern at a district general hospital was inspired by the Royal Berkshire Hospital, where staff have been pioneering the service in the UK since 2009. They were able to demonstrate the potential to prevent clinical deterioration and improve the patients' and relatives' experiences.  The project was originally inspired by the Condition H(elp) system in the USA, which was set up following the death of an 18-month-old child who died of preventable causes. Similar tragic cases in the USA and the UK have prompted campaigning by affected families, resulting in the widespread adoption of comparable services. The project was rolled out in the authors' trust for all adult inpatients. There was a 2-week implementation phase to raise awareness. Between 22 February 2022 and 22 February 2023, the CCOS team received 39 C4C referrals, representing approximately 2.13% of the total CCOS activity. Clinical deterioration of a patient was prevented in at least three cases, alongside overwhelming positive feedback from service users.
  15. Content Article
    NHS hierarchies and paternalistic cultures can mean patients’ and families’ concerns are dismissed or undermined—but challenging them can be lifesaving. In this opinion piece for the BMJ, Zosia Kmietowicz shares the story of her son's experience at A&E, when a nurse intervened to question a doctor's treatment plan to ensure he received antibiotics for meningitis. She highlights the need for a system that allows staff to intervene when they are concerned, regardless of their status or position in the system.
  16. Content Article
    Martha Mills was 13 when she tragically died due to a series of medical errors. In this video by the Patient Safety Movement Foundation (PSMF), Martha's mother Merope Mills tells her story and aims to raise awareness about the consequences of medical errors. Merope advocates for improved patient safety measures including the introduction of Martha's Rule, which will allow patients and their families to trigger an urgent clinical review from a different team if they are in hospital, are deteriorating rapidly and feel they are not getting the care they need.
  17. Content Article
    Early recognition and treatment of sepsis are linked to improved patient outcomes. Machine learning-based early warning systems may reduce the time to recognition, but few systems have undergone clinical evaluation. In this prospective, multi-site cohort study, Adams et al. examined the association between patient outcomes and provider interaction with a deployed sepsis alert system called the Targeted Real-time Early Warning System (TREWS). The findings indicate that early warning systems have the potential to identify sepsis patients early and improve patient outcomes and that sepsis patients who would benefit the most from early treatment can be identified and prioritised at the time of the alert.
  18. Event
    until
    Five people die with sepsis every hour in the UK. Sepsis is a serious complication of an infection. Without quick treatment it can lead to multiple organ failure and death. Sepsis often goes undiagnosed and it is important to raise awareness of the symptoms and what to look out for in order to reduce the number of sepsis-related death. This webinar will give attendees a chance to hear from Dr Ron Daniels, Founder & Joint CEO of the UK Sepsis Trust and Melissa Mead, whose son William died from sepsis in 2014 and has passionately campaigned to raise awareness of the issue ever since. The webinar is free to attend and there will be time for Q&A towards the end. Register
  19. Content Article
    Hospitalised adults whose condition deteriorates while they are on hospital wards have considerable morbidity and mortality. Early identification of patients at risk of clinical deterioration has traditionally relied on manually calculated scores, and outcomes after an automated detection of clinical deterioration have not been widely reported. The authors of this article published in The New England Journal of Medicine developed an intervention program involving remote monitoring by nurses who reviewed records of patients who had been identified as being at high risk. Results of this monitoring were then communicated to rapid-response teams at hospitals. They compared outcomes among hospitalised patients whose condition reached the alert threshold at hospitals where the system was operational, with outcomes among patients at hospitals where the system had not yet been implemented. The authors found that using an automated predictive model to identify high-risk patients, for whom interventions could then be implemented by rapid-response teams, was associated with decreased mortality. 
  20. Content Article
    Reducing the amount of time to give antibiotics to sepsis patients should contribute to better health outcomes, but the broad impact of reducing time-to-antibiotics may vary significantly, according to an AHRQ-funded study. In the study, published in Annals of the American Thoracic Society, researchers found that in 60% percent of hospitalisations patients received antibiotics within 48 hours of presentation and in 13% of hospitalisations patients experienced an adverse event, based on records of over 1.5 million hospitalised patients. The authors then ran simulations of 12 hospital scenarios based on the volume of sepsis cases (high, medium and low volume), and found that the effect of faster time to antibiotics varies markedly across simulated hospital scenarios, but new antibiotic-associated adverse events were rare.
  21. Content Article
    Sepsis Research FEAT and the James Lind Alliance have launched a survey giving health and social care professionals and sepsis patients and their carers the unique opportunity to shape future sepsis research.   The sepsis priority setting partnership (PSP) aims to identify and prioritise unanswered questions relating to sepsis. Input into this survey from your network will be invaluable.  This process is essential to ensuring that resources are channelled towards the issues that will genuinely benefit patients and will elevate underrepresented voices.  The survey and further information can be found from the link below.
  22. Content Article
    Chief Medical Officer Professor Chris Whitty's annual report recommends actions to improve quality of life for older adults and prioritise areas with the fastest growth in older people.
  23. Content Article
    While at Amberley Hall Care Home for rehabilitation, Geoffrey Whatling’s family had raised concerns that he was unwell. He was scored as a 7 on the National Early Warning Score (NEWS2) system on the 8 April 2023. Such a score requires a 999 call to be made, however instead a 111 call was made. The 111 call taker was not made aware of his NEWS2 score. Further observations were carried out on 9 April 2023 (NEWS2 score 6), and 07.00 (NEWS2 score 5) and again on 10 April 2023 at 12.13 (NEWS2 score 9/10), when emergency services were called and Mr Whatling was admitted to Queen Elizabeth Hospital. Despite treatment his condition continued to deteriorate and he died on 26 April 2023.
  24. Content Article
    The National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system. SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes. SIPs are delivered by local healthcare providers working directly with the National Patient Safety Improvement Programmes Team and through 15 regionally-based Patient Safety Collaboratives. The five National Patient Safety Improvement Programmes (NatPatSIP) are as follows: Managing Deterioration Safety Improvement Programme (ManDetSIP) Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) Medicines Safety Improvement Programme (MedSIP) Adoption and Spread Safety Improvement Programme (A&S-SIP) Mental Health Safety Improvement Programme (MH-SIP) This report summarises the progress of the National Patient Safety Improvement Programmes.
  25. Content Article
    These charts have been collaboratively developed by clinical teams across England to standardise how the deterioration of children in hospital is tracked. There are four charts for children of different ages, designed to be used on general children’s wards. PEWS observation and escalation chart: 0 to 11 months PEWS observation and escalation chart: 1-4 years PEWS observation and escalation chart: 5-12 years PEWS observation and escalation chart: ≥13 years
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