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Found 66 results
  1. Content Article
    Key findings National Hip Fracture Database (NHFD) The number of hip fractures changed very little during the pandemic, so this is an ideal marker of the pandemic’s impact on the care of frail and older people and shows how successive waves of Covid-19 affected outcomes (mobility, return home, length of stay and mortality) in Wales. National Audit of Inpatient Falls (NAIF) There were approximately 12,500 inpatient falls in 2021. These led to: over 195 hip fractures loss of confidence and slower recovery distress to families and staff litigation against health boards. Fracture Liaison Service Database (FLS-DB) Based on 1,956 fragility fractures in 2020 and 2,033 fragility fractures in 2021, the number receiving FLS assessment within 12 weeks was similar in 2020 and 2021 (64% and 65% respectively). Recommendations Local health boards should ensure that they have appointed an orthogeriatrician and that they actively support their leadership of multidisciplinary care in each trauma unit. Local health boards should ensure that falls teams in acute, community and mental health hospitals are included in quality improvement activities and are using the data from the National Audit of Inpatient Falls. With falls teams reviewing health board level data and implementing focused quality improvement interventions should help improve the quality and safety of care in hospitals. Health boards without an FLS should contact the Royal Osteoporosis Society and use their implementation toolkit to support them in preparing a business case. Health boards that already have an FLS should ensure it is actively participating in the FLS-DB, and meeting its expected outcomes as defined by the FLS-DB’s set of KPIs.
  2. Content Article
    The resources below have been categorised into the three audits within FFFAP: National Hip Fracture Database (NHFD) National Audit of Inpatient Falls (NAIF) Fracture Liaison Service Database (FLS-DB) Hip fracture: a guide for families and carers All about your hip fracture and what to expect on the road to recovery Recovering after a hip fracture: helping people understand physiotherapy in the NHS How should your hospital prevent and respond falls during your stay Inpatient falls Falls prevention in hospital: a guide for parents, their families and carers What should happen if you or someone you know experiences a fragility fracture Six golden rules for stronger bones Strong bones after 50 - after staying on treatment
  3. News Article
    A new scheme in Wales to help people who have suffered falls has prevented 50 ambulances being unnecessarily sent this year. St John Ambulance works with Hywel Dda health board in Pembrokeshire to send its people when someone calls 999. The pilot has been used 96 times since January but it needs more health board funding to continue after March. Ageing Well in Wales estimates that between 230,000 and 460,000 over 60s fall each year. When people dial 999, it can be directed to the St John Ambulance falls response team, who are sent to perform an assessment and identify whether the person can stay home or needs an ambulance to take them to hospital. St John Ambulance operational team leader Robert James said in 60% of cases, the person was well enough to stay at home. "You can imagine if you were sending an ambulance crew out and it has wasted 60% of the crew's time, well it's a big saving towards the NHS and the ambulance service in itself," he added. "Provided there are no injuries, or reason for them to go to hospital, they can be discharged on the scene." Read full story Source: BBC News, 10 March 2023
  4. Content Article
    March 2023 - GripAble for upper limb rehabilitation, Mindray C2 AEDs, recruitment for Patient Safety Partners, Clostridium difficile infection, Bivona tracheostomy tube, therapy dogs. patient-safety-newsletter-march2023.pdf February 2023 - Patient feedback, Trust's Patient and Public Voice Policy, Patient Safety Partners, safe wheelchair risk assessment, referral to prolonged jaundice clinic. patient-safety-newsletter-february2023.pdf January 2023 - Dementia friendly ward, National Audit for Inpatient Falls (NAIF), investigation training, CQUINS, ePMA, Health Visitor teams. patient-safety-newsletter-janaury2023.pdf December 2022 - Supporting hydration (HCSW Innovation Idea project), deteriorating patient thematic review, investigation training, checking the right saline, Professional Nurse Advocacy, Medical Device Safety Lead. patient-safety-newsletter-december2022.pdf November 2022 - Reducing the use of fall alarms, wound photography, defining levels of assistance when moving patients, Duty of Candour. patient-safety-newsletter-november2022.pdf October 2022 - Reminiscence Interactive Therapeutic Activities RITA systems, pressure ulcers on heels, post falls checklist, importance of carers care plans, Datix and LfPSE. patient-safety-newsletter-october2022 (1).pdf September 2022 - World Patient Safety Day, ordering and fitting mattress toppers, PSIRF, Sussex interpreting services, risk assessment to prevent pressure sores. patient-safety-newsletter-september2022.pdf August 2022 - Thematic review to discuss falls on the unit, Duty of Candour requirement, reporting a pressure ulcer on Datix, UTC and learning disability health facilitation team table top, care home matrons. patient-safety-newsletter-august2022.pdf July 2022 - Collaboration with the IC24 Roving GP service, critical limb ischaemia, Genius 2 and 3 thermometers, implementing the Patient Safety Strategy, introducing Professional Nurse Advocates and Patient Safety Learning's hub. patient-safety-newsletter-july2022.pdf June 2022 - New visual fluid chart tool, bruising in children who are not independently mobile, end PJ paralysis campaign, investigation training and the importance of personalised communication. patient-safety-newsletter-june2022 (1).pdf May 2022 - Why frailty matters’ week, audit of unstageable pressure ulcers reported on Datix and risk assessing pressure ulcer equipment. patient-safety-newsletter-may2022 (1).pdf April 2022 - ICUs engaging in recent table tops to discuss the falls prevention on the ward, paraffin fire risk leaflet, improving the environment for patients with dementia and safeguarding babies. patient-safety-newsletter-april2022.pdf March 2022 - Patients leaflet on what to expect from therapy during ICU admission and the aim of rehabilitation on the unit, falls alarm, falls in toilets and bathrooms, food fortification, project to develop better tools to monitor food and fluid intake, new or changing confusion, and the importance of end of life care. patient-safety-newsletter-march2022 (1).pdf February 2022 - Homeless Health Inclusion Team, ensuring an MDT falls review, following the no response policy, End of Life Care plan and alerts on SystmOne. patient-safety-newsletter-february2022 (2).pdf January 2022 - patient-centred care, NEWS2 on paper, ensuring safe use of Smartcards, fluid balance charts and the importance of education. patient-safety-newsletter-january2022.pdf December 2021 - a PCN Quality feedback session, the impact of student projects, safe use of wheelchairs on the ICU, the delirium alert on SystmOne and the Herbert protocol patient-safety-newsletter-december2021 (1).pdf November 2021 - hover jacks, taking photos of pressure ulcers, enhanced care assessments, an update from the deteriorating patient and resuscitation lead, and ensuring effective communication. patient-safety-newsletter-november2021 (1).pdf
  5. News Article
    A health board has been fined £180,000 for failing to protect a vulnerable pensioner who died after repeatedly falling in hospital. Colin Lloyd, 78, was assessed as posing a high risk of falling and required one-to-one care after being admitted to Raigmore Hospital in Inverness. Despite repeated requests for more nursing staff none were made available and the pensioner suffered falls on the ward, which caused fatal injuries. Fiona Hogg, NHS Highland’s director of people and culture, said: “We are deeply sorry for the failures identified in our care. Our internal review following the incident identified several areas of improvement and we have made a number of changes to our practice.” Read full story (paywalled) Source: The Times, 15 February 2023
  6. Content Article
    Key findings More patients were recommended anti-osteoporosis medication in 2021 than in 2019 (56% vs 52%), and The percentage of patients who were followed up within 16 weeks of their fragility fracture has increased from 41% in 2019 to 47% in 2021. This report also contains a number of recommendations for patients and carers, and for senior executive decision makers. This includes a call for the latter to hold a key stakeholder meeting to explore how local needs for fragility fracture patients can be met.
  7. Content Article
    Mrs Hazel Fleur Wiltshire was admitted to the Princess Royal University Hospital on 14 January 2021 following a fall at home. Although she had a number of factors indicating a risk of further falls, no risk assessments were completed on three wards and there was no evidence that measures that could mitigate the risk of falls were considered. Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to relive herself without assistance which caused her to fall. She died in hospital on 19 February 2021 from pneumonia caused by the fall and by Covid 19 that she acquired in hospital. Coroner's concerns: The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times. Staffing levels were inadequate due to higher dependency of patients with Covid. I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs. Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell. The family could hear other patients on the ward crying out for help. Although Mrs Wiltshire was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed. This suggests a systemic problem across the hospital that requires remedial action.
  8. Content Article
    Summary recommendations The National Screening Committee should reconsider the case for a targeted national screening programme to detect high fracture risk in 2023. The Government should instigate a public health campaign to address the lack of awareness and complacency in the public about bone health. Osteoporosis must be given parity with other long-term conditions, and defined as such within the NHS, to allow enhanced and equitable care and management. NHS England must outline plans to expand DXA services to deliver and exceed their recommended 4% increase in capacity in order to tackle the current backlog and future-proof services, and improve access by including DXA in minimum specifications for Community Diagnostic Centres. Every individual who requires ongoing management or surveillance to reduce their fracture risk should have a personalised ‘bone health management plan’ with a specified timescale for reviews. ICSs should utilise the breadth of skills and expertise within the multi-disciplinary team to optimise and streamline local management pathways for people at high risk of fragility fracture. Establish a new National Specialty Adviser for Fracture prevention and Osteoporosis within the NHS England and NHS Improvement clinical advisory structure, and equivalent in Scotland, Wales and Northern Ireland. The APPG recommends proportionate recognition of the importance of osteoporosis throughout healthcare education, with increased prominence in undergraduate and post-graduate healthcare professional training. Specialist services must support primary care colleagues to provide the best care to patients. All relevant national guidelines should be reviewed to better support imaging of the spine where there is a suspicion of vertebral fracture, particularly in patients with risk factors for osteoporosis. NHS England must provide sufficient funding for ICSs to deliver against national quality standards and NICE clinical guidance.
  9. Content Article
    Key messages Fall-related fractures can happen on any ward There is only one chance to get it right High quality multi-factorial risk assessment (MFRA) is necessary to ensure important fall risk factors are addressed Accurate post-fall checks support effective care All inpatients should have access to flat lifting equipment to move patients from the floor Inpatients who sustain a femoral fracture should have immediate access to analgesia Improvement activities should focus on fall prevention and post-fall management processes
  10. News Article
    The number of falls and bed sores recorded in Scotland's hospitals has increased since the Covid pandemic, new data shows. NHS staffing pressures and the deconditioning effect of the Covid lockdown creating more frail patients are being blamed for the rise. The Scottish government paused work on a national prevention strategy for falls when the pandemic started. The strategy has now been shelved and experts argue this is a mistake. Figures released by NHS Healthcare Improvement Scotland (HIS) show that in 2018-19 - the last full year before the Covid pandemic - a total of 26,489 falls were recorded in hospitals. Dawn Skelton, a professor in ageing and health at Glasgow Caledonian University, said there was a "maelstrom" of problems fuelling the increase in hospital falls. She said: "You've got staffing issues definitely but you've also got people who are going in to hospital a step change frailer than they were pre-Covid because of what has happened with all the restrictions. "The people in these falls figures have got no reserves, blow on them and they will fall over, so they are at more risk when they go in." IProf Skelton said it was time to resurrect the Scottish government's falls and fracture prevention strategy as its "value now cannot be underestimated". She added: "Falls and frailty are one of the main causes of long hospital stays and demands on social care and without a spotlight on both the management, but also prevention, the financial and staffing demands on NHS and social care will only rise." Read full story Source: BBC News, 10 November 2022
  11. News Article
    Elderly people who call for help after a fall at home will no longer be left waiting for hours on the floor, the head of the NHS has said, as she bids to keep patients out of hospital and stop the service being overwhelmed this winter. Amanda Pritchard said she would start a new national service within weeks under which community teams would offer immediate help to people who had had an accident but had avoided serious injury. Pritchard, who took over as chief executive of NHS England last year, said a quarter of less severe 999 calls in January involved falls. The new teams could stop 55,000 elderly people a year being taken to hospital, she said. All NHS areas will be told this week to establish the service before a “very, very, very challenging winter” for the health service. Read full story (paywalled) Source: The Times, 16 October 2022
  12. Content Article
    Recommendations Hip fracture teams should use quarterly governance meetings to review the quality and outcome of the care they provide. Where performance is significantly below average, units should formally discuss possible reasons for this within their regular MDT meeting, and plan a QI project to address it. Quarterly governance meetings should be taken as an opportunity for team members and trainees from all disciplines to make use of the NHFD website as a driver for QI; the new Quarterly Governance Tool is designed to help them do this. The NHFD recommends that governance meetings of surgical, orthogeriatric, anaesthetic, nursing, therapy and management leads should take place on at least a monthly basis. Monthly governance meetings should be used to plan appropriate QI interventions, and to monitor the impact of these using the real-time data reported in the NHFD run charts. Hip fracture teams should use their KPI caterpillar plots to identify better-performing neighbouring units, so they can share best practice and network with them in designing QI work. Hip fracture teams should use KPI 0 as a marker of initial care and a driver to improve the provision of local anaesthetic nerve blocks and fast-tracking of patients to an appropriate ward. Performance should be considered alongside the figures for their unit in the Anaesthesia run chart and Assessment benchmarking table. To help patients avoid further fragility fractures, hip fracture team governance meetings should review KPI 7 alongside their Bone Medication Table and arrangements for 120-day follow-up. Hip fracture teams should signpost patients, their families and carers to the NHFD website resources designed to help them understand their care and recovery following a hip fracture. Hip fracture teams should use monthly governance meetings to review their policies and protocols, and to compare these with those in other units as described in the Facilities Survey. Hip fracture teams should minimise inequalities in health care; specifically by reviewing whether support and information are provided in formats and languages appropriate to their patients.
  13. Content Article
    Issue 10: Unsafe management of sepsis Issue 9: Medicines management - assessment Issue 8: Hypothermia Issue 7: Falls from windows Issue 6: Caring for people at risk of choking Issue 5: Safe management of medicines - treatment Issue 4: Burns from hot water or surfaces Issue 3: Fire risk from use of emollient creams Issue 2: Unsafe use of bed rails Issue 1: Falls from improper use of equipment
  14. Content Article
    As occupational therapists our aim is to maximise independence and support people to carry out daily life activities - their ‘occupations’. These activities include self-care, leisure and productivity - ranging from brushing your teeth to going to the supermarket. Our role requires a deep understanding of the significant impact that these seemingly ordinary routines have on peoples’ health and wellbeing. Occupational therapists are found in a variety of services across both physical and mental health. The role of an OT in any setting involves striking a balance between optimising patient safety, and positive-risk taking. Both of us are currently hospital-based and our primary role is to assess how each patient will manage at home. Our goals are to ensure patients are discharged safely and effectively and to prevent readmission. When working with a patient to increase their independence, we look at three areas: the person, the environment and the activity. We might make adjustments in any or all of these areas. The person For every patient, we consider the physical, cognitive, spiritual and psychological aspects that might affect their recovery and independence. By establishing what restricts, motivates and matters to a patient, we can tailor our support to best support them. Fear of falling is a major barrier to independence for many patients we see in hospital, and helping them overcome the associated anxiety and lack of confidence can make a huge difference to their quality of life and ability to function. Fear of falling can result in patients displaying physical symptoms such as shaking or stiffness and avoidance behaviour. Patients can enter a deconditioning spiral of loss of confidence and anxiety, causing a reduction in activity which leads to decreased muscle strength and mobility. This in turn further decreases independence and increases the patient’s falls risk. As occupational therapists, we can make patients safer by helping them overcome this fear and regain mobility. There is evidence that encouraging someone to keep active through positive risk taking can increase confidence and help them form a realistic view of their falls risk. We educate patients on the actual risks and provide opportunities to learn-through-doing, helping them translate this knowledge into experience and change their behaviours. This might be as simple as suggesting a patient gets up at each advert break when watching TV, walks five steps then sits back down. The environment Occupational therapists consider all aspects of a patient’s environment and use clinical reasoning to decide on interventions to promote their safety and independence. When a patient has fear of falling, we can put in place changes to the environment to help mitigate that fear as well as the actual risk of falling. When we look at a patient’s environment, it’s important we have a clear picture of the setting a patient will be living in. I (Susanna) hate only having a downstairs toilet because it is so far away during the night! If one of our patients was in this situation and needed easy access to a toilet, we would consider all aspects of their living space before deciding on interventions, for example: Do they have a partner living with them who could help if needed? Do they have blood pressure issues and associated risks? Do they have urinary urgency? Are they at risk of falls? In this case, a simple urinal bottle or commode placed next to the bed can save a patient from having to travel large distances to access a toilet during the night. We could also introduce adaptations such as grab rails to assist independent toilet transfers (sitting down and standing up). As a last option at home, carers could be provided to assist with personal care in the morning. The activity (occupation) There is huge pressure on bed-capacity in the NHS, and occupational therapists can play a key role in patient safety in this area. We help free up beds for other patients that need them and make sure our patients are safe to be discharged. An inpatient who is medically fit for discharge is also at risk of picking up hospital-acquired infections, so we need to reduce this risk with prompt discharge. We carry out functional assessments of a patient’s ability to fulfil the basic activities required for independence at home: mobility, transfers from bed/chair/toilet, washing and dressing, and meal preparations. If we can find out the dimensions of a patient’s home furniture, we can sometimes replicate this on the ward to help us assess them more accurately. Working closely with physiotherapists, we provide walking aids and assistive equipment that will make patients safer at home. We also liaise with social workers to put packages of care in place to support independence once a patient has left hospital. Under a new ‘discharge to assess’ government policy, this assessment process is changing to become more community-based and occupational therapists will be carrying out more of these assessments in patients’ homes. Although this is hard to picture now, it means we will get a much more accurate understanding of a patient’s occupations within their own home, where they know where things are and ‘have a knack’ of doing things their own way. Are you an occupational therapist with an interest in patient safety, or a patient who has benefitted from working with an occupational therapist? Tell us about your interests and experiences in the comments. Further reading Roots of recovery: Occupational therapy at the heart of health equity (1 November 2021)
  15. News Article
    The NHS needs to do more to support care homes and people who have fallen with alternatives to ambulance calls and hospital admissions, the NHS England chief executive has said. Speaking at the Ambulance Leadership Forum, Amanda Pritchard acknowledged this winter would be a difficult one for the health service, saying: “The scale of the current and potential challenge mean that we do need to continue to look further for what else we can do… We need to pull out all the stops to make sure that they [patients] get that treatment as safely as possible and as quickly as possible.” She added one area of focus should be making sure certain patient groups can access other – more appropriate – forms of care, rather than calling an ambulance by default and often resulting in hospital admission. On care homes, she said: “Can we wrap around even more care for these care homes so they get to the point where they don’t need to call for help at all or, if they do, there are alternatives pathways [to the emergency department]?” She suggested another area where responses could be made more consistent was for patients who had fallen but without serious injuries, which she said made up a “really significant part of activity”. These patients took a long time to reach and, if admitted to hospital, risked long admissions, she said. Some areas were working to find other ways of responding to non-injury falls patients and trying to keep them away from hospital, she said. Read full story (paywalled) Source: HSJ, 6 September 2022
  16. Event
    This Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the Covid-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. Attending this conference will enable you to: Network with colleagues who are working to improve Hospital at Night Practice Learn from developments as a results of Covid-19 Improve your skills in the recognition management and escalation of deteriorating patients at night Understand and evaluate different models for Hospital at Night Examine the role of task management solutions for Hospital at Night, including handover and eObservations Ensuring effective and safe staffing at night, including adequate breaks Examine Hospital at Night team roles, competence and improve team working Improving safety through the reduction of falls at night Supporting staff and reducing fatigue at night Develop the role of Clinical Practitioner and Advanced Nursing Practice at night Identify key strategies to change practice and ways of working in Hospital at Night Understand how hospitals can improve conditions for night workers and support Junior Doctors Improve the management of pain at night Work across whole systems to improve support for patients out of hours Self assess and reflect on your own practice Gain CPD accreditation points contributing to professional development and revalidation Evidence Register There are a limited number of free places for hub members. Email: info@pslhuborg if interested. Follow on Twitter @HCUK_Clare #hospitalatnight
  17. Content Article
    Never Events 1 April 2021 – 31 March 2022 by type of incident: Wrong site surgery – 171 Retained foreign object post procedure – 98 Wrong implant/prosthesis – 47 Misplaced naso or oro gastric tubes and feed administered – 31 Administration of medication by the wrong route – 21 Unintentional connection of a patient requiring oxygen to an air flowmeter – 13 Overdose of insulin due to abbreviations or incorrect device – 11 Transfusion or transplantation of ABO incompatible blood components or organs – 7 Falls from poorly restricted windows – 3 Mis selection of high strength midazolam during conscious sedation – 2 Overdose of methotrexate for non-cancer treatment – 2 Mis selection of a strong potassium solution - 1