Search the hub
Showing results for tags 'Monitoring'.
Found 156 results
-
EventThis conference focuses quality accreditation, monitoring and assurance. The conference will support you to develop systems and processes for local accreditation for quality. Accreditation can be used as a tool to encouraging ownership of continuous quality improvement, reduce variation and increase staff pride and team working. This conference will also update delegates on the New CQC Single Assessment Framework. For further information and to register visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/quality-accreditation or email [email protected] Follow the conference on X @HCUK_Clare #QualityAccreditation hub members receive a 20% discount. Email [email protected] for discount code.
-
Content ArticleWhen they get into the system, people living with mental health issues are typically prescribed medication. The most common prescriptions are for antidepressants, anti-anxiety medications, stimulants for ADHD, and antipsychotics for conditions like schizophrenia and bipolar disorder. These are dangerous drugs if not taken properly, with potentially serious side effects. So taking them on time, in the right dosage, is vitally important. According to the Pharmaceutical Press: “Adhering to (or compliance with) the recommendations on how to take all these medicines is essential if they are to work successfully and with minimal side effects”. But those at home living with mental health issues are the ones most likely to fail to remember to take their meds, or to deliberately overdose. So there need to be systems in place to monitor and report on this most vulnerable group. What could those systems look like, and what are the most effective mechanisms for ensuring adherence and safety?
-
Content Article
To support the implementation of the National Patient Safety Plan of the Republic of North Macedonia, this handbook provides a structured framework using the Plan-Do-Check-Act (PDCA) cycle and focuses on six core intervention areas, including infection prevention, medication safety, surgical safety, safe birth practices, capacity strengthening, and error-reduction strategies. It emphasises stakeholder engagement, monitoring and evaluation, risk management, and sustainability planning. By providing a clear roadmap, this initiative aims to foster a culture of patient safety and improve health-care quality in North Macedonia. -
EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore MNSI’s Health Equity Warning Score (HEWS) and the Health Equity Assessment and Resource Toolkit (HEART). MNSI's health equity, diversity and inclusion leads developed this assessment tool to systematically identify, acknowledge, investigate and analyse factors affecting health equity which impact care and perinatal outcomes. Join this webinar to find out how you can put this tool into practice in your trust. Register for the webinar
-
News Article
Teen died from asthma attack after she was wrongly discharged from hospital
Patient Safety Learning posted a news article in News
A coroner has voiced serious concerns over a recurring "lack of observations" at London's Royal Free Hospital following the death of a teenager. Sixteen-year-old Billie Wicks died after suffering her first ever asthma attack. Her parents rushed her to the Hampstead hospital on 17 September last year, but a new report reveals the A&E department was "understaffed" that night. The coroner's concerns highlight a potential systemic issue at the hospital regarding patient monitoring. Senior coroner for Inner North London, Mary Hassell, said that Billie should have had routine checks, or observations, taken every hour. If she had these observations, then medics would have recognised the severity of Billie’s illness, Ms Hassell said. “Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived,” she wrote in a prevention of future deaths report. “Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. “That senior medical review would have changed the course of her management and saved her life.” Read full story Source: The Independent, 18 March 2025 -
Content ArticleOn 17 September 2024, Edwin Buckett, commenced an investigation into the death of Billie Wicks aged 16 years. The investigation concluded at the end of the inquest on 6 March 2025. Billie had been brought to the Royal Free Hospital just before midnight the night before her death with an asthma attack. A first presentation of asthma at the age of 16 years without any family history is unusual, and it was a busy night in the accident and emergency department. Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived. The MATTERS OF CONCERN are as follows: On the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations. Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need. I heard that Billie was safety netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction. In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).
-
Content ArticleIn traditional infusion processes, issues such as untimely medication replacement and patients’ difficulty in continuously monitoring their medication levels are prevalent. This study presents the design of a smart infusion automatic medication replacement device aimed at automating infusion management through three key modules: high-precision liquid level monitoring, automated medication replacement, and a smart control system. By monitoring liquid levels in real time, the system eliminates the need for patients to constantly check their medication levels, accurately controlling the amount of medication dispensed and transmitting monitoring signals within safe thresholds. By replacing repetitive manual adjustments with automated processes, healthcare professionals can focus more on patient care rather than the cumbersome medication replacement procedures. The smart infusion automatic medication replacement device enhances the quality of infusion therapy for patients and alleviates the repetitive workload of medical staff.
-
Content ArticleExamples of how two NHS trusts have designed a virtual ward using the system-wide digital healthcare platform, Luscii. The team at Maidstone and Tunbridge Wells NHS Trust (MTW) in collaboration with the Home Treatment Service (HTS) have designed a virtual ward to cater for frailty patients, allowing them to provide acute-level care without the need for hospital admission. MTW’s innovative approach means patients are empowered to live fuller and freer lives with access to hospital care from the comfort of their own homes. Maidstone and Tunbridge Wells NHS Trust_ Frailty Case Study.pdf Nurses at London North West University Healthcare NHS Trust (LNWH) have created a virtual ward caring for hundreds of heart failure patients. The new virtual heart failure ward is a fascinating case study of the power and potential for technology to optimise the use of critical resources and improve care outcomes. The Future of Care - Inside LNWH's Virtual Heart Failure Ward (1).pdf
-
News Article
Nationwide roll out of AI tool that predicts falls and viruses
Patient Safety Learning posted a news article in News
An AI tool is being rolled out across the NHS that can predict a patient’s risk of falling with 97% accuracy, preventing up to 2,000 falls and hospital admissions each day. The predictive tool, developed by Cera, is being used in more than two million patient home care visits a month, monitoring vital health signs such as blood pressure, heart rate and temperature, to predict signs of deterioration in advance so it can then alert healthcare staff. It is in use across more than two-thirds of NHS integrated care systems and helps to provide care at home by flagging up to 5,000 high-risk alerts a day, reducing hospitalisations by up to 70%. Dr Vin Diwakar, national director of transformation at NHS England, said: “This new tool now being used across the country shows how the NHS is harnessing the latest technology, including AI, to not only improve the care patients receive but also to boost efficiency across the NHS by cutting unnecessary admissions and freeing up beds ahead of next winter, helping hospitals to mitigate typical seasonal pressures. “We know falls are the leading cause of hospital admissions in older people, causing untold suffering, affecting millions each year and costing the NHS around £2 billion, so this new software has the potential to be a real game-changer in the way we can predict, prevent and treat people in the community. “This AI tool is a perfect example of how the NHS can use the latest tech to keep more patients safe at home and out of hospital, two cornerstones of the upcoming 10-year Health Plan that will see shifts from analogue to digital, and from hospital to community care.” The software will also be used to detect the symptoms of winter illnesses like Covid, flu, RSV, and norovirus, allowing NHS and care teams to intervene before hospital care is needed. Read full story Source: Digital Health, 5 March 2025 -
News Article
Why popular blood sugar monitors could actually be harming your health
Patient Safety Learning posted a news article in News
Popular glucose monitors used to take regular blood sugar readings could be driving poor diets and food restrictions due to inaccurate measurements, according to a new study. Continuous Glucose Monitors (CGMs) take blood sugar readings every five minutes and were originally designed for people with diabetes to assess how their body responds to different foods. But they are growing in popularity and in recent years have increasingly been used by the health-conscious to track their diet and avoid glucose spikes. Carried out in healthy, non-diabetic volunteers, the research compared results from a CGM to the gold standard finger-prick test for blood sugar levels. Scientists found that the CGMs consistently reported higher levels than the finger-prick test. The monitors overestimated the time spent above the Diabetes UK’s recommended blood sugar level threshold by nearly 400 per cent, causing unnecessary concern for people whose blood sugar was actually well-controlled. Professor Javier Gonzalez, from the university’s department of health, warned people should stick with the finger-prick test if they are looking for accurate readings. “Continuous glucose monitors (CGMs) are fantastic tools for people with diabetes because even if a measurement isn’t perfectly accurate, it’s still better than not having a measurement at all,” he said. “However, for someone with good glucose control, they can be misleading based on their current performance." Read full story Source: The Independent, 26 February 2025 -
News Article
“Life-changing” services marks milestone of care
Patient Safety Learning posted a news article in News
A mum-of-four has praised a hospital-at-home service – hailing it as a “life changing miracle” for her family. Maria Hicklin, whose two young sons Roman, aged seven, and Ricco, aged two, have both battled respiratory conditions, knows firsthand the benefits of the Paediatric Virtual Ward delivered at Sandwell and West Birmingham NHS Trust. The service has treated over 2,000 children with 143 of these being via direct access to the virtual ward, effectively saving 3,800 bed days and making a cost saving of over £1.7 million. Maria, from Oldbury, explained how it has helped her two boys: “The virtual ward service has transformed our experience and saved us money. We’ve had minimal hospital admissions and the medical team provides home visits, monitoring equipment, and offers continuous support. “They’ve even helped build my confidence in administering medication. The team comes out within an hour if we need help, and they know the boys by name. Roman and Ricco are now comfortable and less anxious about their medical conditions. “It’s a stark change from previous winters. Every cold and flu season, we were constantly rushing to A&E. It was destroying our family. “Roman is also autistic, and this made hospital visits even more traumatic. He wouldn’t eat hospital food, and the constant needles and medical procedures were overwhelming for him.” NHS England introduced virtual wards to allow patients to get hospital-level care at home safely and in familiar surroundings, helping speed up their recovery while freeing up hospital beds for patients that need them most. Dr Maria Atkinson, Consultant Paediatrician, said: “Our virtual ward allows us to provide acute medical care directly in patients’ homes, reducing the stress of hospital admissions and keeping families together during challenging medical periods. “Roman has had a particularly challenging medical journey, having first contracted COVID-19 and then developed severe asthma and pneumonia, leading to repeated hospital visits. His younger brother Ricco suffers from viral-induced wheeziness, which added to the family’s medical challenges. “This isn’t just about saving money. We’re providing personalised, compassionate care that keeps children in their home environment through admission avoidance, and by facilitating a reduced length of hospital stay this can support the entire family.” Read full story Source: NHS Sandwell and West Birmingham, 6 February 2025 -
Content ArticleEngland is likely to need between 23,000 and 39,000 more hospital beds by 2030/31. Providing hospital care in people’s homes could be a practical alternative to building more NHS facilities, helping to reduce risks and improve efficiency. There have been high expectations of remote monitoring as a key element of NHS England’s virtual ward (otherwise known as “Hospital at Home”) programme. But its use on virtual wards caring for people with frailty has been low compared with other virtual wards. The reasons why remote tech monitoring hasn’t had such high uptake on frailty wards aren’t clear – so THIS Institute set out to find out. This study looks at the views and experiences of people involved in virtual wards – for example as health professionals, managers, policymakers, or evaluators. The project was guided by a patient and public involvement group. What the study found There were four main challenges with using remote monitoring in virtual wards for frailty care: Healthcare professionals weren’t sure about the benefits of remote monitoring for people with frailty. Some people said that that remote monitoring would require significant changes in how patients, carers, and staff worked. The right tools and technology weren’t always available, and products needed to be improved to give frail patients and virtual wards better support. Virtual wards differed greatly in operation and use of remote monitoring, making comparison difficult. Standardisation efforts were sometimes viewed as unhelpful, and the balance between standardisation and local flexibility wasn’t always right. Although using remote monitoring has been a major goal of the NHS virtual wards programme, this study highlights several of the key challenges in making it work for frail patients. If technology is going to work, the solutions will need to be co-designed with input from patients, carers, and staff who care for patients with frailty across different health and social care sectors.
-
Content ArticleAll Together Better Sunderland is an alliance of local health and social care services working as an integrated ‘out of hospital’ system. By working in a much more joined up way, it supports Sunderland residents with long-term illness, health problems, mental health issues and disabilities. The service enables them to access care as close to home as possible and live healthy, independent lives. The alliance wanted to find a digital solution which would enable hundreds of elderly and vulnerable people in self-isolation to receive healthcare support with the use of home care technology.
-
Content ArticleSuboptimal intrapartum electronic fetal heart rate monitoring using cardiotocography has remained a persistent problem (EFM-CTG). This study aimed to identify the range of influences on the safety of using EFM-CTG in practice. The authors looked at 142 articles and 14 reports and identified influences on EFM practice across all 19 domains of the contributory factors framework, including those relating to cognitive, social and organisational factors and interactions between professional work and tools used for fetal monitoring. They concluded that to reduce avoidable harm associated with electronic fetal monitoring a systems approach is required based on a sound understanding of the full range of influences on practice.
-
Content ArticleHarry Vass was a 24yr old, he had a history of ADHD, poor mental health, psychosis, paranoia secondary to recreational drug use and illicit drug dependency including cocaine. Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as “mental health”, he was expressing paranoid thoughts. He had a high heart rate and was sweating. He underwent a physical assessment and was assessed by the Mental Health Team. At some point he took cocaine in the toilet of the hospital after which he became more agitated and there were concerns being raised that others in the department felt threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were called but when they attended Harry was calm from the effects of the medication. The police were called and attended again when Harry’s agitation increased. It was during this discussion that the police officer raised the possibility of Harry having ABD (acute behavioural disturbance). The police officer said that he’d seen close to a dozen cases, that Harry had similar symptoms. The two mental health practitioners said that they knew very little about ABD. After some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was admitted under s136 Mental Health Act to The Mason Unit (a place of safety) within the hospital at around 23.00hrs. Once on the Mason Unit Harry continued to be distressed and agitated, he was given further medication to calm him. Harry remained disturbed but had periods of calm, he became fearful of isolation, he became sleepy and at around 3.30hrs on 27th December 2022, he vomited. Observations were carried out confirming that Harry had low oxygen saturations and a high temperature. At 4.45hrs his extremities were discolouring, and he became unresponsive, an ambulance was called. He was transferred back to the A&E department but died at 06.36hrs. The coroner's report included the following matters of concern: Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.” The full report can be found via the link below. You can also read the Royal College of Nursing response here.
-
Content ArticleThe early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study in the Journal of Patient Safety aimed to improve the proportion of patients receiving antibiotics within one hour of triage and compliance with sepsis bundles. A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 2018 to December 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. After this initial stage, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared and showed that: the proportion of patients receiving antibiotics within one hour of triage improved from 44% to 84%. intravenous crystalloid administration within three hours improved from 62% to 94%. serum lactic acid measurement within three hours improved from 62% to 94%. vasopressor initiation within six hours improved from 76% to 94%. mortality rates decreased from 32% to 21% between the 2 study periods.
-
Content ArticleThis cohort study examined how hospital six early warning scores compare with one another, based on 362,926 patient encounters. The authors compared three proprietary artificial intelligence (AI) early warning scores: Simultaneous Epic Deterioration Index (EDI) Rothman Index (RI) eCARTv5 (eCART) against three publicly available simple aggregated weighted scores: Modified Early Warning Score (MEWS) National Early Warning Score (NEWS) NEWS2 scores. In the study, eCART outperformed the other AI and non-AI scores, identifying more deteriorating patients with fewer false alarms and sufficient time to intervene. NEWS, a non-AI, publicly available early warning score, significantly outperformed EDI. The authors concluded that, given the wide variation in accuracy, additional transparency and oversight of early warning tools may be warranted.
-
News Article
Hospital warned over safety and ‘undermining behaviour’
Patient Safety Learning posted a news article in News
Regulators are carrying out “enhanced monitoring” of clinical radiology services at a major London hospital, after concerns about safety and “undermining behaviour”. The General Medical Council introduced the special measures on the department at Northwick Park Hospital in Harrow last month, it has emerged, after concerns were raised in the regulator’s annual survey by higher specialty trainees. Enhanced monitoring is used when a department or hospital has failed to improve after concerns have been raised locally, and where the GMC feels the quality of training could affect patient safety or junior doctors’ ability to progress. In relation to Northwick Park’s clinical radiology, issues highlighted included staff behaviour, whether there is a “supportive environment”, trainee safety, clinical supervision out of hours, educational supervision, and resources for trainers. GMC medical director and director for education and standards Professor Colin Melville said it was concerned about “the quality of training in the department and undermining behaviours”. He added: “We’ll continue to work closely with NHS England London to make sure an improvement plan is implemented. We will check that progress is being made to make sure trainees and registrants are working in a safe, supportive, and sustainable training environment.” Read full story (paywalled) Source: HSJ, 23 October 2024 -
EventuntilTelemetry monitors are patient-worn devices that allow the patient's heart rate, heart rhythm, and other physiologic conditions to be assessed without restricting the patient to a bed. These devices allow cardiac patients to move around the facility while still being monitored. Monitors are designed to transmit an alarm signal to nursing staff if the patient develops a concerning heart rhythm or other condition that requires attention. The safety and effectiveness of a telemetry monitoring program depends heavily on the organization's alarm management strategy. Any failure to recognize or delay in responding to a potentially life-threatening change in the patient's condition could lead to severe harm. As with any physiologic monitoring system, healthcare organizations must scrutinize all aspects of how telemetry alarms are initiated, how they are communicated, and how staff respond. The use of inappropriate alarm settings or notification processes can prevent staff from learning about a change in the patient's condition or may lead to frequent false alarms or nuisance alarms that overwhelm, distract, or desensitize staff—a phenomenon known as alarm fatigue. Either situation can result in valid alarm conditions being missed by staff, and thus a patient's deterioration going unnoticed. Improvements in the way that telemetry systems are implemented and managed can help combat alarm fatigue and reduce the risk of alarm-related adverse events. During this lab webcast, we will discuss: Alarm fatigue: what it is, why it is a concern, and how telemetry implementation decisions can contribute to this hazard Criteria for selecting patients for telemetry monitoring Policies and procedures for setting and disabling alarms Alarm escalation processes and secondary alarm notification systems Strategies to optimize the monitor watching function Register for the webcast The webcast will take place at 12:00 ET, 17:00 BST
-
EventThis conference focuses on quality accreditation, monitoring and assurance. The conference will support you to develop systems and processes for local accreditation for quality. Accreditation can be used as a tool to encouraging ownership of continuous quality improvement, reduce variation and increase staff pride and team working. There will be an extended focus on meeting the CQC Quality Statements in line with the new assessment framework. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/quality-accreditation or email [email protected] Follow on Twitter @HCUK_Clare #QualityAccreditation hub members receive a 20% discount. Email [email protected] for discount code.
-
EventuntilAntipsychotic medication management and monitoring can be challenging. Join us to learn how handheld ECG devices support vulnerable patients and improve the physician and patient experience through: Comfortable, accurate, and fast ECG readings with the first personal ECG device to be recommended by the National Institute for Health and Care Excellence (NICE) More accessible and available measurements for detecting cardiac abnormalities in psychiatric services, such as a prolonged QT interval Reducing stress and anxiety among psychiatric patients with tests in familiar surroundings Key learnings: Local NHS experience: How the pandemic ushered innovation into clinical practice. How NICE recommended technology can implement new pathways and break down barriers. Register
-
Content Article
Health Education England: THINK SEPSIS
Patient Safety Learning posted an article in Deterioration and sepsis
“THINK SEPSIS” is a Health Education England programme aimed at improving the diagnosis and management of those with sepsis. A number of sepsis cases result in death every year. Some of the deaths are preventable. Prompt recognition of sepsis and rapid intervention will help reduce the number of deaths occurring annually. The learning materials that are available on this website support the early identification and management of sepsis. It includes a film and a wide range of learning materials for primary care, secondary care and paediatrics. -
Content ArticleA series of videos on managing deterioration, including: Introduction to sepsis and serious illness Preventing the spread of infection Soft signs of deterioration NEWS What is it Measuring the respiratory rate Measuring oxygen saturation Measuring blood pressure Measuring the heart rate Measuring the level of alertness How to measure temperature Calculating and recording a NEWS score Structured communications and escalation Treatment escalation plans and resuscitation Recognising deterioration in people with a learning disabilities How to use your pulse oximeter and Covid-19 diary.
-
Content Article
Impact of virtual wards
Patient_Safety_Learning posted an article in Digital health and care service provision
Access outline their virtual ward offer and 10 case studies from NHS trusts and other organisations from which they present findings as testimony, to show the impact of virtual wards on the NHS’ ability to provide care. -
Content ArticlePatients are vulnerable during emergency episodes outside the formal care sector, for example, care provided by paramedics responding to a stroke or heart attack at home. Yet much less is known about the safety of Emergency Medical Services (EMS) as compared with primary or secondary healthcare. This relative lack of information is important given there are aspects of EMS care that create unique patient safety challenges. This BMJ Editorial discusses how we can improve patient safety in the Emergency Medical Services.
