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Content ArticleAmbulatory infusion pumps are small, battery powered devices that allow patients to carry out day-to-day activities while receiving medication. They are used for many healthcare needs, including symptom relief during palliative care, and in different settings including hospitals, hospices and patients’ homes. Despite having audio and visual warning alarms to notify when medication is not being delivered as it should be, there is a risk that alarms can go unnoticed, particularly by healthcare staff in inpatient settings. The patient case in the Health Services Safety Investigations Body (HSSIB) investigation report is Stephen, a 45-year-old cancer patient on palliative care in hospital, who did not receive his pain relief medication for six hours. Over the course of six hours, there were eight warnings.
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EventuntilOn the back of the National Point of Care Testing guidance issued in May by the IBMS, RCPath and ACB. This webinar will explore the use case of rapid diagnostic testing to Care, Monitor and Protect. The purpose of a POCT service is to enable the delivery of high quality, accessible diagnostics at the point of need for clinical services, improving clinical outcomes and enhancing the patients’ healthcare experience. The aim should be to ensure that POCT services nationally utilise (and inform) advances in technology to innovate the way in which patients can access diagnostics and clinical services. Technology plays an important part of the patient pathway and in 2022 The World Health Organisation (WHO) published The Target Product Profile (TPP) for readers of rapid diagnostic tests detailing the preferred product characteristics and target regimen profiles. The webinar will provide a guide for commissioners, NHS settings and community pharmacies delivering NHS services. The NHS Long Term Plan highlights the importance of patients receiving care closer to home, shifting from a traditional model of hospital-based services towards a more adaptive community-based approach. Learn about Previous case studies of how Testing to Care, Monitor and Protect has been robustly rolled out across the NHS. Issues faced and how they were overcome. Impact of digital readers when combined with high-quality lateral flow tests in a clinical setting How The Target Product Profile (TPP) for readers of rapid diagnostic tests was developed according to a process based on the WHO Target Product Profiles, Preferred Product Characteristics, and Target Regimen Profiles. Speakers Dr George Newham PhD, Research and Development Manager, SureScreen Diagnostics Dr Rahul Batra, Clinical Innovations and Disruptive Technologies Lead in the Centre for Clinical Infection and Diagnostics Research at Guy’s and St Thomas’ Hospital Julie Hart, NHS Pathway Transformation and Market Access Expert: Diagnostics and Artificial Intelligence Dr Andrew Botham, Chief Scientific Officer - TestCard Register for the webinar
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Content ArticleWhile 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.
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News Article
Children's health warning system rolled out by NHS
Patient Safety Learning posted a news article in News
NHS England is rolling out a national early-warning system to help medics spot and treat a deteriorating child patient quickly - and act on parents' concerns. Parents and carers are "at the heart of the new system", NHS chiefs say. Scores for signs such as blood pressure, heart rate and oxygen levels will be tracked on a chart. But if a parent is worried their child is sicker than the chart suggests, care will be rapidly escalated. While similar systems already exist in many hospitals, NHS national medical director, Prof Sir Stephen Powis, said staff and patients alike would welcome the introduction of a standardised system across hospitals. "We know that nobody can spot the signs of a child getting sicker better than their parents, which is why we have ensured that the concerns of families and carers are right at the heart of this new system, with immediate escalation in a child's care if they raise concerns and plans to incorporate the right to a second opinion as the system develops further," he said. The rollout follows the patient safety commissioner, Dr Henrietta Hughes, recommending that Martha's rule is delivered across England's hospitals, giving patients and families the right to an urgent second opinion and rapid review from a critical care team if they are worried about a patient's condition. Read full story Source: BBC News, 3 November 2023 -
Content ArticleSussex Community NHS Foundation Trust share their patient safety newsletters with the hub.
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News ArticleThe chief executive at a trust behind one of the UK’s first ‘virtual hospitals’ has said this model is the ‘new gold standard’ for care provision and the trust is looking at a significant expansion. West Hertfordshire Teaching Hospitals Trust boss Matthew Coats said the trust aimed to eventually have “hundreds” of virtual beds for patients to be monitored at home. The trust has been at the forefront of NHS England’s programme to significantly expand the use of virtual wards across the NHS. It was also among the first to launch a virtual ward to monitor Covid patients at home during the pandemic. Its virtual ward model has since evolved beyond covid, to what the trust calls its “virtual hospital”, providing remote care for patients across several different pathways and specialties, including heart failure, respiratory and frailty patients, who are admitted from either a hospital bed, the emergency department or by GPs. Mr Coats told HSJ its virtual hospital is not only supporting better flow through the hospital, but is also leading to better patient experience. Read full story (paywalled) Source: HSJ, 25 September 2023
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Content ArticleThis article published by the Betsy Lehman Center looks at the benefits of real-time monitoring of electronic health records (EHRs). Early adopter hospitals have demonstrated dramatic gains in safety by monitoring patients' EHR's in real time for signals of potential safety events, allowing providers to more quickly and effectively address safety gaps and improve outcomes. This monitoring is carried out by automated safety surveillance software that continuously runs in the background of EHR systems and can detect hundreds of categories of adverse events as they occur. Expert analysis then quickly helps organisations gain insight from the data, which can be used to proactively reduce safety risks and reliably measure incidence of harm over time.
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Content ArticleThe National Early Warning Score (NEWS2) is calculated using routine vital sign measures of temperature, pulse and so on. It is used by ambulance staff and emergency departments to identify sick adults whose condition is likely to deteriorate. NEWS2 has been shown to work among the general population. However, it has been unclear if it could monitor the condition of care home residents because of their age, frailty, and multiple long-term conditions. New research from the National Institute for Health and Care Research (NIHR) shows that, among care home residents admitted to hospital as an emergency, NEWS2 can effectively identify people whose condition is likely to get worse.
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Content ArticlePatients in seclusion in mental health services require regular physical health assessments to identify, prevent and manage clinical deterioration. Sometimes it may be unsafe or counter-therapeutic for clinical staff to enter the seclusion room, making it challenging to meet local seclusion standards for physical assessments. Alternatives to standard clinical assessment models are required in such circumstances to assure high quality and safe care. The primary aim of this study was to improve the quality of physical health monitoring by making accurate vital sign measurements more frequently available. It also aimed to explore the clinical experience of integrating a technological innovation with routine clinical care. The results showed that the non-contact monitoring device enabled a 12 fold increase overall in the monitoring of physical health observations when compared to a real-world baseline rate of checks. Enhancement to standard clinical care varied according to patient movement levels. Patients, carers and staff expressed positive views towards the integration of the technological intervention.
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Content ArticlePreventing patients from self-harming is an ongoing challenge in acute inpatient mental health settings. New technologies that do not require continuous human visual monitoring and that maintain patient privacy may support staff in managing patient safety and intervening proactively to prevent self-harm incidents. This study in the Journal of Mental Health aimed to assess the effect of implementing a contact-free vision-based patient monitoring and management (VBPMM) system on the rate of bedroom self-harm incidents. The results showed a 44% reduction in bedroom self-harm incidents and a 48% reduction in bedroom ligatures incidents, suggesting that that the VBPMM system helped staff to reduce self-harm incidents, including ligatures, in bedrooms.
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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. -
News Article
Woman dies after doctors fail to properly read brain tumour scans
Clive Flashman posted a news article in News
Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, May Ashford was not offered surgery until five years later. A woman died unnecessarily after doctors failed to operate soon enough on a growing brain tumour, according to the health complaints service. May Ashford, from Blackpool, was diagnosed with a brain tumour in 2010 after experiencing headaches and seizures. Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, she was not offered surgery until five years later. An investigation by the Parliamentary and Health Service Ombudsman (PHSO) said the treatment was too late as medical staff had failed to monitor the scan results properly. Medical experts said Mrs Ashford should have been operated on at least three years earlier, before the tumour had time to grow and affect the surrounding area of the brain. She tragically died aged 71 from a stroke following surgery. Link to full article here -
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.
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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.
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Content ArticlePostpartum hypertensive disorders pose a serious health risk to new mothers; nearly 75 percent of maternal deaths associated with hypertensive disorders occur in the postpartum period. For the past decade, the obstetrics department at the Hospital of the University of Pennsylvania (HUP) has tried to lower these risks by checking patients’ blood pressure after they are released from the hospital. Their initial efforts to have patients return to the office for an in-person blood pressure check shortly after discharge yielded disappointing results, so the team revamped their approach and ultimately developed an extremely successful program called Heart Safe Motherhood. The programme started when the team at HUP gave a small group of women a blood pressure cuff each. They told them they would receive text messages after discharge instructing them to take their blood pressure at 8am, and that they would need to send in the reading. At 1pm, they would get another text requesting that they send their blood pressure again. This article describes how Heart Safe Motherhood evolved to improve the likelihood of mothers submitting their readings, and how the programme was scaled up to five hospitals in the group. It looks at how the approach has helped tackled health inequalities and improved the safety of postpartum mothers.
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Content ArticleDelays in the detection or treatment of postpartum haemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum haemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. Authors of this study, published in the New England Journal of Medicine, conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum haemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum haemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group).
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Content ArticlePostpartum haemorrhage is a leading cause of maternal deaths. Now a new study points to a surprisingly simple and inexpensive solution. If the woman lies on a plastic sheet with a small transparent pouch at the other end to collect the blood, the medical team has an immediate sense of how much danger she's in and can take swift action. Read the full article, published by NPR, via the link below.
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Content ArticleThis article highlights three questions tabled in the House of Commons relating to the Yellow Card Scheme, the system for recording adverse incidents with medicines and medical devices in the UK.
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Content ArticleIn March 2019, NHS England published Saving Babies Lives version 2, which included information for providers and commissioners of maternity care on how to reduce perinatal mortality across England. One element of this recommends the appointment of a fetal monitoring lead with the responsibility of improving the standard of fetal monitoring. The aim of the fetal monitoring lead is to support staff working on the labour ward to provide high quality intrapartum risk assessments and accurate CTG interpretation and should contribute to building and sustaining a safety culture on the labour ward with all staff committed to continuous improvement. The importance of fetal monitoring was highlighted again in the Ockenden Report, published December 2020. The report recommended, as an essential action, that all maternity services must appoint a dedicated lead midwife and lead obstetrician, both with demonstrated expertise, to focus on and champion best practice in fetal monitoring. Monitoring May is a month long learning event based around fetal monitoring, human factors, maternity safety and shared learning. The East Midlands Academic Health Sciences Network has shared the recording of Monitoring May’s discussions and presentations.
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Content ArticleRemote digital postoperative wound monitoring provides an opportunity to strengthen postoperative community care and minimise the burden of surgical-site infection (SSI). This study aimed to pilot a remote digital postoperative wound monitoring service and evaluate the readiness for implementation in routine clinical practice. It concluded that remote digital postoperative wound monitoring successfully demonstrated readiness for implementation with regards to the technology, usability, and healthcare process improvement.
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News Article
Children with type 2 diabetes to be given sensors to replace finger-prick testing
Patient Safety Learning posted a news article in News
Hundreds of children who manage their type 2 diabetes by regularly pricking their finger can now monitor their glucose levels using automated sensors, the government’s expert health advisers have announced. Doctors and nurses in England, Wales and Northern Ireland have been advised they can now give glucose monitoring devices to children with type 2 diabetes who currently use the more intrusive finger-prick testing methods, the National Institute for Health and Care Excellence (NICE) said on Thursday. The health minister Helen Whately said that offering children the devices would relieve a burden and “empower them to manage their condition more easily”. She said: “Type 2 diabetes is increasingly being diagnosed in children, many of whom face the constant stress of needing to monitor their blood glucose levels by finger-prick testing – often multiple times a day – just to stay healthy and avoid complications.” The NICE committee that reached the decision heard that children found finger pricking to check their glucose levels several times a day “burdensome”, “tiring” and “stressful”. The devices, which give a continuous stream of real-time information on a smartphone, have already been recommended for children with type 1 diabetes, a less aggressive form of the disease. Read full story Source: The Guardian, 11 May 2023 -
News ArticleMaternity services at a trust in Staffordshire have been rated as 'requires significant improvement' by the Care Quality Commission (CQC). University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely. It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be. Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services. The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage. Read full story Source: ITV News, 28 April 2023
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News Article
NHS Ayrshire & Arran team hailed for Parkinson's medication breakthrough
Patient Safety Learning posted a news article in News
A team from NHS Ayrshire & Arran has successfully created a system to ensure that people with Parkinson’s get their medication on time while they are in hospital. Parkinson’s nurse specialist Nick Bryden, who led the team, explains: “The timely administration of medication is hugely important in helping to control symptoms in people with Parkinson’s. "Guidance states that Parkinson’s medication should be administered within 30 minutes, either side, of the prescribed time which can be challenging within a busy hospital ward environment." Nick, who works out of Biggart Hospital in Prestwick, added: “When we initially worked with our digital pharmacist, Richard Cottrell, it was to develop a system that would alert us to when a Parkinson’s patient was admitted to hospital. "It then became clear that we could take the system a step further and use it to monitor if people are on the right medication and whether or not it is being administered at the right time.” The team worked to develop a further system of clear visual prompts with NHS Digital services, which appear alongside relevant patient details on wards’ electronic whiteboards. Every patient prescribed Parkinson’s medication has a tulip symbol beside their name which changes colour and flashes when it’s close to the time to administer the medication. The system was initially piloted in a couple of wards and, due to its success, has now been rolled out to almost every ward in Ayrshire and Arran. Read full story Source: The Herald, 19 April 2023 Related reading on the hub: Top picks: Seven resources about Parkinson’s Professionals with Parkinson’s tackle time critical patient safety issue: a blog by Sam Freeman Carney -
Community PostI would be interested to know, if overnight, patients who score 0-2 on NEWS which has not changed with no concerns since the last set of observations, what your trust policy is on observation frequency? Does your trust require observations to be carried out 4 hourly minimum regardless of patients NEWS score and stability? Or if there are no concerns and the patient is clinically stable with consecutive NEWS 0-2 that they do not have observations taken overnight? Looking forward to hearing what other trust practices are.
