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Found 42 results
  1. Content Article
    As a result of the investigation, one recommendation has been made to the Care Quality Commission (CQC) on assessing factors such teamwork and psychological safety in its regulation of maternity units. Based on the evidence gathered, the report also sets out a series of questions to consider in order to help staff identify strengths and opportunities for improvement within their own maternity unit. Safety recommendation It is recommended that the Care Quality Commission, in collaboration with relevant stakeholders, includes assessment of relational aspects such as multidisciplinary teamwork and psychological safety in its regulation of maternity units. Questions to consider Does your unit have a role, or another means, separate from the labour ward co-ordinator, dedicated to monitoring and anticipation of activity across the maternity service and troubleshooting, such as a roving bleep holder? Do you have regular multidisciplinary ward rounds throughout the day? Do you have regular safety huddles and multidisciplinary handovers using a structured information tool? Do you hold multidisciplinary in situ simulation and facilitated debriefing that includes both technical and non-technical skills? Are scenarios and incidents encountered in your unit included in the training? Do you know what your staff’s perceptions of teamwork, psychological safety and communication are within your unit? Are actions taken in response? How are midwifery staff empowered to contact consultants directly if they have concerns? Is time and resource dedicated to regular multidisciplinary forums that provide a safe space to openly discuss scenarios where things did not go well? Do these forums also include discussion and reflection on scenarios where things went well despite unexpected events? Are senior midwifery staff assigned to triage and assessment areas? Is there adequate medical presence in these areas? In larger units, is the workload on the labour ward separated into elective and emergency work? If so, are there separate labour ward co-ordinators for each? How does the physical infrastructure support work? For example, use of DECT telephones, availability of equipment, consultant offices on/near the labour ward, proximity of antenatal ward and neonatal unit to the labour ward. How are issues with staffing and workload escalated and responded to? Are senior trust personnel aware and involved?
  2. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  3. Content Article
    The purpose of this review from Hutchinson et al. was to systematically examine published and grey research reports in order to assess the state of the science regarding the validity and reliability of the RAI-MDS 2.0 Quality Indicators (QIs). The authors found that evidence for the reliability and validity of the RAI-MDS QIs remains inconclusive. The QIs provide a useful tool for quality monitoring and to inform quality improvement programs and initiatives. However, caution should be exercised when interpreting the QI results and other sources of evidence of the quality of care processes should be considered in conjunction with QI results.
  4. Content Article
    Key points This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety: Past harm: this encompasses both psychological and physical measures. Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems. Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis. Anticipation and preparedness: the ability to anticipate, and be prepared for, problems. Integration and learning: the ability to respond to, and improve from, safety information.
  5. Content Article
    The outcome is that the RCP released a statement on its website relating to revised guidance on the use of early warning scores for COVID-19 inpatients. The RCP suggest that all staff should be aware that any increase in oxygen requirements should be an indicator of clinical deterioration as the early warning score might not significantly increase.
  6. Community Post
    Hello I would be interested in hearing from anyone who has done any work on how we monitor patient deterioration overnight? I am currently working on am improvement project looking at patient surveillance of deterioration during night shifts. I have chosen this project as part of a Clinical Improvement Scholarship Program I am on. The program is combined with my day job as a Critical Care Outreach Sister as well as enabling me to develop my research and leadership skills alongside implementing improvements in clinical care. I am in the early stages of my work, however I have some literature and local research around deficiencies in how we monitor patients for deterioration overnight (as well as personal experiences as a CCOT nurse) which is why this topic is so important to me. I would be interested in hearing from anyone who has worked on anything similar, or can point me in the direction of anyone who maybe able to help. Thank you 🙂
  7. Content Article
    Key learning points If the patient had been more closely observed it is likely cardio-respiratory arrest and subsequent hypoxic brain injury could have been avoided. Effective procedures for nurse communication, effective handover and observation of critically unwell patients in intensive care and high dependency units are very important to safe patient care. Bedside and remote monitoring equipment provide vital information to staff and should be properly maintained and replaced where necessary.
  8. Content Article
    This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety: Past harm: this encompasses both psychological and physical measures Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis Anticipation and preparedness: the ability to anticipate, and be prepared for, problems Integration and learning: the ability to respond to, and improve from, safety information.
  9. Content Article
    Better use of data is essential to speed up diagnosis, research new treatments, plan better NHS services and monitor the safety of drugs. And yet, more than two thirds of the population feel they don’t know how patient data is used in the NHS. These animations have been developed in partnership with charities, patients and clinicians. Find out why and how patient data is used.
  10. Community Post
    I 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.
  11. Content Article
    From the analysis of inspection reports, notifications of incidents and enforcement notices, the CQC have categorised the most common areas of risk with medicines across regulated health and adult social care services. This did not include providers of online consultations over the internet or by other remote means, as we have previously reported on these services. These six common areas are summarised as follows: prescribing, monitoring and reviewing administration transfer of care reporting and learning from incidents supply, storage and disposal staff competence and workforce capacity.
  12. Content Article
    Findings Participants’ perceptions regarding their engagement as a patient safety strategy were expressed through three overarching themes: the word 'patient' obscures the message safety is a shared responsibility involvement in safety is a right. Themes were further defined by eight subthemes. Conclusions Using direct messaging, such as 'your safety' as opposed to 'patient safety' and teaching patients specific behaviours to maintain their safety appeared to facilitate patient engagement and increase awareness of safety issues. Patients may be willing to accept some responsibility for ensuring their safety by engaging in behaviours that are intuitive or that they are clearly instructed to do. However, they described their involvement in their safety as a right, not an obligation. Interpretation Clear, inviting communication appears to have the greatest potential to enhance patients’ engagement in their safety. Nurses’ ongoing assessment of patients’ ability to engage is critical insofar as it provides the opportunity to encourage engagement without placing undue burden on them. By employing communication techniques that consider patients’ perspectives, nurses can support patient engagement.
  13. Content Article
    This document provides the guidance for the CQUIN scheme for 2020/21. It sets out details of both the CCG and Prescribed Specialised Services (PSS) schemes. This includes: prevention of ill health mental health patient safety best practice pathways.
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