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News Article
More than 100,000 treated on ‘virtual wards’
Patient Safety Learning posted a news article in News
More than 100,000 patients, including children, have been treated in so-called virtual wards over the last year, NHS officials have said. Leading medics said that the use of the system to monitor patients at home has been a “real game changer”. Officials say virtual wards can help patients avoid unnecessary hospital trips altogether, or enable them to be sent home from hospital sooner. Using various equipment and technology, clinicians can monitor vital signs such as a patients’ heart rate, oxygen levels and temperature remotely. NHS England’s national medical director, Professor Sir Stephen Powis, said: “The advantages of virtual wards for both staff and patients have been a real game-changer for the way hospital care is delivered and so it is a huge achievement that more than 100,000 patients have been able to benefit in the last year alone, with the number of beds up by nearly two thirds in less than a year. “With up to a fifth of emergency hospital admissions estimated to be avoided through better supporting vulnerable patients at home and in the community, these world-leading programmes are making a real difference not just to the people they directly benefit but also in reducing pressure on wider services.” Read full story Source: The Independent. 11 March 2023 -
Content ArticleMarch 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
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Content ArticleRisk assessment themes The review identified seven key areas: The language used to discuss and document risk assessments should encourage a dynamic and holistic assessment of the individual pregnant woman/person’s risk (‘dynamic’ means the risk is continually assessed to allow for unknown factors and to handle uncertainty, while ‘holistic’ refers to looking at other factors that might be relevant) that promotes the need for maternity care to be provided by multi-professional teams. Telephone triage services should support 24-hour access to a systematic structured risk assessment of pregnant women/people’s needs. Telephone triage services should be operated by appropriately trained and competent clinicians who are skilled in the specific needs required for effective telephone triage. Face-to-face triage in maternity units should use a structured approach to prioritise pregnant women/people to be seen in order of clinical need. Clinicians should be enabled to proactively monitor and recommend the place of labour care and birth for pregnant women/people based on the individual’s specific care needs during the course of their pregnancy and labour. Each pregnant woman/person should be helped to understand their individualised risk associated with a vaginal or caesarean birth after a previous caesarean birth, based on their specific risk factors and care needs. Pregnant women/people whose labour has been induced need clinical oversight and an individualised plan of care for maternal and fetal monitoring. Prompts for NHS trusts This thematic review also includes prompts for NHS trusts to consider how these risks may be mitigated: Are risk assessment and screening documents designed and presented in a consistent and logical way? Does the language used in risk assessment and screening documents avoid binary definitions of risk, and instead promote dynamic and holistic risk assessments supporting a multi-professional approach? Does risk assessment and screening documentation support a holistic consideration and documentation of risk, or does it focus on only single risk factors? Do telephone triage services facilitate 24-hour support for systematic risk assessment? Are clinicians equipped with the appropriate training, skills and competencies to manage an effective telephone triage service? Is a structured approach used so that pregnant women/people are seen in order of clinical need within your maternity face-to-face triage service? Are there frequent opportunities to revisit and recommend the place of birth based on the pregnant woman/person’s individual needs? Does your risk assessment tool encourage clinicians to think about the most suitable place of birth when a pregnant woman/person in labour is admitted? Do processes support holistic risk assessments to be revisited during labour to proactively assess the most suitable place for fetal monitoring and birth? In antenatal discussions with pregnant woman/people, are structured tools used to support individualised care planning and decision-making when planning a birth after a previous caesarean birth? Is there an opportunity to revisit these discussions when there is a change in circumstance, such as induction of labour? Are clinicians encouraged to make individual plans, taking into consideration a pregnant woman/person’s and baby’s risk during the induction of labour process and including frequency of observations, fetal monitoring and place of induction? Is there a system to prioritise pregnant women/people requiring induction of labour according to clinical need, and to ensure appropriate escalation and action when there are delays?
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News Article
Urgent action ordered at maternity scandal trust
Patient Safety Learning posted a news article in News
The trust at the centre of a maternity scandal has been ordered to report on urgent improvements in services for women and babies, amid ‘significant concerns’ about the risk of harm. The Care Quality Commission (CQC) used its enforcement powers to issue the conditions on East Kent Hospitals University Foundation Trust, after it carried out an unannounced inspection last month. However, the “section 31” warning letter has just been made public, and the first deadline for the trust to report back to the CQC is Monday (20 February). The CQC said some of the problems it found were due to the labour ward environment – but others involved monitoring of women and babies whose conditions deteriorate and the risk of cross-infection due to poor cleanliness standards. “We have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care,” Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said in a statement today. Read full story (paywalled) Source: HSJ, 17 February 2023 -
News Article
First patient in UK fitted with sensor to give early heart failure alert
Patient_Safety_Learning posted a news article in News
A heart failure patient has become the first in the UK to be fitted with an early warning sensor the size of a pen lid which gives off an alert if their condition deteriorates. Consultant cardiologists Dr Andrew Flett and Dr Peter Cowburn have pioneered the procedure to fit the FIRE1 System during trials at University Hospital Southampton (UHS), Hampshire. Dr Flett said: “This innovative new device has the potential to improve patient safety and outcomes in the management of patients with chronic heart failure and we are delighted to be the first site in the UK to implant as part of this ground-breaking study". Read full story Source: The Independent, 12 February 2023 -
News Article
More failings discovered at maternity scandal trust
Patient Safety Learning posted a news article in News
East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light. The Care Quality Commission has highlighted: Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup. Read full story (paywalled) Source: HSJ, 6 February 2023 -
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Content ArticleWhat is the National Patient Safety Board? Since early 2021 there has been a growing coalition of healthcare organisations and groups calling to create the National Patient Safety Board in the United States.[1] This is a proposed federal agency with the goal of preventing and reducing patient safety events in healthcare settings, modelled after the National Transportation Board and the Commercial Aviation Safety Team.[2] Legislative proposal Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board as a non-punitive, collaborative, independent agency to address safety in healthcare.[3] Its proposed duties are: Supporting Federal departments and agencies in monitoring and anticipating patient safety events with patient safety data surveillance technologies. Providing expertise to study the context and causes of patient safety events and solutions. Formulating recommendations and solutions to prevent patient safety events from occurring. In carrying out this role, the National Patient Safety Board would be required to submit annual reports to the United States Congress and would also be able to hold hearings, take testimony, receive evidence and issue reports as appropriate. It’s proposed to comprise: Five Board members, each nominated by the President, by and with the advice and consent for the US Senate, for a term of 6 years. A Chair and Vice Chair, designated by the President from among the members of the Board to serve a term of 3 years. It is also proposed that it establishes and maintains a public-private team, known as the Health Care Safety Team, to sit underneath this to review, update and prioritise patient safety event measures and data sources related to patient and provider safety in healthcare settings, including survey data, electronic health records data, claims data, health information exchange data and reports of patient safety events.[4] National Patient Safety Board campaign You can find out more details about the campaign to support the creation of a National Patient Safety Board, and if relevant how to contact your US House member’s office in regards to this, here. References National Patient Safety Board, About, Last Accessed 9 December 2022. National Patient Safety Board, A New Solution to Address the Problem of Medical Errors, 26 July 2022. Business Wire, House Bill Establishes Federal Agency Dedicated to Patient Safety, 8 December 2022. H.R.9377 - 117th Congress (2021-2022): National Patient Safety Board Act of 2022, 1 December 2022.
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Content ArticleThis document has been developed to support providers of mental health inpatient services that are considering, actively implementing, or who are already advanced in use of vision-based patient monitoring systems (VBPMS) to create or update their protocols, policies, and governance arrangements to support safe use for the benefit of patients and staff. Its aim is to support individual healthcare providing organisations in their current or future use of VBPMS to standardise implementation approaches across the country and provide a platform for sharing learning. Particular attention has been paid to recommendations that underpin governance of the system in addition to its safe, effective, and ethical use. Recommendations from the document should be used at the discretion of each organisation to fit their specific needs and local circumstances.
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Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
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AvMA case study - Evadney's story
Patient-Safety-Learning posted an article in Inquests
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News Article
Remote monitoring service to be expanded in Norfolk following success
Patient Safety Learning posted a news article in News
Norfolk Community Health and Care it is using a remote monitoring service from Inhealthcare which allows patients to monitor their vital signs at home and relay readings via a choice of communication channels to clinicians who monitor trends and intervene if readings provide any cause for concern. Analysis of the six months before and after introduction showed a significant reduction in hospital bed days, A&E attendances, GP visits and out-of-hours appointments. Lead heart failure nurse at the trust, Rhona Macpherson, spoke to Digital Health News about the impact of the services on patients and nurses. For Macpherson, the service has helped promote self-management. “We give each of the patients a set of scales, blood pressure monitor and pulse oximeter and we get them to do their observations,” she said. “So we’re promoting self-management and looking at things but also it means that we can get accurate information on what’s happening with their observations. “We then set parameters to alert if they go outside of the parameters, and it just means we can intervene much more quickly than we would do, and we can see what’s going on between our visits as well as what’s happening when we’re actually there.” The service has transformed working practices for nurses, increasing efficiency and saving valuable time. Macpherson said: “We’re using the technology to try and make ourselves a little bit more efficient, so it’s saving on the travel time and face to face visits. “We can do a lot more with telephone. We’ve got the option of using video, but telephone is actually quite useful. So it’s less face to face visits, less travel and also, we’re trying to empower the patients to do their own observations and monitor themselves, rather than us just doing it for them.” -
Content ArticleThe objectives of this study protocol is to establish baseline data related to the types and frequency of infusion pump alarms from the B. Braun Outlook 400ES Safety Infusion System with the accompanying DoseTrac Infusion Management Software. This exploratory study will analyse the aggregate alarm data for each hospital by care area, drug infused, time of day, and day of week, including overall infusion pump alarm frequency (number of alarms per active infusion), duration of alarms (average, range, median), and type and frequency of alarms distributed by care area. Infusion pump alarm data collected and analyzed in this study will be used to help establish a baseline of infusion pump alarm types and relative frequencies. Understanding the incidences and characteristics of infusion pump alarms will result in more informed quality improvement recommendations to decrease and/or modify infusion
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Content ArticleThis guideline includes recommendations on: information for patients measuring temperature warming patients before their operation, including transfer to the operating theatre keeping patients warm during their operation, including ambient temperature in the operating theatre and temperature of intravenous fluids keeping patients warm after their operation
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Content ArticleCoroner's concerns Whilst at King’s College Hospital, Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries. The bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to the coroner very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring. The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. Evidence suggests that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments, and to ensure that there is pro-active paediatric intensive care outreach. However, the intended programme has stalled, partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future. Response from King's College Hospital Further reading Sharing her story in the Guardian, Merope, Martha's mother, gives a heart breaking account of how Martha was allowed to die: ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (Guardian article)
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Content ArticleHSIB was notified about potential patient safety issues by Sarah, who was concerned about the care she had received when her babies were delivered. The investigation used interviews, observations of the maternity unit and reviews of guidelines and organisational documents in order to understand the system-wide factors that contributed to Sarah’s experience and the decisions made by staff. The evidence suggested that the process of decision making in the context of Sarah’s care was relevant to this investigation, so the investigation has summarised the key factors that appear to have influenced the decision making associated with her care and the delivery of her babies Findings There are currently no proven treatments available to reduce the risk of preterm labour for twin pregnancies. There are gaps in scientific knowledge and challenges to completing research in the field of preterm labour and birth. This creates a challenge for the development of detailed guidelines to support clinical decision making. Guidelines and equipment recommended for managing and monitoring singleton (one baby) and full-term pregnancies are used to assist with clinical decision making about preterm twin pregnancies; some interventions within the guidelines are unproven for use in preterm twin pregnancies. Research and national improvement initiatives, such as the British Association of Perinatal Medicine perinatal optimisation care pathway and NHS England and NHS Improvement ‘Saving babies’ lives care bundle version two’ and the Maternity and Neonatal Safety Improvement Programme are improving the standardisation and implementation of evidence-based interventions. Intelligence from national data gathered by maternity units can support the learning on preterm labour and birth in twin pregnancies. Safety observations It may be beneficial if further research aimed to generate additional knowledge to predict and prevent preterm labour for twin pregnancies among different groups of women/pregnant people. It may be beneficial to increase awareness among the public and healthcare professionals of the limitations of interventions for the prevention of preterm labour of multiple births. It may be beneficial to regularly analyse data on multiple births so the interpretation of this data can inform learning and research. Safety actions Following stakeholder feedback received during an update of the guideline for preterm labour and birth, the National Institute for Health and Care Excellence decided to delete the recommendation relating to milking the cord and amend the subsequent recommendation on clamping of the cord to wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need earlier clamping.
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Content ArticleDid you know? Key causes of anti-infective medication error claims: Failure to check allergy status. Failure to cross-check the ingredients of a medication against allergy status. Failure to adjust dose of medication to the patient’s weight. Failure to adjust dose of medication according to renal function. What can you do? When prescribing antibiotics, refer to the British National Formulary (BNF) for guidance on adjusting dosages according to patient weight, kidney function and the frequency of monitoring. Refer to the traffc light system for antibiotics and penicillin allergy. Ensure that the weight of a patient is regularly checked and adjust drug doses accordingly. • Check the allergy status of the patient at each point of the medication process. Review local guidelines to ensure they incorporate national guidance and support clinicians to prescribe, administer and monitor the effects of anti-infectives appropriately. Examples of relevant national guidance include NICE quality standards on on antimicrobial stewardship and sepsis. Access the NICE guidelines on acute kidney injury to fnd information and advice on the prevention, detection, and management of acute kidney injury. Review your organisation’s claims history regarding medication errors and ensure that learning is shared with clinicians.
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Content ArticleThe vision-based patient monitoring and management system described in this article has been deployed, or scheduled for deployment, in 18 Mental Health Trusts in NHS England (in April 2020). The system is not a replacement for nursing skills. Rather, it provides an enhancement to nursing practice. As with the adoption of any new technology into clinical workflows, it is important for practitioners to learn how to manage the cultural shift required to take advantage of a vision-based patient monitoring and management system. The engineering framework described in this article will help them to understand how the tasks involved in patient care (assess, observe, intervene, and improve) can be optimised through the adoption of a vision-based system, which offers nonintrusive physical and physiological monitoring of quantified patient state. Potential further developments in the vision-based system include metrics of sleep quality, agitation, and more detailed analysis of patterns of behavior. Development of non–contact-sensing of patient temperature at a distance and with affordable technology would also be valuable.
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News Article
NHS Wales: App helping keep heart patients out of hospital
Patient Safety Learning posted a news article in News
Mobile apps to track patients' health are keeping them out of hospital and could cut waiting times, experts have said. It follows a trial of a new app which heart patients are using through their mobile phones. The trial allows clinicians to change treatments quickly and uses video consultations, avoiding unnecessary hospital visits. Rhodri Griffiths is the innovation adoption director at Life Sciences Hub Wales, and is looking for more ways to introduce similar technology. He believes the pandemic accelerated the use and acceptance of digital solutions in healthcare, by patients and clinicians. "We really are looking at a big digital revolution within healthcare and there are an amazing myriad of things coming through," he said. He explained data collected by smartphones and watches can help predict who is likely to have a heart attack. "We can avoid that happening. So prevention is key but it's also looking at how some of this can impact on waiting lists," he said. "So, looking at how theatres are used, which patients can be prioritised? "In social care it's looking at how pain is managed by face recognition." Mr Griffiths said he believed the data collected could also identify wider problems: "It's combining these digital solutions with our genetic information - bringing big data together on a population level we can start spotting trends". Read full story Source: BBC News, 4 August 2022 -
News ArticleNHS England patients with Type 1 diabetes will now be eligible for life-changing continuous glucose monitors after the health service secured a new cut-price deal. The wearable arm gadget sends information to a mobile app and allows diabetes patients to keep track of their glucose levels at all times without having to scan or take a finger prick test. Traditionally, continuous glucose monitors are more expensive than their flash monitor counterparts – which record glucose levels by scanning a sensor – but thanks to the NHS agreeing on a new cost-effective deal with manufacturers DEXCOM, they will now be available for NHS patients on prescription at a similar price. The monitor, called Dexcom ONE Real Time-Continuous Glucose Monitoring, uses a sensor no bigger than a bottle cap that attaches to the arm for up to 10 days and measures glucose levels from just under the skin. Patients will receive their starter pack – which will include information on the product and usage, a sensor and transmitter – from the hospital or GP surgery once prescribed, after which they can go to the pharmacy for their repeat prescription. Dr Partha Kar, national speciality advisor for diabetes and obesity said: “This is a huge step forward for Type 1 diabetes care and these monitors will be life-changing for anyone with the illness – giving them more choice to manage their condition in the most convenient way possible – as well as the best chance at living healthier lives, reducing their risk of hospitalisation and illnesses associated with diabetes, which in turn reduces pressure on wider NHS services. “The new deal also delivers on our commitment to get patients the latest cutting-edge medical technology at the best value for taxpayer money – saving the NHS millions over the coming years”. Read full story Source: NHS England, 2 August 2022 You may also be interested in: “I felt lucky to get out alive”: why we must improve hospital safety for people with diabetes Peer support makes a big difference to living with type 1 diabetes Improving safety for diabetic inpatients: 4 key steps - Interview with Dr Partha Kar
