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Found 26 results
  1. Content Article
    The authors of this JAMA article describe the experience of a family member who was in critical care, and who is deaf. They outline a lack of awareness amongst healthcare professionals about their relative's deafness and highlight the lack of understanding in how to communicate with her. They go on to outline a number of approaches to communicating with patients who are deaf or hard of hearing.
  2. Content Article
    This is the video recording of a House of Lords debate on the delivery of maternity services in England, put forward by Baroness Taylor of Bolton.
  3. News Article
    Nearly 38,000 vital follow-up appointments with mental health patients were missed at the time when they were most at risk of suicide, the Royal College of Psychiatrists has said. The medical body has called for “urgent action” to ensure more people are seen for follow-ups within 72 hours of their discharge from inpatient care, to prevent them from falling “through the cracks when they are so vulnerable”. The risk of suicide is highest on the second and third days after leaving a mental health ward, but 37,999 follow-up appointments with patients were not made within this timeframe in England between April 2020 and May 2022. According to NHS data, of the 160,430 instances when patients were eligible for follow-up care within 72 hours after discharge from acute adult mental health care, only three-quarters (76%) took place within that period. The Royal College of Psychiatrists is calling for more trained specialists to check on those perceived to be at risk, which they say requires more staffing and funding. The president of the Royal College of Psychiatrists, Dr Adrian James, said: “We simply can’t afford to let people fall through the cracks at a time when they are so vulnerable. It’s vital that our mental health services are properly staffed and funded to offer proper follow-up care and help prevent suicides. “Staff are working as hard as they can to provide high-quality care, but it’s clear that current resources are not enough to meet these targets. We need urgent action to tackle the workforce crisis and achieve the suicide prevention goals set out in the NHS long-term plan.” Read full story Source: The Guardian, 22 August 2022
  4. Content Article
    This article explains the emerging role of simulation in improving quality and safety. It is part of the Cambridge University Press 'Elements of Improving Quality and Safety in Healthcare' series. The article covers: Healthcare Simulation as an Improvement Technique Definition and Description of Healthcare Simulation How Simulation Became Integrated into Approaches to Improve Quality and Safety Simulation in Action Exploring Working Environments and the Practices and Behaviours of Those in Them Improving Clinical Performance and Outcomes Testing Planned Interventions and Infrastructural Changes Helping Healthcare Professionals to Learn about and Embed a Culture of Improvement Critiques of Simulation Is Simulation an Effective Technique for Improvement? How Should We Integrate Simulation into Healthcare Improvement? Can We Build a Business Case for Simulation?
  5. Content Article
    In this letter to Steve Barclay MP, Secretary of State for Health and Social Care, the chair and chief executive of the Patients Association, Sir Robert Francis and Rachel Power, raised their concerns about how the Government is dealing with the growing crisis in health and social care. The letter asked him to declare a national incident in the NHS and to publish solutions to the current crisis, developed with patients and carers. The letter also asked the Minister to publish the long-term workforce plan and includes an offer from the Patients Association to work with the Department for Health and Social Care (DHSC).
  6. Content Article
    This census of the consultant physician workforce in the UK conducted by the Royal College of Physicians shows that the number of doctors needed to meet patient demand continues to significantly outnumber the supply.
  7. Content Article
    This article looks at a safety issue around the initiation of humidified oxygen treatment. It examines an incident which resulted in a patient's death when they did not receive oxygen.
  8. Community Post
    These comments were made by people with diabetes in response to a Twitter thread asking "Why is a hospital stay scary if you have diabetes?" If you have diabetes, or care for someone who does, please share your experience with us by adding a comment to this community thread, “I was in ICU after a car accident—none of the staff knew how to work my CGM and/or my insulin pump. I had to manage my own care” “For me it was when I went into hospital for surgery and the nurse said 'Type 1... so do you take insulin for that?'... that's not a reassuring thing to hear minutes before you're taken into the theatre!” “Lucky to get out alive.” “DKA 10 years ago, once back in normal range the consultant insisted I didn't need anymore insulin & refused to let me have any. Obvs within 3 hours I was back in DKA, he wouldn't come see me but had a convo with my husband on the ward phone where hubs explained how T1 works.” “I've been given a full day's bolus, through my iv and then told I was wrong when I said that I only bolused when I ate. Massive hypo followed quickly. I was then told it was my fault and I should have said something.” “After being admitted as an emergency, my own insulin ran out. I was given 2 (2!) of the wrong types of insulin and told that 'it would be okay'.” “They were often confused about T2 versus T1 - lots of emphasis about low fat foods and only being allowed a low fat yoghurt for puddings even though I was on a pump! I had a bag of snacks though as it was a planned hospital stay” “After a major medical issue I was denied insulin in the ICU for over 24 hours but was told I could have some pills to treat my type 1 diabetes” “Last time I went to the hospital, they took my pump (forcefully) and refused to give it back. When I protested, they sedated me. I was in and out of sedation having a panic attack bc I couldn’t breathe. They sedated me again and put me on DKA protocol, even tho I wasn’t in DKA.” “it’s so scary right like you know that you’re the expert on your condition and your needs but that power gets totally taken away” “Handing over your care over to a group of nurses who have no idea what they are doing. It’s super scary. I hate it when they lock it all away and you can’t get to it.” “I didn’t feel safe either. Told them on a few occasions I felt ‘low’. Finally Lucozade got wheeled out but it was almost an inconvenience” “Totally understand why they don’t know much about it if it’s not their specialism BUT some are so arrogant that what they were told one afternoon 10yrs ago is the absolutely way to deal with, and that the person living with it doesn’t know what they’re talking about!” Sarcastic responses “You seem to know a lot about it!” “The neurologist told me I am a terrible diabetic.” “I never feel safe because they don’t allow me to dose my own insulin and last time dropped me from 600 to 40 in three hours and then shot me back up so fast when i specifically told them that i would go low and high from that much insulin” Report of being diagnosed with type 1 diabetes while in hospital, despite telling every healthcare professional she had T1. “I smuggled in my own tester and meds and took care of myself.” “I think the biggest thing for me is them not understanding insulin dose when they’re writing up your chart and how you don’t really have a “typical” insulin dose that fits neatly into their charts because of carb counting or correction doses/reduction dose. It’s strange, when I’ve had DKA admissions and I’m on the sliding scale IV it’s fine because there’s clear guidelines but for just day to day injection management it’s soooo difficult.” "Daughter had food and insulin withheld in a mental hospital." “the ward nurses didn’t even know I had T1 until the more mobile lady opposite me went and fetched a nurse who had been ignoring my call button. I was hypo and couldn’t reach my treatment.” "Taken off insulin for two days as no doctor to prescribe." “Particularly bad experience when a nurse left the glucose drip on but turned off the insulin. It terrifies me to think how bad this could have been.”
  9. News Article
    The quality and performance of services will suffer if medical training is not ‘prioritised and funded’ by trusts, Health Education England (HEE) has warned. HEE has set out actions in its “Covid training recovery interim report” that must be done alongside NHS England, the Department of Health and Social Care and others to protect post-covid workforce recovery. At the beginning of the pandemic, junior doctors’ training was severely disrupted because thousands of staff were redeployed to covid wards, while most routine elective operations and diagnostic procedures were stopped. HEE says training has still not returned to pre-covid levels, and fears there could be further disruptions over winter if significant volumes of elective care are cancelled. According to its report, if medical training is not “prioritised and funded”, the “long-term costs to service are significantly greater”. “If delivery recovery is prioritised over training recovery there will be an initial increase in service delivery time and value, but this will be followed swiftly by a reduction in service delivery time and value,” it warned. Read full story Source: HSJ, 13 October 2021
  10. Content Article
    This is the annual report of the National Diabetes Inpatient Audit–Harms (NaDIA-Harms) programme, which aims to monitor and reduce instances of key life-threatening diabetes specific inpatient events. The programme covers hypoglycaemic rescue, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) and diabetic foot ulcer. Overall 4,605 inpatient harms were submitted to the NaDIA-Harms audit between May 2018 and October 2020; the majority of which related to hypoglycaemic rescue (69%). This report also covers: the number of submissions of each inpatient harm. the impact of the Covid-19 pandemic on inpatient harms. patient profiles of people that experience each inpatient harm. These include demographics, diabetes characteristics, treatment targets, care processes, admission characteristics and comorbidities.
  11. Content Article
    This article in the journal Clinical Medicine looks at the safety of people with diabetes when they are admitted to hospital as an inpatient. Having diabetes in hospital is associated with increased harm. Although the National Diabetes Inpatient Audit has shown that inpatient care for people with diabetes has slowly improved over the last few years, there are still challenges in terms of providing appropriate staffing and education. Progress is still needed to ensure the safety of people with diabetes in hospital. The authors look at some of the key areas of concern for people with diabetes in hospital, including increased risk of hypoglycaemia, hyperglycaemia (including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemia state), medication errors, hospital acquired foot ulcers, increased length of stay and overall increase in death.
  12. Content Article
    In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents.
  13. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
  14. Content Article
    Handover in healthcare settings can be a time when the risk of error and harm is increased. This blog summarises the results of global survey that asked the opinions of healthcare workers on the safety of handover. It highlights ten key points raised by the results: Handover causes frequent errors and patient safety incidents Handover errors can cause serious harm to patients Most people think they are better than average at handover The longer you’ve been around, the scarier handover appears  Different types of handovers have a similar safety profile The safety of handover is a problem all over the world  Most practitioners use manual or informal systems to support handover EPR systems are not up to the job of supporting handover Staff need more training, and we need more time Healthcare leaders want better electronic systems The results of the survey have been published in Preprints.
  15. Content Article
    In this joint blog, Patient Safety Learning and Sling the Mesh highlight several issues with the specialist mesh centres set up by the NHS to provide treatment and surgery for women who have been harmed by mesh. We identify key patient safety issues and look at what needs to be done to ensure women receive timely, compassionate and appropriate treatment for complications they face as a result of mesh implants.
  16. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to the use of a flush fluid and blood sampling from an arterial line in people who are critically ill in hospital. As its ‘reference case’, the investigation uses the experience of Keith, a 66 year old man who during a stay in a clinical care unit had blood samples taken from an arterial line which were contaminated with the flush fluid containing glucose. As a result he received incorrect treatment which led to his blood glucose levels being reduced to below the recommended limit.
  17. Content Article
    This article, published in Women Fitness Magazine, argues that a lack of awareness about safety measures and a shortage of healthcare professionals make it difficult for hospitals to ensure patient safety in the United States. It sets out six ways hospitals can ensure patient safety during treatment.
  18. Content Article
    In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the safety issues faced by people with diabetes in hospital settings. Reflecting on feedback from Twitter users with diabetes, she looks at why so many people with diabetes fear having to stay in hospital, and asks what the NHS and its staff can do to make it a safer, less stressful environment.
  19. Content Article
    This paper addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the first Delphi study round was to establish how the World Health Organisation’s Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. It used a combination of closed and open-ended questions that solicited specific information about current practice and research literature, that generated ideas and allowed participants freedom in their responses. The study asked theatre managers, matrons and clinical educators that work in operating theatres and deliver the surgical safety checklist daily, and who are therefore considered to be theatre safety experts. Participants were from the seven regions identified by NHS England. The study revealed that the majority of trusts don’t receive formal training on how to deliver the SSC, checklist champions are not always identified, feedback following a ‘never event’ is not usually given and that the debrief is the most common step missed. While the intention of the study was not to establish whether the lack of training, cyclical learning and missing steps has led to the increased presence of never events, it has facilitated a broader engagement in the literature, as well highlighting some possible reasons why compliance has not yet been universally achieved. Furthermore, the Delphi study is intended to be an exploratory approach that will inform a more in-depth doctoral research study aimed at improving patient safety in the operating theatre and informing policy making and quality improvement.
  20. Content Article
    On 23 April 2020 Jaqueline Lake commenced an investigation into the death of Eliot Harris aged 48. Eliot had schizophrenia and diabetes. Eliot had not been taking medication for several days and his condition deteriorated. He was admitted to Northgate under the Mental Health Act after assessment on 5 April. He was initially in seclusion then on the ward from 6 April, he spent a lot of time in his room and only ate cheese sandwiches. He only accepted medication in intramuscular form and on 9 April by depot injection. His physical observations were recorded as being normal, and a blood test on 7 April showed he did not have diabetes. His intake of food and fluid remained minimal but he was not put on a chart to monitor this. Staff last entered his room at 17:46 on 9 April. He was last seen conscious at 18:10 on 9 April. He was found unresponsive at 01:33 and declared dead at 02:00.  The investigation concluded at the end of the inquest on 8 August 2022. Medical cause of death: 1a) Unascertained Conclusion: Open – the evidence does not reveal the means by which Eliot Harris came by his death.
  21. Content Article
    Can we now create a space for interprofessional learning, where trust and respect are born and where clinical skills and clinical reasoning is shared between our professional tribes, asks Lucy Brock in this HSJ article. Lucy works at UCLPartners as the lead for education and simulation. She is also a respiratory physiotherapist and returned to clinical practice to support colleagues on intensive care in March 2020. Regulatory bodies and education systems exist to ensure that patients are surrounded by competent professionals, but the potential of our workforce is unduly limited by their territorial nature and siloed funding. The urgency of a pandemic offered almost no time for creative thinking but we now have a relative reprieve and so a chance to reconsider the limits of professional scope. Can we now create a space for interprofessional learning, where trust and respect are born and where clinical skills and clinical reasoning is shared between our brilliant professional tribes? Might this be key in mobilising a more efficient and agile workforce, better prepared for the next wave?
  22. Content Article
    NHS Improvement has designed this programme to help trusts develop evidence-based approaches to effective staffing decisions, taking into account all elements that contribute to safe, effective care and great patient experience.
  23. Content Article
    In January 2017, I read an article in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. The Oregon woman filed a million-dollar lawsuit against the Oregon Outpatient Surgery Center in Tigard, Ore., saying she suffered severe burns when her face caught on fire during an electrocautery procedure. Having read this tragic story and escalated it to my theatre manager and colleagues, I decided to design and evaluate a FRAS (Fire Risk Assessment Score) and use it as part of the WHO Surgical Checklist at "time out" to raise awareness of fires in operating theatres.
  24. Content Article
    The purpose of this study was to describe patient engagement as a safety strategy from the perspective of hospitalised surgical patients with cancer.
  25. Content Article
    e-PAIN is the place to start for anyone working in the NHS who wishes to better understand and manage pain. e-PAIN is a multidisciplinary programme based on the International Association for the Study of Pain's recommended multidisciplinary curriculum for healthcare professionals learning about pain management. Registration to the programme is free to all NHS staff members, those with OpenAthens accounts and students.
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