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Content ArticleNo adverse event should ever occur anywhere in the world if the knowledge exists to prevent it from happening. However, such knowledge is of little use if it is not put into practice. Translating knowledge into practical solutions is the ultimate foundation of the safety solutions action area of the World Alliance for Patient Safety. In April 2007, the International Steering Committee approved nine solutions for dissemination: Look-Alike, Sound-Alike Medication Names (PDF) Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. Patient Identification (PDF) The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. Communication During Patient Hand-Overs (PDF) Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. Performance of Correct Procedure at Correct Body Site (PDF) Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. Control of Concentrated Electrolyte Solutions (PDF) While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. Assuring Medication Accuracy at Transitions in Care (PDF) Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. Avoiding Catheter and Tubing Mis-Connections (PDF) The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. Single Use of Injection Devices (PDF) One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI) (PDF) It is estimated that at any point in time more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Effective hand hygiene is the primary preventive measure for avoiding this problem.
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Community Post
Better use of data for medication safety in hospitals
Kenny Fraser posted a topic in Medicine management
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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks- Posted
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Content Article
The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. Nearly one in five inpatients in UK hospitals has diabetes.[1] Where we work at University Hospital Southampton, we have 1200 inpatient beds, meaning that over 200 of our patients have diabetes at any point in time. As the prevalence of diabetes increases across the population, that figure is expected to rise to one in three over the next few years. When people with diabetes are admitted to hospital, more often than not, it is for reasons other than diabetes—recent data suggests that at least 90% of patients are in hospital for reasons other than their diabetes.[2] Although not all forms of diabetes require complex additional intervention, diabetes management is often thrown out of sync by a hospital stay. For this reason, it’s vital that healthcare professionals in all specialties understand the basics of managing diabetes, including the differences between type 1, type 2 and other forms of diabetes. Worryingly, research shows us that this isn’t the case—the most recent Diabetes Getting It Right First Time (GIRFT) national report highlights nationwide failures in monitoring patients with diabetes, a high prevalence of insulin errors and a high rate of diabetic ketoacidosis in patients with type 1 diabetes.[2] The report indicates a widespread lack of knowledge across healthcare professionals about the fundamentals of caring for inpatients with diabetes. Our own experience as a diabetes inpatient team bears this out; we come across many doctors, nurses and other professionals who aren't aware of the most basic principles of diabetes management, or who lack confidence to apply their knowledge safely. A solution to help staff understand the basics of inpatient diabetes care As a team, we realised the situation was giving us an unsustainable workload and putting patients at risk. We often receive calls from junior doctors who are not familiar with the most basic principles of diabetes care, and from wards asking us to visit patients for simple blood sugar management decisions that could be taken by anyone with the right knowledge, often by using our existing app-based guidelines. These requests take our attention from those patients with diabetes with the highest level of need who require our specialist support. We needed to do something to make sure all inpatients with diabetes are cared for safely, whichever ward or specialty they end up in, so we came up with a plan. With project management support and funding from Diabetes UK, we developed the D1abasics campaign, which aims to make sure every person working in the hospital understands the basics of diabetes care. We have produced banners, lanyards and other resources to provide quick reference points for staff while they are providing care for a person with diabetes. D1abasics is an acronym that covers different aspects of care including identifying patients with diabetes, listening to their concerns and views, understanding the importance of blood glucose monitoring and timely insulin administration in patients with type 1, and recognising the impact of other medical conditions, medications and treatments on diabetes control. You can access these resources at the bottom of this page. We have also visited every ward in the hospital to talk about D1abasics and explain what we’re trying to achieve. It’s really important that new staff are on board from the beginning of their time at the hospital, so we’re embedding D1abasics training in the induction process—in July, we will be seeking to reach up to 500 new starters about the initiative, via a recorded ‘introduction to diabetes in hospital’ video, as part of their hospital induction. Diabetes has an image problem which results in a reluctance among some healthcare professionals to get involved in aspects of diabetes care, as it seems complex and unpredictable. One of the aims of D1abasics is to demystify diabetes and increase people’s confidence that they can provide safe care. Part of this is helping people understand when they can do it themselves, and when they need to ask for our help—there will of course be times when we need to offer specialist care to patients whose diabetes is not responding to standard interventions, or who have complex medical situations. Our hope is that D1abasics will free up our time to focus on those patients that really need our input. Engaging staff and patients in the process While we were developing D1abasics, we spoke to staff about what would most help them and tried to understand the elements of diabetes care that were causing patient safety issues. We also asked patients for feedback, which was really helpful as they helped us see areas where slightly changing the language would make our messages clearer. The patients we spoke to were very grateful for the initiative, as going into hospital can be worrying for people with diabetes. Measuring impact and rolling D1abasics out to other hospitals We’re very hopeful that D1abasics will make a tangible difference to the safety of people with diabetes staying in our hospital. Over the next few months, we’ll speak to ward managers and other staff to get their feedback on the difference the resources and training are making. We’ll also be keeping tabs on the quality of referrals we receive and the number and nature of incident reports involving patients with diabetes. The issues we have identified are not confined to Southampton, they are present in every hospital trust in the country. Since launching D1abasics, we’ve had a lot of interest from people working at other organisations, and we are keen that other hospitals use the resources. We left our hospital logo off our materials on purpose—we don’t ‘own’ the initiative and if it can be used and adapted to improve care and outcomes for people with diabetes, we’re all for it! Access D1abasics resources Related reading Top picks: 5 key resources about diabetes Improving safety for diabetic inpatients: 4 key steps (Partha Kar) “I felt lucky to get out alive”: why we must improve hospital safety for people with diabetes References 1 Dhatariya K, Mustafa O, Rayman G. Safe care for people with diabetes in hospital. Clin Med, 15 January 2020 2 Rayman G, Kar P. Diabetes: GIRFT Programme National Specialty Report. NHS, November 2020 -
Content ArticleThis paper from Parsons et al. looked at how patients prefer to be addressed by their healthcare providers and assessed their knowledge of their attending medical team's identity. The researchers conducted a survey which included 300 inpatients, with findings showing over 99% of patients prefer informal address and 57% of patients unable to correctly name a single member of their attending medical team.
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Content ArticleThe aim of this qualitative service evaluation, published by Nursing in Critical Care, was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable. This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re‐escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams.
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Content ArticleFrimley Health NHS Foundation Trust have devised a patient leaflet to help patients play a role in their safety while at the hospital.
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Content ArticleThe Joint Commission has released a simplified breakdown of eight patient safety goals for US hospitals in 2024. The Joint Commission's eight patient safety goals for hospitals: Identify patients correctly — use at least two ways to identify patients, such as name and date of birth. Improve staff communication — Get the right test results to the right staff member on time. Use medicines safely — Label medicines that are not labelled prior to a procedure, take extra care with patients who take medicines that thin blood, and record and pass along correct information about patient medication. Use alarms safely — Make improvement to alarms on medical equipment so they are heard and responded to on time. Prevent infection — Use the CDC's hand cleaning guidelines and set goals to improve hand cleaning. Identify patient safety risks — Reduce risk of suicide. Improve healthcare equity — Treat improving equity as a quality and patient safety priority. Prevent mistakes in surgery — Ensure the correct surgery is done on the correct patient and in the correct location on the body, and pause before surgery to ensure that no mistake is being made.
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Content ArticleThis national learning report (NLR) draws on findings from investigation reports completed by the Healthcare Safety Investigation Branch (HSIB) that considered the risks associated with patient identification. ‘Positive patient identification’ is correctly identifying a patient to ensure that the right person receives their intended care. To support patient identification in England, the patient’s NHS number should be used alongside other identifiers, such as their name, date of birth and address. Patient misidentification is where a patient is identified as someone else. This may mean that a patient does not receive the care meant for them, or that they receive the care meant for someone else. Patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. Despite the time that has passed, patient misidentification remains a persistent risk to patient safety that can result in significant harm. The aim of this NLR was to combine and analyse HSIB’s previous investigations and relevant international research literature, with the goal of informing national learning and influencing national actions to help reduce the risk of patient misidentification. Findings Patient misidentification is challenging to address and previous efforts to reduce the risk have not been as successful as hoped. There may be a benefit in proactively ensuring that processes for identifying patients are safe, rather than reacting to incidents of harm. Positive patient identification is seen as a routine task, but is common, complex and critical for patient safety. It relies on staff following instructions described in policies and procedures, which might not always be fully appropriate to the circumstances within which staff are identifying patients. Patients are at higher risk of being misidentified in certain situations and settings. Examples include handovers and when care is transferred between different healthcare organisations. The risk of patient misidentification is underestimated and patient misidentification can result in significant harm to patients. Under-recognition of the risk is preventing allocation of already limited safety resources to further mitigate the risk. The main control in preventing patient misidentification in England is the NHS number. However, there is sometimes no, varied or limited use of the NHS number in clinical practice due to various factors. Technology alone is unlikely to reduce the risk of patient misidentification. Work systems involving people, technology and tools need to be designed to improve identification processes. The designs of current software and identification processes may be disadvantaging some patient groups (for example, patients with a disability or of certain cultural backgrounds) due to limited consideration of their needs. It is not yet possible to eliminate the risk of patient misidentification. However, a series of interventions – including using new technologies and optimising workplaces – may help to reduce the risk. When a patient is misidentified, it is difficult to correct the misidentification and ensure their records are made accurate. HSSIB makes the following safety recommendations HSSIB recommends that NHS England assesses the priority, feasibility and impact of future research to quantify and qualify the risk of patient misidentification. This is to support future prioritisation of work programmes to improve safety in high-risk situations and settings. HSSIB recommends that the Care Quality Commission develops its methodology for assessment of integrated care systems and organisations to include arrangements for the positive identification of patients at transfer between healthcare organisations. This is to reduce variability in processes and what information is used for identification. HSSIB recommends that NHS England reviews and identifies system-wide requirements for scanning in positive patient identification. This is to support local organisations to use scanning technology to reduce misidentification incidents. HSSIB makes the following safety observations Future improvement programmes considering the risk of patient misidentification can improve patient safety by prioritising high-risk situations and settings, such as handovers and transfers of patient care. Multiple controls may need to be introduced, including new technologies and standardising of processes. Healthcare organisations can improve patient safety through the use of principles of ‘user-centred design’ to help them understand and optimise clinical work settings for positive patient identification. Healthcare organisations can improve patient safety by assessing and addressing their local barriers to using the NHS number for patient identification. Those designing patient identification processes, including related software, can improve patient safety by undertaking effective equality impact assessments and by considering the needs of specific patient groups that are at high risk of being misidentified. Those purchasing and implementing electronic patient record systems in healthcare organisations can improve patient safety by ensuring those systems are compliant with relevant risk management standards (such as DCB0129, DCB0160 and DCB1077). Healthcare services can improve patient safety by seeking to better understand and address the risks associated with positive patient identification through a safety management system approach. HSSIB suggests the following safety actions for integrated care boards HSSIB suggests that integrated care boards assure processes for the transfer of patient care between healthcare organisations in their geographical footprints to reduce variation in processes for patient identification. HSSIB suggests that integrated care boards assure that where a patient misidentification has occurred, healthcare organisations in their geographical footprints have collaborative processes to learn why and to ensure health records are correctly allocated.
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Content ArticleThis study in JAMA Psychiatry aimed to assess whether multivariate machine learning approaches can identify the neural signature of major depressive disorder in individual patients. The study was conducted as a case-control neuroimaging study that included 1801 patients with depression and healthy controls. The results showed that the best machine learning algorithm only achieved a diagnostic classification accuracy of 62% across major neuroimaging modalities. The authors concluded that although multivariate neuroimaging markers increase predictive power compared with univariate analyses, no depression biomarker could be uncovered that is able to identify individual patients.
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Content ArticleThe Healthcare Safety Investigation Branch's (HSIB's) local investigation pilot aimed to evaluate the organisation's ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning. It differs from HSIB's usual national investigations, which make safety recommendations to organisations that can make changes at a national level across the NHS in England. The pilot published three investigations focused on cross boundary and multi-agency safety events: Investigation 1: incorrect patient identification Investigation 2: incorrect patient details on handover Investigation 3: transfer of a patient with a stroke to emergency care The report summarises how the HSIB local investigation pilot was undertaken, and shares findings applicable to local healthcare systems including healthcare organisations and Integrated Care Systems. Safety observations It may be beneficial if local healthcare systems consider how best to support the investigation of cross-organisation safety events as they implement the Patient Safety Incident Response Framework. It may be beneficial if national and regional bodies consider how healthcare organisations can be supported to develop effective systems-based solutions to identified patient safety risks. It may be beneficial if healthcare organisations develop processes to identify safety improvement themes from patient safety investigation reports. It may be beneficial if providers of NHS care consider low-harm and no-harm safety events as sources of learning in local patient safety incident response plans. The pilot investigations made safety recommendations to the local healthcare organisations. They aimed to highlight issues identified, that if addressed would reduce the risk of future, similar events occurring.
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Content ArticleReliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
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Content Article
In this blog, Jayne Flood, Falls Prevention Practitioner at East Kent Hospitals NHS Foundation Trust, describes how her team introduced ‘yellow kits’* to assist patients at high risk of falls in A&E, and evaluated their impact. *Developed in partnership with Medline Industries Ltd. In 2020-21, the number of people visiting the A&E department at the East Kent University Hospital Trust (EKHUFT), one of the largest trusts in the south east, increased by up to 25%. At that time, we noted a surge in cases of falls in A&E, particularly those resulting in severe harm. The risk factors were clear: A&E departments were busier than they had ever been The quality of health in patients seeking help at A&E was declining Those seeking help had longer-than-usual waiting times in A&E departments There was no clear way for staff to indicate which patients they had assessed as having a high risk of falling Falls with harm are not only devastating to patients and families, but they also have considerable financial implications for healthcare providers. For example, the estimated cost of a single fractured neck of femur (NoF) or hip is £26,000.[1] In 2020 alone, EKHUFT recorded five NoF cases in just one A&E department, representing a bill of £130,000, excluding possible litigation costs. Implementing Yellow Kits to prevent falls in A&E To try and tackle the increasing number of falls we were seeing, we decided to trial the use of yellow kits in A&E. These kits act as a visual cue for staff, helping them to quickly identify patients at risk of falling. Each yellow kit contains a small yellow fleece blanket and a pair of yellow double-tread falls prevention slipper socks. We used our FallStop four-step approach to introduce the yellow kits: Step 1: Ensure you have the support of everyone in the department and senior management It is very hard to identify effectively, at a glance, whether a patient is at risk of falling, and I am aware of how upsetting patient falls incidents can be for staff. Issues often arise at handover as it happens very quickly and information about patients most at risk of falling is often not passed on - until it’s too late. I knew A&E staff would welcome an intervention to help raise their awareness and keep them vigilant. We made sure we had the support of all A&E staff - senior management, healthcare workers, porters and housekeeping staff - which meant that as the results of the evaluation emerged, everyone involved could see the benefit and share in the success of the initiative. Step 2: Integrate visual cues into the care protocol to help staff manage patients at high risk of falling We chose blankets and socks for the yellow kits as they are items that stay with the patient throughout hospitalisation, regardless of location. They can also go home with the patient. The bright yellow colour reminds all staff that extra precautions need to be taken with particular patients, and that they should act decisively if they see these patients trying to move around unassisted or attempting to get off the trolley. The yellow kits also help ward staff during patient transfers, as each patient has already been identified as a falls risk, triggering a full fall risk assessment, in line with Trust guidelines. Step 3: Make the case for the financial impact of not taking action There is nothing more frustrating than knowing there is a simple solution that works, and being unable to implement it as others - whose support you need - just see additional costs. I needed to show the financial burden of ignoring the problem, or only addressing its symptoms, to hospital management. As mentioned, the total cost of care for a hip fracture is £26,000 and there have been five NoF fractures in our A&E during 2020. We needed to prove the effectiveness and value of visual cueing as an intervention, so we developed a single site evaluation of the intervention, with clear outcomes. The program started to develop its own momentum as we demonstrated that yellow kits could help us protect our patients and cut long-term costs at the same time. Step 4: Ensure education before, during and after the intervention To make the intervention effective, we spent time with staff in A&E, particularly in the early stages, to ensure they fully understood when to use the kits and what they mean. We ensured that all staff in the department knew which patients they should issue yellow kits to. We developed a clear protocol for issuing kits: Presenting due to a fall Acutely unwell (for example, respiratory compromised, diabetic ketoacidosis, heart problems) Patients with confusion due to dementia or delirium with any of the following features: agitation, wandering, inability to use the call bell reliably, challenging behaviour, reduced safety awareness and disorientation Likely to attempt to mobilise on their own and unsafe to do so Alcohol or drug misuse causing challenging behaviour We also ensured that staff from other departments working with A&E understood the need for extra vigilance around patients with yellow kits. Medline, the company that supplies the kits, provides educational materials such as posters for staff notice boards, storerooms and public spaces, which we used to promote the initiative. We also involved our communications team to help promote yellow kits through the staff newsletter and intranet, and even got our Chief Executive on board to promote the project through her podcast! The impact of yellow kits on falls in hospital So, did the yellow kits work? In short, 100% yes! The kits empowered A&E staff to think and work differently, and they were pleased to be part of this highly effective initiative. The trial ran for six weeks, and over this period, we lowered the number of falls by 50%. In fact, the only patients who fell were those who did not have a yellow kit. The story was the same for patients admitted to wards - not one fell in the first 24 hours, which is the period when most falls would usually happen on wards. Since the evaluation, we have continued using the kits in A&E and have also been given funding to use them in our Acute Medical Unit. I shared the results of the trial on Twitter and the yellow kits went global! There are now yellow kits being used in A&E departments up and down the UK and some trusts are trialling the scheme in their frailty units. There are also hospitals in Chile, Spain and Australia now using yellow kits. To find out more about yellow kits and the FallStop programme, follow Jayne on Twitter. Related reading East Kent Hospitals University NHS Foundation Trust's FallStop programme FallStop: Winner of the 'Professionalising patient safety' category 2019 National Audit of Inpatient Falls (NAIF) Annual report 2021 How do occupational therapists contribute to patient safety? Community thread: Red walking aids References 1 NHS Digital. October 2021- Posted
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News Article
Hundreds of organisations breached patient data rules, reveals BMJ
Patient Safety Learning posted a news article in News
Hundreds of organisations, including drug companies, private healthcare providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals. “High risk” breaches were revealed to have occurred at healthcare groups, pharmaceutical giants and educational institutions including Virgin Care, GlaxoSmithKline (GSK) and Imperial College London, during audits by NHS Digital, according to an investigation by the BMJ. This means these organisations were handling information outside the remit agreed in data contracts and may be failing to protect confidentiality, the journal said. In one instance, local NHS commissioners allowed sensitive, identifiable patient data to be released to Virgin Care without permission from NHS Digital. When auditors tried to get access to Virgin Care to check their compliance, they were denied access for several weeks and the company refused to delete the patient data, the BMJ reported. Records about mental health, including children and young people, those with learning disabilities, diagnostic imaging and other confidential patient data was being processed outside the scope of objectives agreed with NHS Digital, at an address that had not been agreed, and without a data sharing contract. A spokesperson for Virgin Care said it had “robust data protection in place”. “It is outrageous that private companies and university research teams are failing to comply,” said Kingsley Manning, the former chair of NHS Digital. “How is it that these organisations can be so lax with data?” Read full story Source: The Guardian, 11 May 2022 -
Content ArticleThe South Thames Paediatric Network's aim is to enable children within the South Thames region (South London, Kent, Surrey and Sussex) to have access to high-quality specialist paediatric care in the place most suitable to their needs, at the appropriate time with a focus on surgery in children, critical care, long term ventilation and gastroenterology. This infographic sets out standardised, safe care of children and young people who are receiving or for consideration of receiving Heated humidified high flow therapy (HHHFT).
