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Found 8 results
  1. Content Article
    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.
  2. Content Article
    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).
  3. News Article
    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providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals.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
  4. Content Article
    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