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Found 59 results
  1. Content Article
    Key points Novel clinical risk prediction models (QCOVID) have been developed and evaluated to identify risks of short term severe outcomes due to COVID-19 The risk models have excellent discrimination and are well calibrated; they will be regularly updated as the absolute risks change over time QCOVID has the potential to support public health policy by enabling shared decision making between clinicians and patients, targeted recruitment for clinical trials, and prioritisation for vaccination.
  2. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  3. News Article
    Almost half of NHS Trusts in England have reported risks classified as “significant” or “extreme”, with issues facing funding, buildings and failing equipment, according to an analysis by Labour. Highlighting warnings of staff shortages and patient safety, the party demanded urgent action from the government to prepare the health service for the winter months as cases of COVID-19 accelerate across the country. Labour said its study of 114 NHS Trusts’ risks registers showed that over three quarters of trusts logged a workforce risk. The analysis also revealed that 66% reported a financial risk, 82% highlighted risks directly related to COVID-19 and 84% recorded a risk to patient safety. Almost half of Trusts (54), the party said, had outlined risks described as “significant” or “extreme”. One hospital trust reported it was “not financially stable” beyond the current financial year while another recorded a potential risk to patient safety due to “structural deficiencies” in roof structure. NHS hospitals are expected to consider risks to their operations and processes and when risks are identified, it is likely they will have been considered at board level and mitigations put in place. Describing the registers – compiled between March and August - as “worrying” in a normal winter, Jonathan Ashworth, the shadow health secretary, said: “In the coming winter, with the incompetent handling of the test and trace system leaving the NHS wide open and poorly supported, they take on a whole new meaning." "We urgently need a commitment from ministers to fix the problems with test and trace and a timetable by which these issues will finally be sorted. On top of this it is vital that ministers confirm that the NHS will get the additional support it needs to address these risks." Read full story Source: The Independent, 6 October 2020
  4. Content Article
    The link below will take to you a number of case studies showing how healthcare teams have responded and made changes to improve how they protect, support and engage staff. The case studies include examples from primary care, secondary care, infection prevention and staff education programmes. Also included is information and guidance on: risk assessments protecting all staff speaking up regional support.
  5. Event
    The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
  6. Content Article
    This report sets out to explore how antimicrobial stewardship (AMS) programmes are working to tackle antimicrobial resistance (AMR), by asking Clinical Commissioning Groups (CCGs) about their practice and experience of local stewardship. It is a follow-up to the Patients Association’s 2016 report on the same subject, and highlights some progress and areas for improvement in key areas. Using Freedom of Information Requests (FOIs), CCGs in England were asked a range of questions about their AMS programmes, relating to national guidance, toolkits and practice. The national policy and practice landscape puts AMS programmes at the heart of fighting AMR, and securing long-term quality healthcare for patients as a result. Primary care professionals are key to making these successful.
  7. Content Article
    Project charters are written documents that come in many forms. For improvement projects, they should include, as a minimum, a concise summary of: What the team wants to achieve from their improvement efforts, described as an improvement aim. Include how much improvement will be achieved, who the improvement is for and when the improvement will be achieved by. Why the work is important – the rationale or business case for the work. This should outline; the problem the work will address, how this links to strategic objectives, how you know this is a problem, who is affected, the impact of doing nothing and the benefits to be derived from improvement e.g. outcomes and costs. The scope of the project - what is included in the work. How the team intend to achieve the improvement aim – this should include initial ideas for change and the supporting activities to make the work happen. How the team will measure the impact of the work. Who will be involved the work and their role. Key people should include; subject matter experts, process owners who can make changes, representatives of those impacted by your project (families, young people, patients, customers etc), finance representative (where needed), and a sponsor linked to executive level for leadership support. Any risks to the delivery of the project, so that decisions can be made on how these should be addressed.
  8. Content Article
    Complaints from staff are not being heeded. Why is it that healthcare staff's opinions and pleas for their safety and the safety of patients do not matter? Here are just some examples of where safety has been compromised: Disposable gowns are being reused by keeping them in a room and then reusing after 3 days. There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fit tests were given. I queried about fit checks only to discover that it was not part of the training and, therefore, staff were wearing masks without seals for three months before fit tests were introduced and even after fit tests! I taught my colleagues how to do fit checks via telephone. There was no processes in place at the hospital to aid staff navigation through the pandemic (no red or green areas, no donning or doffing stations, no system for ordering PPE if it ran out); it was very much carry on as normal. A hospital pathway was made one week ago, unsigned and not referenced by governance, and with no instructions on how to don and doff. Guidelines from the Association for Perioperative Practice (AFPP) and Public Health England (PHE) for induction and extubation are not being followed – only 5 minutes instead of 20 minutes. Guidelines state 5 minutes is only for laminar flow theatres. None of the theatres in this hospital have laminar flow. One of my colleagues said she was not happy to cover an ENT list because she is BAME and at moderate/high risk with underlying conditions. She had not been risk assessed and she felt that someone with lower or no risk could do the list. She was removed from the ENT list, told she would be reprimanded on return to work and asked to write a report on her unwillingness to help in treating patients. The list had delays and she was told if she had done the list it would not have suffered from delays. Just goes to show, management only care about the work and not the staff. It was only after the list, she was then risk assessed. Diathermy smoke evacuation is not being used as recommended. Diathermy is a surgical technique which uses heat from an electric current to cut tissue or seal bleeding vessels. Diathermy emissions can contain numerous toxic gases, particles and vapours and are usually invisible to the naked eye. Inhalation can adversely affect surgeons’ and theatre staff’s respiratory system. If staff get COVID-19 and die, they become a statistic and work goes on as usual. The examples listed above are all safety issues for patients and staff but, like me, my colleagues are being ignored and informed "it's a business!" when these safety concerns are raised at the hospital. The only difference is they are permanent staff and their shifts cannot be blocked whereas I was a locum nurse who found my shifts blocked after I spoke up. Why has it been allowed to carry on? Why is there no Freedom To Speak Up Guardian at the hospital? Why has nothing been done? We can all learn from each other and we all have a voice. Sir Francis said we need to "Speak Up For Change", but management continues to be reactive when we try to be proactive and initiate change. This has to stop! Actions needed We need unannounced inspections from the Care Quality Commission (CQC) and HSE when we make reports to them. Every private hospital must have an infection control team and Freedom To Speak Up Guardian in post.
  9. Content Article
    Key findings The review found that the largest disparity found was by age. Among people already diagnosed with COVID19, people who were 80 or older were seventy times more likely to die than those under 40. Risk of dying among those diagnosed with COVID-19 was also higher in males than females. Higher in those living in the more deprived areas than those living in the least deprived. Higher in those in Black, Asian and Minority Ethnic (BAME) groups than in White ethnic groups.
  10. Content Article
    Key points Reducing elective waiting times from ‘18 months to 18 weeks’ was one of the English NHS' major achievements in the 2000s. In January 2020, before coronavirus (COVID-19) began to impact on the UK, more than one in six patients were waiting more than 18 weeks for routine treatment. To free up NHS capacity, non-urgent planned care was postponed for 3 months from 15 April 2020. Even before the COVID-19 pandemic, to meet the 18-week standard for newly referred patients and clear the backlog of patients who will have already waited longer than 18 weeks, the NHS would have needed to treat an additional 500,000 patients a year for the next 4 years. The pandemic is likely to make waiting lists grow further and the challenge will be even greater. At the end of April, the NHS in England was asked to begin a cautious programme to resume some of the routine services suspended in response to COVID-19. Returning the NHS to ‘normal’ is hugely important but poses significant challenges. For example, treating patients with enhanced infection control arrangements will reduce the volume of patients that can be treated relative to normal. For planned hospital care, this challenge has to be seen against a backdrop of growing waiting lists and waiting times. In January 2020, before large numbers of COVID-19 hospitalisations, a total of 4.4 million patients were on the waiting list – around 730,000 of whom had waited more than 18 weeks. The rates of spending growth, set out in the NHS Funding Bill in February 2020, will not be sufficient to cover the cost of meeting the 18-week standard by March 2024, even before any additional costs and demand arising from COVID-19. The Health Foundation estimates that spending growth would need to increase by a further £560m a year – assuming the NHS can prioritise patients to make the most effective use of available capacity. Without a radical intervention to increase capacity, it is unrealistic to expect the 18-week standard can be achieved by 2024 with current infrastructure and staffing levels. Meeting the 18-week standard would require hospitals to increase the number of patients they admit by an amount equivalent to 12% of all the patients admitted for planned care in 2017/18. This would be an unprecedented increase in activity. COVID-19 makes the challenge even greater. Over the coming years there will need to be long-term changes to how routine care is delivered, considerable effort at the front line and potentially an important role for the independent sector if the NHS is to return to a position of meeting the 18-week standard. But even with huge efforts, the reality is that longer waiting times for planned care are likely to be a feature of the NHS in England for several years at least.
  11. Content Article
    As the health and social care system focuses its attention on tackling Covid-19, the need to pay attention to patient safety is now more important than ever. In addition to creating new patient and staff safety challenges, the pandemic is magnifying existing issues, increasing the underlying causes of known patient safety problems, and detracting attention from safety initiatives that, to date, may have had traction and success. It is vital that we understand the impact Covid-19 is having on patient safety and identify and address the system issues that are causing avoidable harm. Patient Safety Learning’s response to the Inquiry is structured as follows: The pandemic’s impact on non Covid-19 care and patient safety Considering key themes and issues emerging in non Covid-19 care and treatment including: public avoiding NHS for non Covid-19 treatment delays in treatment lack of chronic disease management lack of support for specific health conditions whether we are learning from patient safety incidents during this period. Balancing Covid-19 and ‘ordinary’ health care This section outlines of insights Patient Safety Learning has gathered, focusing on the patient safety concerns around home births, social care, and rapid hospital discharge. Transitioning to the ‘new normal’ and a ‘safe restart’ Considering the long-term patient safety challenges presented by the impact of the pandemic on non Covid-19 care and treatment, such as: tackling the new backlog in elective care safe staffing and the importance of workforce planning in returning to normal levels of care. ensuring staff welfare. It also looks at the opportunities to improve health and social care as services normalise including: increasing accessibility to services sharing knowledge and innovations a renewed focus on staff safety developing safe systems. Concluding comments In the concluding comments Patient Safety Learning call for the Health and Social Care Select Committee to recommend to the Government that the redesign of health and social care has patient and staff safety at its core with: Patient safety at the heart of improved care delivery models with explicit safety strategies and goals for leadership, shared learning, and culture Innovation for safer care shared and implemented widely. Transitioning to new ways of working and a ‘safe restart’ to be designed with patient and staff safety at its core and publicly reported. Patient engagement and communication to be prioritised, providing information and assurance to patients and families as to the safety of their care and how their concerns can be addressed. Reference [1] UK Parliament, Delivering Core NHS and Care Services during the Pandemic and Beyond, Last Accessed 7 May 2020. https://committees.parliament.uk/work/277/delivering-core-nhs-and-care-services-during-the-pandemic-and-beyond/