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Found 86 results
  1. Content Article
    Although estimated ED error rates are low (and comparable to those found in other clinical settings), the number of patients potentially impacted is large. Not all diagnostic errors or harms are preventable, but wide variability in diagnostic error rates across diseases, symptoms, and hospitals suggests improvement is possible. With 130 million U.S. ED visits, estimated rates for diagnostic error (5.7%), misdiagnosis-related harms (2.0%), and serious misdiagnosis-related harms (0.3%) could translate to more than 7 million errors, 2.5 million harms, and 350,000 patients suffering potentially preventable permanent disability or death. Over two-thirds of serious harms are attributable to just 15 diseases and linked to cognitive errors, particularly in cases with "atypical" manifestations. Scalable solutions to enhance bedside diagnostic processes are needed, and these should target the most commonly misdiagnosed clinical presentations of key diseases causing serious harms. New studies should confirm overall rates are representative of current U.S.-based ED practice and focus on identified evidence gaps (errors among common diseases with lower-severity harms, paediatric ED errors and harms, dynamic systems factors such as overcrowding, and false positives). Policy changes to consider based on this review include: Standardising measurement and research results reporting to maximise comparability of measures of diagnostic error and misdiagnosis-related harms. Creating a National Diagnostic Performance Dashboard to track performance Using multiple policy levers (e.g., research funding, public accountability, payment reforms) to facilitate the rapid development and deployment of solutions to address this critically important patient safety concern.
  2. News Article
    A young mother lost both her feet and all 10 fingers to sepsis after a significant delay in treatment, an investigation has found. Sadie Kemp has been left permanently disabled from the “dangerous condition”, whilst an NHS hospital probe found a 3.5 hour delay in starting her care. Sadie is now calling for lessons to be learned after the internal report found numerous concerns in her treatment that ultimately led to her needing multiple amputations. The 35-year-old mother-of-two first attended A&E with agonising back pain caused by a kidney stone on Christmas night 2021. She was given pain relief at Hinchingbrooke Hospital, Cambridgeshire, and sent home to return the following morning for a kidney scan. She returned the same night at 4am as her pain endured. An assessment at 5.40am found she may have also been suffering from sepsis, but the step-by-step guide to chart and treat the illness was not found in her notes as being done at the time. The investigation found not only should the sepsis have been discovered and treated sooner, but the “lack of effective treatment” of the sepsis prior to the surgery meant she needed prolonged critical care. Read full story Source: The Independent, 22 November 2022
  3. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the HSIB Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #DeterioratingPatient
  4. Content Article
    Rocco Friebel and Laia Maynou examined the prevalence of five avoidable in-hospital patient safety incidents (adverse drug reactions, hospital-acquired infections, pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis, and postoperative sepsis) for four developmental disability groups (people with intellectual disability, chromosomal abnormalities, pervasive developmental disorders, and congenital malformation syndrome) in the NHS during the period April 2017–March 2019. The authors found that the likelihood of experiencing harm in disability groups was up to 2.7-fold higher than in patients without developmental disability. Patient safety incidents led to an excess length-of-stay in hospital of 3.6–15.4 days and an increased mortality risk of 1.4–15.0 percent. The authors show persisting quality differences in patients with developmental disability, requiring an explicit national policy focus on the needs of such patients to reduce inequalities, reach parity of care, and lower the burden on health system resources.
  5. News Article
    Tina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on. Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich. A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit. The grandmother-of-five was eventually transferred to the acute medical unit at 3am the next morning where sepsis was finally diagnosed, but she continued to deteriorate and was admitted to intensive care four hours later and put on a ventilator. She died the following morning. A serious incident investigation report by Sandwell and West Birmingham Hospitals NHS Trust has since found there was "a delay in explicit recognition of sepsis". Read full story (paywalled) Source: The Telegraph, 4 October 2022
  6. Content Article
    Issue 10: Unsafe management of sepsis Issue 9: Medicines management - assessment Issue 8: Hypothermia Issue 7: Falls from windows Issue 6: Caring for people at risk of choking Issue 5: Safe management of medicines - treatment Issue 4: Burns from hot water or surfaces Issue 3: Fire risk from use of emollient creams Issue 2: Unsafe use of bed rails Issue 1: Falls from improper use of equipment
  7. News Article
    The looming NHS staffing crisis could lead to more patients dying from sepsis, a major UK charity has warned. Doctors have told the UK Sepsis Trust that staff shortages and high numbers of patients to treat are two of the most common factors preventing them from following national sepsis guidance. The chief executive of the UK Sepsis Trust, Dr Ron Daniels, warned that the NHS was in a “fragile” state and said workforce shortages were some of the “biggest potential causes of harm” in the context of diagnosing the condition. In a report by the trust, shared with The Independent, 65 out of 100 doctors in the UK warned that they had missed cases of sepsis. The most common reason for this was staff shortages alongside “high patient caseloads”, they said. Dr Daniels warned that staff might find it increasingly difficult to spot sepsis in the coming months as the staffing crisis intensifies. He told The Independent: “The NHS is in a fragile state after the pandemic... and staff absence is a fact of life within the NHS at the moment. That’s partly because staff have left, it is partly because we have high caseloads, but it is also because staff are still off sick". “It is my view that staff shortages are one of the biggest potential causes of harm that our public face in the context of developing sepsis, and we need to urgently address it.” Read full story Source: The Independent, 26 September 2022
  8. News Article
    The most common reasons why people with type 2 diabetes (T2DM) are admitted to hospital with greater frequency than the general population are changing, with hospitalisation for traditional diabetes complications now being accompanied by admissions for a diverse range of lesser-known complications including infections (i.e., pneumonia, sepsis), mental health disorders, and gastrointestinal conditions, according to an analysis of national data from Australia spanning seven years. The findings, being presented at this year's European Association for the Study of Diabetes (EASD) Annual Meeting in Stockholm, Sweden (19-23 Sept), reveal that just four traditional diabetes complications (cellulitis, heart failure, urinary tract infections, and skin abscesses) were ranked in the top ten leading causes of hospitalisation in men and women with T2DM. "Although traditional complications such as heart failure and cellulitis remain a substantial burden for people with T2DM, infections less commonly linked with diabetes and mental health disorders are emerging as leading causes of hospital admissions, and have substantial burdens that sometimes exceed the top-ranked well-known complications," says lead author Dr. Dee Tomic from the Baker Heart and Diabetes Institute, Melbourne, Australia. She adds, "The emergence of non-traditional diabetes complications reflects improvements in diabetes management and people with diabetes living longer, making them susceptible to a broader range of complications. Increasing hospitalizations for mental health disorders as well as infections like sepsis and pneumonia will place extra burden on healthcare systems and may need to be reflected in changes to diabetes management to better prevent and treat these conditions." Read full story Source: MedicalXpress, 1 September 2022
  9. News Article
    At least 12,000 people were treated for sepsis in hospitals in Ireland last year, with one in five of those dying from the life-threatening condition. However, the HSE said the total number of cases is likely to be much higher. Marking World Sepsis Day, it said the condition kills more people each year than heart attacks, stroke or almost any cancer. The illness usually starts as a simple infection which leads to an “abnormal immune response” that can “overwhelm the patient and impair or destroy the function of any of the organs in the body”. Dr Michael O’Dwyer, the HSE’s sepsis clinical lead, said: “The most effective way to reduce deaths from sepsis is by prevention. “A healthy lifestyle with moderate exercise, good personal hygiene, good sanitation, breastfeeding when possible, avoiding unnecessary antibiotics and being vaccinated for preventable infections all play a role in preventing sepsis. “Early recognition and then seeking prompt treatment is key to survival. Recognising sepsis is notoriously difficult and the condition can progress rapidly over hours or sometimes evolve slowly over days.” Read full story Source: Independent Ireland, 13 September 2022 hub resources on sepsis RCNi: Sepsis resource collection NSW Clinical Excellence Commission - Sepsis toolkit Dr Ron Daniels video: Recognising sepsis Introducing the Suspicion of Sepsis Insights Dashboard
  10. News Article
    A 13-year-old girl who died after contracting sepsis in an NHS hospital probably would have survived if doctors had identified the warning signs and transferred her to intensive care earlier, a coroner has ruled. Martha Mills was the first ever child to die at King’s College hospital (KCH) with a pancreatic injury of the type she sustained in a fall from her bike on an off-road family trail in Wales while on holiday last year. She was transferred to the south London hospital because it is one of three national centres for the care of children with pancreatic trauma. An inquest at St Pancras coroner’s court, north London, heard that several opportunities were missed to refer Martha to intensive care, which probably would have saved her life. In an emotional witness statement, Martha’s mother, Merope, said that after their daughter contracted an infection on 21 August last year, she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but doctors sought to reassure them rather than escalate her care. Mills said in her statement that she explicitly raised her fears about Martha going into septic shock over the bank holiday weekend. On 29 August, Martha had high fever, low blood pressure, a racing heart and a rash, which was misdiagnosed by a junior doctor despite Mills voicing her concern that it was caused by sepsis. It was only the next day that Martha was admitted to paediatric intensive care. “I felt that my anxieties about all of Martha’s symptoms, and especially what they might mean when put together and considered in the round, weren’t given proper acknowledgement,” Mills told the court. Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review. He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier. The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views. Read full story Source: The Guardian, 3 March 2022
  11. Content Article
    Coroner'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)
  12. Content Article
    At the start of last summer, Merope Mills' 13-year-old daughter Martha was busy with life. She’d meet her friends in the park, make silly videos on her phone and play “kiss, marry, kill”. Her days were filled with books and memorising song lyrics. She’d wonder aloud if she might become an author, an engineer or a film director. Her future was brimming with promise, crowded with plans. By the end of the summer she was dead, after shocking mistakes were made at one of the UK’s leading hospitals. "Her preventable death is an example of what a hospital official described to us, in a barbarous phrase, as a 'poor outcome'. I will spend decades asking: why was my child the one to suffer such an unlikely fate?", writes Merope. Further reading Prevention of Future Deaths Report: Martha Mills
  13. News Article
    Trust boards should start scrutinising performance against new indicators set out by NHS England this month as part of a national push to iron out unwarranted variation in performance on key sepsis blood tests, according to an NHSE report. Blood cultures are the primary test for detecting blood stream infections, determining what causes them, and directing the best antimicrobial treatment to deal with them. However, it is too often seen as part of a box-ticking exercise, according to a report published by NHSE yesterday. Improving performance on this important pathway should be integrated into existing trust governance structures for sepsis, antimicrobial stewardship, and infection control “to help secure a ‘board to ward’ focus on improvement,” the report says. It says there is too much variation in how blood cultures are taken prior to analysis and sets out two targets for trusts to use to standardise their collection. The first is ensuring clinicians collect two bottles of blood, each containing at least 20ml for culturing. The more blood collected, the higher the rate of detecting bloodstream infections. Blood culture bottles “are frequently underfilled”. The second is ensuring blood cultures are loaded into an analyser as fast as possible, within a maximum of four hours, because delaying analysis reduces the volume of viable microorganisms that can be detected. Read full story (paywalled) Source: HSJ, 1 July 2022
  14. Content Article
    NHS England and NHS Improvement make the following four recommendations for improving the blood culture pathway: Build upon existing national guidance and best practice. Implement local monitoring to identify areas for improvement. AMR to be a core part of clinical leadership and trust governance. Improve regulation and accreditation.
  15. News Article
    Two drugs that combat superbugs are being introduced on the NHS, offering a lifeline to thousands of patients with deadly infections such as sepsis which fail to respond to antibiotics. About 65,000 people a year in the UK develop drug-resistant infections and 12,000 die, many after routine operations or from infections such as pneumonia or urinary tract infections. These superbugs such as MRSA have mutated to develop resistance to many different types of antibiotics as a result of overuse of the drugs. It means patients end up dying from common infections that would previously have been easily treatable with antibiotics. In a attempt to “turn the tide” on antibiotic resistance, the NHS has announced a deal for two drugs, cefiderocol and ceftazidime–avibactam, which can kill bacteria that is resistant to many other types of drugs. The drugs, manufactured by Shionogi and Pfizer respectively, will save the lives of about 1,700 patients a year. They will be offered to patients with conditions such as drug-resistant pneumonia, sepsis or tuberculosis who have run out of other treatment options. Amanda Pritchard, NHS chief executive, said this would make the UK a world leader in tackling “the global challenge of antimicrobial resistance”. Read full story (paywalled) Source: The Times, 15 June 2022
  16. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient
  17. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 not only in an acute setting but also in the community and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub member receive a 20% discount. Email info@pslhub.org for the code. Follow on Twitter @HCUK_Clare #deterioratingpatient
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  19. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians on NEWS2 and COVID-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and COVID-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. Follow the conference on Twitter #deterioratingpatient Register
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