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Found 105 results
  1. News Article
    One in five deaths around the world is caused by sepsis, also known as blood poisoning, shows the most comprehensive analysis of the condition. The report estimates 11 million people a year are dying from sepsis - more than are killed by cancer. The researchers at the University of Washington said the "alarming" figures were double previous estimates. Most cases were in poor and middle income countries, but even wealthier nations are dealing with sepsis. There has been a big push within the health service to identify the signs of sepsis more quickly and to begin treatment. The challenge is to get better at identifying patients with sepsis in order to treat them before it is too late. Early treatment with antibiotics or anti-virals to clear an infection can make a massive difference. Prof Mohsen Naghavi said: "We are alarmed to find sepsis deaths are much higher than previously estimated, especially as the condition is both preventable and treatable. We need renewed focus on sepsis prevention among newborns and on tackling antimicrobial resistance, an important driver of the condition." Read full story Source: BBC News, 17 January 2020
  2. News Article
    Trainee oncologists at a major cancer centre covered clinics and made “critical” decisions without senior supervision, including for cancers they were not trained for, HSJ has revealed. A Health Education England (HEE) reviews aid: “The review team was concerned to hear that trainees were still expected to cover clinics where no consultant was present, including clinics relating to tumour sites that they were unfamiliar with.” Guy’s and St Thomas’ Foundation Trust’s trainee clinical oncologists felt “they could only approach 50–75% of the consultants for critical decision-making”, the document said. The HEE “urgent concern review” report said: “The trainees also reported that there was a continued lack of clear consultant supervision for inpatient areas in clinical oncology, which meant that they were not able to access senior support for decision-making.” A trust spokesman said: “We recognise that senior support to the clinical team is a vital part of keeping our patients safe.” Read full story (paywalled) Source: HSJ, 16 January 2020
  3. Content Article
    Key points Medication errors are the most common type of error affecting patient safety and the most common single, preventable cause of adverse events. Medicines calculations can assist in preventing an inaccurate medicines dose from being administered to the patient, which could result in suboptimal therapeutic benefit and/or possible harm to the patient. It is crucial for IV infusion calculations to be accurate, because these medicines directly enter the venous system and generally have a prompt action. Therefore, there is limited possibility of removing the medicine if an error is made. Individual nurses and healthcare organisations must ensure that medicines calculation skills are developed and maintained in practice.
  4. Content Article
    Case study examples The following case studies show how trusts have been using the tool. Roles and responsibilities of staff have been reviewed and new workforce plans have been co-designed with staff at the frontline to deliver new ways of working that put the patient at the centre of care – whatever the setting. The Hillingdon Hospitals - Safety Supervision and Savings.pdfThe Hillingdon Hospitals - Ward Reconfiguration for Safety.pdf GIG Cymru NHS Wales - Residential Nursing homes Case Study.pdfChelsea and Westminister Hospital Case Study - Empowering Staff.pdf GIG Cymru NHS Wales - District Nursing Principles Case Study (1).pdfBerkshire Health Community Nursing Case Study.pdf Organisational benefits Integrated care levels, costs and common language enables clinical and corporate leads to collaborate and meet the requirements of a next-generation health and social care workforce: Precise staffing profiles and options appraisal support CIP development and budgeting. Gap analysis compared to budget and standards for exact hours and WTE requirement for each band. Uplift for leave is specific to each role and expected joiners, avoiding blanket uplifts that may not fit the needs of the unit. Governance and control underpinned by agreed, costed roster templates, with ready reckoners to keep within range. Improved recruitment and retention with evidence of staffing levels and support. Outcomes track quality, with benchmarking to assure. Clinical benefits Professional judgement in workforce planning is supported by this NICE-endorsed tool: Planning care levels and WTE for expansion, efficiency, reconfiguration and new service models. Evaluating alternative shift models to reorganise, invest or save. Modelling skill-mix and impact of new roles. Understanding and validating variation. Challenging peaks and troughs in cover to improve safety, release capacity and release cost savings. Benchmarking and triangulation of patient care levels, with outcomes for correlation. Mapping other staff group input across each setting. Background on 'Establishment Genie' Creative Lighthouse was founded in response to frustration at the focus on financially led decisions in health and social care management that did not consider the safety and care of patients or staff. We set out to build a platform that would allow all management groups in the healthcare sector to collaborate on safe staffing and financial governance. Creative Lighthouse self-funded the development of a unique workforce-planning tool under the brand name ’Establishment Genie’, endorsed by the National Institute of Health and Care Excellence (NICE) in 2017. In April 2017, the Creative Lighthouse team were awarded a grant from Innovate UK to continue to develop the tool to include all settings of care in the knowledge that patient safety and workforce planning is not only the responsibility of acute services, but of all providers and commissioners of care. This is a critical aspect of enabling the improvement of quality and patient outcomes in a cost effective way, whilst providing data driven analytics to support professional judgment. About the author I am a healthcare professional with over 15 years’ experience working in and consulting to public and private health and social care organisations. I have worked with a variety of health and care sector clients in the delivery of complex change, from transformational change and organisational design process to programme leadership and execution. I am passionate about the safe staffing agenda, recognising that in order for any organisation to ensure appropriate care and evidence for professional judgement, there must be consistency in approach and a way of linking staffing levels to quality outcomes that can then be benchmarked within and across organisations. This passion resulted in the birth of ‘Establishment Genie’.
  5. News Article
    Hospitals will be required to employ patient safety specialists from next April as part of efforts by the health service to reduce thousands of avoidable errors every year. NHS trusts will be told to identify staff who will be designated as the safety specialist for each organisation. These workers, who will get specific training and work as part of a network across the country, will help to tackle a fragmentation in the way safety issues are dealt with in the NHS and ensure nationwide action on key safety risks is coordinated. The proposals are part of a national patient safety strategy which is aiming to save 928 lives and £98.5m across the NHS, as well as reducing negligence claims by £750m by 2025. The specialists will be identified from existing staff, with part of the role focused on embedding a so-called “just culture” approach to safety. This means reducing blame, supporting staff who make honest errors and tackling systemic causes of mistakes. Read full story Source: The Independent, 26 December 2019 What do you think? Join the conversation on the hub.
  6. Content Article
    In this five minute video, the authors chose to focus on the main theme – the human cost to healthcare workforce when there is a failure to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events.
  7. 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).
  8. News Article
    A lot has been written about the workforce crisis in health and social care. 43,000 registered nurse vacancies, a 48% drop in district nurses in eight years and not enough GPs to meet demand. When we talk about workforce, the focus is always on numbers. There are campaigns for safe staffing ratios and government ministers like to tell us how many more nurses we have. But safety is not just about numbers. Recent workforce policy decisions have promoted a more-hands-for-less-money approach to staffing in healthcare. More lower-paid workers mean something in the equation has to give. In this case, it’s skill and expertise. In this article in The Independent, Patient Safety Learning's Trustee Alison Leary discusses how healthcare has failed to keep frontline expertise in clinical areas due to archaic attitudes to the value of the experienced workforce. Read full story Source: The Independent, 15 December 2019
  9. Content Article
    The 2015 Montgomery ruling created practical implications for how clinicians obtain consent and support patients to make decisions about their healthcare. The implication of the Montgomery ruling is that healthcare professionals must: clearly outline the recommended management strategies and procedures to their patient, including the risks and implications of potential treatment options discuss any alternative treatments discuss the consequences of not performing any treatment or intervention ensure patients have access to high-quality information to aid their decision-making give patients adequate time to reflect before making a decision check patients have fully understood their options and the implications document the above process in the patient’s record.
  10. Content Article
    Key themes: Situational awareness Handover resources Interruptions and distractions Delegation Task-fixation, helicopter view & closed-loop communication Ask for help.
  11. Content Article
    This page links to videos explaining what types of errors and challenges there are when using EHR's. By highlighting these errors and challenges may help mitigate future harm for patients.
  12. Content Article
    This is an easy-read leaflet that you can download and print to give to your patients, service users, families and carers to inform them about STOMP.
  13. Content Article
    This page is a catalogue of material to support CCGs, GP practices and others to undertake initiatives to support STOMP.
  14. Content Article
    This video by the NHS England STOMP team and service users, explains what STOMP is and what frontline staff need to know.
  15. News Article
    Half of the unexpected deaths in Belgian hospitals are due to a shortage of nurses, according to a study by the University of Antwerp. Researchers from the University of Antwerp show the link between the number of nurses in hospitals and the death of the patients they care for, based on data from 34,567 patients’ medical records in four Flemish, one Walloon and two Brussels hospitals. The records showed that, on average, three out of every thousand patients in the hospital died ‘unexpectedly’. A death is considered as unexpected when a patient suddenly dies during active treatment, with no care plan for the end of their life having been started. “We know from previous research that part of these unexpected deaths can be avoided, which is always heartbreaking for the family as well as the staff,” said Filip Haegdorens, a researcher at the university. “As a sector, we must do everything we can to prevent this,” he added. The average nurse in Belgium is responsible for 9.7 patients at a time. For 89% of all departments, the number of nurses per hospital department was too low to be able to ensure good quality care. “Compared to, for example, Australian hospitals, where legal minimums exist, our Belgian figures could be improved,” said Haegdorens. The study also shows a link between the training level of nurses and the number of unexpected deaths in the hospital. “In some hospital services, we found that more nurses with a high level of education would reduce the risk of unexpected deaths,” Haegdorens added. Read research paper Read full story Source: The Brussels Times, 4 December 2019
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