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Found 71 results
  1. News Article
    A woman who died shortly after giving birth to her daughter did not receive the correct medication, a coroner has ruled. Jess Hodgkinson, 26, from Chesterfield, died from a pulmonary embolism in 2021. Assistant coroner Matthew Kewley said there was a "failure" to ensure Ms Hodgkinson received blood thinners right up until the birth. Chesterfield Coroner's Court heard Ms Hodgkinson had a high risk pregnancy due to severe hypertension. On 21 April 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting, the inquest heard. During the inquest, the consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth. Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a "failure to communicate" the medication plan, Mr Kewley said. After being discharged, clinicians in Chesterfield "failed to identify" Ms Hodgkinson was no longer receiving the medication, the coroner said in his ruling. On 13 May, Ms Hodgkinson attended Chesterfield Royal Hospital and a decision was made to carry out an emergency Caesarean section. The procedure was successful and Ms Hodgkinson's baby was born. But after delivery, Ms Hodgkinson went into cardiac arrest and later died. In his concluding remarks, Mr Kewley said: "There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess' death". Read full story Source: BBC News, 31 January 2023
  2. Content Article
    The workshops brought together a group of patients, whose recommendations for specialist advice and guidance are: Establish a three-way dialogue between the patient, GP, and the specialist to ensure patient partnership and shared decision making. Streamline the referral process for GPs to get the advice. Include pharmacists into the advice and guidance process. The group also suggested ways to better engage patients in the service: Consider the individual’s care and communication needs. Allow patients to add information to the e-referral system and increase patient access to their medical records. What matters most to the patient should guide the referral Provide information to patients on how to manage their health while they wait for the referral or outcome of the advice and guidance request. To raise awareness of the service among patients, the group suggested that two type of resources: one to raise awareness, and one to provide guidance about the actual service and how it works. The group also said that since it’s patients who benefit from the specialist advice and guidance service, any evaluation of the service should be patient-focused and provide information on how the service is working for patients and opportunities for making improvements. The group’s suggestions for evaluating the service are: Impact of specialist advice on patient experience, access, and patient journey. Impact of specialist advice on supporting greater patient engagement, shared decision making, patient choice, and self-care. Patient awareness and knowledge of specialist advice. Effective communication and information-sharing during the specialist advice/referral process. Impact of specialist advice on equality and health inequalities and ensuring ease and equity of access to care. Availability and access to advocacy and assistance services during the specialist advice process.
  3. News Article
    Angry exchanges between paramedics and A&E staff in Liverpool have broken out after new measures were deployed to hold and treat patients in the back of ambulances. Sources said there have been “Mexican standoff” situations at Aintree Hospital in recent days, after hospital staff insisted patients who had been brought inside should be returned to ambulance vehicles. Staff at North West Ambulance Service told HSJ they were informed of a new protocol last week, which said patients should be kept in the back of ambulances if the corridor of the emergency department is full with patients. There have been repeated orders from NHS England and the Care Quality Commission over the past year for hospitals to ensure patients can be offloaded by ambulance crews, even if they fear they do not have adequate staffing or beds to accept them. One senior source at NWAS said: “To see a new protocol like this is absolutely unprecedented. I very much doubt the execs had approved it. “We’ve had Mexican standoff situations over the weekend with crews who have brought patients into ED being told to take them back out to their vehicles, but they’ve refused to do this as it means they cannot cohort. “We completely accept that taking extra patients means the ED and hospital staff have to deal with additional and unacceptable risk, but holding ambulances is not the solution because the risks to patients out in the community are even greater. Despite repeated instructions from NHS England and the CQC this still doesn’t seem to be understood.” Read full story (paywalled) Source: HSJ, 17 October 2022
  4. Content Article
    WHO states that medication harm accounts for around 50% of the overall preventable harm in medical care and comes with a huge financial cost, estimated at $42 billion USD annually. Patients can be subject to avoidable harm as a result of medication in a range of different ways, including: prescription errors—being underprescribed or overprescribed medicines or receiving a prescription which does not address the health condition and subsequently results in deterioration. dosage errors—missed doses or incorrect doses, which can occur in a range of different settings. mistakes in administration—such as administering a medicine which should be take intravenously by the intrathecal route. Global Patient Safety Challenge This year World Patient Safety Day, on Saturday 17 September 2022, is focused on medication safety. It is intended to build on the existing WHO Global Patient Safety Challenge: Medication Without Harm. Formally launched in 2017, the aim of this is to reduce severe avoidable medication-related harm by 50% in the next five years. This challenge focuses on three key action areas: Medication safety in polypharmacy—this concerns is the concurrent use of multiple medications. Although there is no standard definition, it is often defined as the routine use of five or more medications. Medication safety in high-risk situations—this concerns circumstances where the medication being used may be associated with a particularly high risk of harm, where provider and patient factors that may increase the level of risk and where system factors (work environment) that may increase the level of risk. Medication safety in transitions of care—this concerns the various points where a patient moves or returns from a particular physical location or makes contact with a healthcare professional for the purposes of receiving healthcare, Each of these actions are mapped against four different domains where greater awareness and action is required: 1. Patients and the public Public awareness and medication literacy Patient engagement Reporting by patients Involvement of patient organisations 2. Health care professionals Education and training Communication and teamwork Capability at point of care Incident reporting and learning 3. Medicines Product quality and safety Naming, labelling, and packaging Logistics, storage, and disposal Right product at point of care 4. Systems and practices of medication Leadership and governance Prescribing, preparation, and dispensing Administration and patient monitoring Monitoring and evaluation 5 Moments for Medication Safety tool As part of this Challenge, WHO has developed a patient engagement tool: 5 Moments for Medication Safety. This looks at the key points where a patient or carer can reduce the harm associated with the use of medication/s, with the intention of empowering them to be involved in their care and patient safety. Medication Safety webinar series WHO has recently run a series of excellent webinars with global experts, healthcare professionals and patients, to introduce the strategic framework for implementation of this Global Challenge. These include strategies, tools, and technical support to countries for reducing medication-related harm, in addition to sharing country and patient experiences of implementing the challenge. Recordings and presentations from each of these webinars can be accessed below: WHO Global Patient Safety Challenge: Medication Without Harm & World Patient Safety Day 2022 (8 February 2022) Engaging Patients and Families for Medication Safety (8 March 2022) Medication Error Reporting and Learning Systems, and Pharmacovigilance (12 April 2022) Medication Safety in High-risk Situations (17 May 2022) Medication Safety in Transitions of Care (7 June 2022) Medication Safety in Polypharmacy (12 July 2022) Related reading You can find a wide range of articles related medication safety, including research, risks, opinion pieces and examples of good practice, on the hub. You can also find a number of examples of medication error traps, situations which could lead to avoidable harm if not mitigated, on the hub error traps gallery.
  5. News Article
    Private and NHS ambulance services are reviewing safety procedures after the Care Quality Commission identified a series of risks to mental health patients being transported by non-emergency providers. The care watchdog wrote to all providers of non-emergency patient transport earlier in the summer, warning of concerns identified at recent inspections about use of restraints, sexual safety, physical health needs, vehicle and equipment safety standards, and unsafe recruitment practices. The letter, seen by HSJ, stated: “We know there are many independent ambulance providers providing a good standard of care. Unfortunately, our recent inspections suggest that this is not always the case." “We expect providers to deliver on their commitment to provide safe, high-quality care and we will do everything within our powers to ensure this happens.” Read full story (paywalled) Source: HSJ, 4 August 2022
  6. Event
    The International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the 6th webinar of the medication without harm webinar series is "Medication Safety in Polypharmacy and Transitions of Care”. Register for the webinar The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm.
  7. Community Post
    I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things are difficult and we accept there are waits. Having information on the progress of your referral, and an assurance that is is being clinically prioritised is vital. If patients are fully informed and assured of the progress of their referrals in real-time it could save time and effort in fielding enquiries and prevent them going missing or 'falling into a black hole', which is a reality for some people. It would also prevent clinical priorities being missed. Maybe this is happening, and patients are being kept fully informed in real-time of the progress of their referrals. It would be good to hear examples of best practice.
  8. Content Article
    The report makes the following recommendations: By 2022, there needs to be a multidisciplinary mental health workforce plan, alongside the refresh of the mental health strategy, that provides the staffing needed to provide care at the point of need. A guarantee mental health receives its share of Covid health funding, and that there is a longer-term assessment of what funding is needed to meet the mental health needs of all Scots. A national transitions strategy for our most vulnerable young people, ensuring they can transition into adulthood with the right care and support. A public health-led approach to addressing drug and alcohol addictions, including access to care and treatment for those with a dual diagnosis. By 2026, use 1% of what we spend on health to support the mental health of our young people through Child & Adolescent Mental Health Services (CAMHS).
  9. Content Article
    Investigation summary The investigation explores: Patient flow through hospitals. How delays in discharging patients from hospitals to social and community care impacts on the ability to move patients from an ambulance into an emergency department and on to the right place of care. Safety recommendations HSIB recommends that the Department of Health and Social Care leads an immediate strategic national response to address patient safety issues across health and social care arising from flow through and out of hospitals to the right place of care. HSIB recommends that the Department of Health and Social Care conduct an integrated review of the health and social care system to identify risks to patient safety spanning the system arising from challenges in constraints, demand, capacity and flow of patients in and out of hospital and implement any changes as necessary.
  10. Community Post
    Hi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione
  11. Community Post
    Morning all, As a Critical Care Outreach nurse of many years, one of my greatest bugbears is SBAR handover, or there lack of! Within my trust, there is an SBAR proforma attached to the NEWS2 chart, which appears to be fit for purpose currently. (We are still on paper obs charts, moving to e-obs by the end of the year) SBAR is taught and embedding in all our teaching and training, the candidates at the time of the courses are all able to giver perfect SBAR handovers in simulation but as soon as they walk out the door all of that seems to disappear. It is all too often we receive poor handovers for referrals, the lack of information and clarity means that we cannot prioritise patients effectively. I am currently looking at the nuts and bolts of why this is and what we need to do to address the issues. I have started by sending a survey out to all registered nursing staff so that we can get feedback from those who should be using it. Hopefully, from the responses this may mean we can formulate a plan to improve this. Does anyone else have the same issues/ concerns in you line of work? Has anyone got anything that they do in their trust that works?
  12. News Article
    Serious patient safety and wellbeing concerns about the latest hospital discharge guidance have been raised to HSJ by senior clinicians and charities. Senior geriatricians warned that the guidance could prompt an increase in “urgent readmissions”, “permanent disability” and “excess mortality”, while charities said families could be left with “unsustainable caring responsibilities” because of the new rules. The government guidance, Hospital Discharge Service: policy and operating model, published in August, said clinicians should consider discharging patients when they were “medically optimised” rather than “medically fit”. It said 95% of these patients would return straight home with additional social care and rehabilitation support if needed. Many of the concerns raised surround the retention of the “criteria to reside”. This was originally agreed in March when there was a push from NHS England to free up acute beds over fears hospitals would become overwhelmed with covid admissions as the pandemic hit the UK. The criteria has, however, been maintained in the new guidance, despite a significant fall in infections and deaths from the virus. Rachel Power, chief executive of The Patients Association charity, warned: “This guidance makes it clear that the NHS is still having to take drastic emergency action in the face of covid-19, that will continue to take a heavy toll on patients. It is clear that many patients will be rushed home who would normally have had a longer period of hospital care.” Read full story (paywalled) Source: HSJ, 8 September 2020
  13. News Article
    GP leaders have written to NHS England to demand that an NHS hospital trust urgently restores routine referrals as it has 'closed its doors' to some patients, ‘destabilising’ practices in the process. Oxfordshire LMC said local GPs are ‘concerned and angry’ about the ‘ongoing closure’ to routine referrals across multiple ‘high-demand’ specialties by Oxford University Hospital Foundation Trust, while warning GPs are also being asked to carry out tests that should be done in hospital. A ‘significant’ number of specialties are affected, including ENT, general gynaecology, dermatology, ophthalmology, endoscopy and urology, as well as plastics and maxillofacial, it added. The hospital trust said it had remained open for urgent and emergency care and was accepting clinically urgent and suspected cancer referrals, while reinstating services to support 'the vast majority' of routine referrals. But Oxfordshire LMC has this week written to NHS England and the council of governors at OUHFT to demand that there are ‘no further delays’ in restoring the services amid concerns of ‘patient harm’. It said: ‘The LMC believes the continuing closure of some specialty services to routine referrals is now so serious for patients that it has taken a decision to formally raise the concerns of Oxfordshire’s GPs with NHS England.’ Read full story Source: Pulse, 13 August 2020