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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Recording of a webinar lead by Dr Jacqui Dyer introducing the advancing mental health equalities strategy and summarising the core actions that NHS England and NHS Improvement will take to bridge the gaps for communities fairing worse than others in mental health services.
  2. Content Article
    The COGER study is collecting data to gain insight into the course of functional and medical recovery in older people affected by COVID-19 participating in rehabilitation across Europe.
  3. News Article
    Concern is growing that NHS hospitals may face a third wave of the coronavirus pandemic with a much higher level of covid-positive inpatients than at the beginning of the second wave. This raises the prospect of the service being overwhelmed during the January-February “winter pressures” period and having to once again halt elective and non-urgent work in many areas. HSJ understands national NHS leaders are concerned that anything over 5,000 covid patients in hospital by the year end would leave the service vulnerable to being overwhelmed. Their concerns are based on the fact that the second wave added 13,000 hospitalised covid patients at peak. During the first wave, covid hospitalisation peaked at just over 17,000, and in order to prepare for it the NHS cancelled most elective and non-urgent work. Read full story Source: HSJ, 7 December 2020
  4. Content Article
    Healthcare professionals are experiencing unprecedented levels of occupational stress and burnout. Higher stress and burnout in health professionals is linked with the delivery of poorer quality, less safe patient care across healthcare settings. In order to understand how we can better support healthcare professionals in the workplace, this study from Johnson et al. evaluated a tailored resilience coaching intervention comprising a workshop and one-to-one coaching session addressing the intrinsic challenges of healthcare work in health professionals and students. The authors found preliminary evidence that the intervention was well received and effective, but further research using a randomised controlled design will be necessary to confirm this.
  5. Content Article
    People who suffer an injury caused by the negligence of someone else need, and have a right, to rebuild their lives. Going through a personal crisis – whether it is short-term or life-changing – is bad enough without being made to feel ashamed about making a claim. People who have been injured needlessly must have access to justice and the care and support they need on the road to recovery.  Injured people deserve our empathy and understanding. As a nation we should be focused on what genuinely injured people need, rather than on myths about their motivation, and misconceptions about the specialist lawyer s who fight for their rights and help put them on the road to recovery. ‘Rebuilding Shattered Lives’ tells the real story of personal injury and of people who need expert support to help them build brighter futures.
  6. News Article
    More people signed off sick with mental health problems during lockdown, analysis reveals. Millions of people expected to need help after effect of coronavirus on UK A GP fit note is issued after the first seven days of sickness absence if a doctor agrees the patient is too ill to work The proportion of people applying for fit notes from their GP for mental health reasons jumped 6% during lockdown in England, according to new research. It adds to growing concern the UK will see a surge in mental health problems as a result of the pandemic and the impact on society and the economy. It could be the first signs of increasing mental health illnesses since the pandemic started. The Centre for Mental Health think tank has warned the government needs to prepare for the aftermath of COVID-19. Its analysis, based on research into COVID-19 and the effects of other epidemics on mental health, predicts 8.5 million adults and 1.5 million children in England will need support for depression, anxiety, post-traumatic stress disorders and other mental health difficulties in the coming months and years. That is the equivalent of 20 per cent of all adults and 15 per cent of all children. A third of patients would need help for the first time. Read full story Source: Independent, 6 December 2020
  7. News Article
    The coronavirus vaccine is the "beginning of the end" of the epidemic in the UK, Prof Stephen Powis has said, as vaccinations begin on Tuesday. But the NHS England medical director warned the distribution of the Pfizer/BioNTech vaccine would be a "marathon not a sprint". It will take "many months" to vaccinate everybody who needs it, he said. Frontline health staff, those over 80, and care home workers will be first to get the COVID-19 vaccine. In England, 50 hospitals have been initially chosen to serve as hubs for administering the vaccine. Scotland, Wales, and Northern Ireland will also begin their vaccination programmes from hospitals on Tuesday. Prof Powis was speaking outside Croydon University Hospital in south London, which became one of the first hospitals in the UK to take delivery of the vaccine on Sunday. Read full story Source: BBC News, 6 December 2020
  8. News Article
    Women in a newly opened psychiatric intensive care unit (PICU) had concerns for their sexual safety, a Care Quality Commission (CQC) report has revealed. Inspectors found women in the PICU at Cygnet Health Care’s Godden Green Hospital, in Kent, were afraid to shower because male staff did not always knock before entering bedrooms and staff entered bathrooms without permission. Patients were often looked after by male staff despite having asked for a female staff member and, in some cases, had an all-male care team. Most patients the inspectors spoke to had concerns about their sexual safety. The CQC carried out an unannounced inspection of the PICU in October, following concerns raised by members of the public and to check concerns identified in an earlier inspection of the hospital’s child and adolescent mental health services were not organisational. The PICU opened in November 2019. Since the summer, Kent and Medway NHS and Social Care Partnership Trust has commissioned some of the beds, but HSJ understands it stopped admissions for a time to review the care being provided. Inspectors found records referred to PICU patients as “difficult” and “troublemakers” and warned a ”culture of negativity towards patients had developed among some staff”. Read full story (paywalled) Source: HSJ, 4 December 2020
  9. Content Article
    James Titcombe, Patient Safety Campaigner and co-founder of Harmed Patients Alliance, discusses the findings of the recent Bill Kirkup report 'The Life and Death of Elizabeth Dixon: A Catalyst for Change'.
  10. News Article
    Healthcare practitioners who committed child sexual abuse commonly did so under the guise of medical treatment, which went unchallenged by other staff even when unnecessary or inappropriate because of their position of trust, research has found. An independent inquiry into child sexual abuse report into abuse in healthcare settings between the 1960s and 2000s found that perpetrators were most commonly male GPs or healthcare practitioners with routine clinical access to children. As a result their behaviour was not questioned by colleagues, the children or their parents. In many cases patients’ healthcare needs related to physical, psychological and sexual abuse they suffered at home. They spoke of attending health institutions seeking treatment, care and recovery, but were instead subjected to sexual abuse. This included fondling, exposing children to adult sexuality, and violations of privacy. More than half who shared their experiences described suffering sexual abuse by penetration. Read full story Source: The Guardian, 4 December 2020
  11. News Article
    A new mother has spoken of her distress after wrongly-imposed Covid rules led to her being separated from her six-week-old baby for almost a week while she received treatment in hospital. Charlotte Jones, 29, was taken to Princess Royal University hospital in Kent by ambulance last Wednesday, after complications following the birth of her son, Leo. When she arrived, she asked whether she would be able to see her baby, whom she is breastfeeding, while in hospital, but was told it would not be allowed because of the threat of coronavirus. She did not see him until her release six days later. The restrictions as applied in Jones’s case, appear to contravene official guidance and go against the advice of NHS England, which specifies that mothers and babies should be kept together unless it is absolutely necessary to separate them. Separation at such a critical time can have an adverse impact on the physical and mental health of the mother, baby and wider family, say healthcare professionals and charities. King’s College NHS foundation trust, which manages the hospital, has admitted that although it is limiting the number of visitors during the pandemic, there is no policy stopping babies to be brought in to be breastfed. The trust has pledged to ensure staff are aware of its policies. Read full story Source: The Guardian, 4 December 2020
  12. News Article
    NHS staff will no longer get the coronavirus vaccine first after a drastic rethink about who should be given priority, it emerged last night. The new immunisation strategy is likely to disappoint and worry thousands of frontline staff – and comes amid urgent warnings from NHS chiefs that hospitals could be “overwhelmed” in January by a third wave of COVID-19 caused by mingling over Christmas. Chris Hopson, the chief executive of NHS Providers, said: “If we get a prolonged cold snap in January the NHS risks being overwhelmed. The Covid-19 restrictions should remain appropriately tough. “Trust leaders are worried about the impact of looser regulations over Christmas.” Frontline personnel were due to have the Pfizer/BioNTech vaccine when the NHS starts its rollout, which is expected to be next Tuesday after the Medicines and Healthcare products Regulatory Agency (MHRA) approved it on Wednesday. However, hospitals will instead begin by immunising care home staff, and hospital inpatients and outpatients aged over 80. The new UK-wide guidance on priority groups was issued by the joint committee on vaccination and immunisation (JCVI) amid uncertainty over when the rest of the 5m-strong initial batch of doses that ministers ordered will reach the UK. Read full story Source: The Guardian, 4 December 2020
  13. News Article
    More than 60,000 people in the UK have now died within 28 days of a positive COVID-19 test, official figures show. A further 414 were recorded on Thursday, taking the total to 60,113. Two other ways of measuring deaths - where Covid is mentioned on the death certificate, and the number of "excess deaths" for this time of year - give higher total figures. Only the US, Brazil, India and Mexico have recorded more deaths than the UK, according to Johns Hopkins University. However, the UK has had more deaths per 100,000 people than any of those nations. In terms of deaths per 100,000 people, the UK is the seventh-highest country globally, behind Belgium, San Marino, Peru, Andorra, Spain and Italy. Read full story Source: BBC News,
  14. News Article
    A hospital serving the prime minister’s constituency has been issued a warning notice by inspectors over poor infection control, including staff having to share two small toilet cubicles for changing. The Care Quality Commission (CQC) announced it has issued the notice to The Hillingdon Hospitals FT today following an unannounced inspection in September. It comes after the watchdog placed urgent conditions on the provider following a coronavirus outbreak among staff at Hillingdon Hospital in August. At least 70 members of staff had to isolate, some of whom had tested positive for covid. The watchdog said it found there had been improvements, but that “further work is needed”. The CQC’s inspection report, published today, said there were no staff changing rooms available for people to change in and out of their scrubs, and that they were sharing two small toilet cubicles at the start and end of shifts. These were not cleaned with an “enhanced” cleaning schedule, it added, and the lack of separate changing rooms “caused a risk of cross-contamination”. However, senior leaders were aware of the risk and were seeking ways to improve access to changing areas for staff. Read full story (paywalled) Source: HSJ, 4 December 2020
  15. News Article
    Thirteen trusts are facing billions of pounds of maintenance — in some cases, making it more cost-effective to rebuild the hospital — over ‘significant safety issues’ stemming from outdated construction methods. Reinforced autoclaved aerated concrete planks were used when constructing public sector buildings in the 1960s, 70s and 80s, including a group of prefabricated hospitals under the government’s “Best Buy” building programme. However, RAAC planks used in buildings constructed prior to 1980 have now exceeded their shelf life, meaning affected trusts need to carry out frequent inspections and expensive maintenance. For at least three of the affected trusts — Mid Cheshire Hospitals FT, Airedale FT and The Queen Elizabeth Hospital King’s Lynn FT — it would be more cost-effective to build new hospitals than replace the planks in their existing facilities. Victoria Pickles, director of corporate affairs at Airedale FT, told HSJ 85% of the trust’s buildings’ floors, roofs and walls comprised RAAC planks, with one ward closing due to the risk. Read full story (paywalled) Source: HSJ, 3 December 2020
  16. News Article
    Staff at a mental health unit missed "multiple opportunities" to realise a woman had become unwell before she died, a coroner has said. Sian Hewitt, 25, died at Milton Keynes Hospital last year after collapsing at the nearby Campbell Centre. Coroner Tom Osborne said there was "a failure to start effective CPR". A spokesman for the centre said changes have been made to how care is delivered. Ms Hewitt, who had Asperger's syndrome and bipolar disorder, was admitted to the inpatient unit on 13 March 2019. She died less than a month later on 6 April 2019 at Milton Keynes Hospital, where she was taken after collapsing on Willow Ward at the centre. An inquest concluded she died of a pulmonary embolism, caused when a blood clot travels to the lungs. In a Prevention of Future Deaths Report, Mr Osborne said the centre failed to carry out a risk assessment and there was a delay in administering a drug resulting in "her mania not being brought under control". His report said the "failure to recognise how seriously ill she had become" had "resulted in lost opportunities to treat her appropriately that may have prevented her death". He said her death suggested the NHS was "unable to provide a place of safety for those who are suffering from Asperger's syndrome" or other forms of autism "when they are also suffering additional mental health problems such as bipolar". Read full story Source: BBC News, 4 December 2020
  17. Content Article
    This guidance from the Chartered Institute of Ergonomics and Human Factors (CIEHF) is aimed at early career pharmacists, especially those in foundation pharmacist positions managing the transition from education to the workplace environment.  Support in clinical decision-making is recognised as an educational development need for early career pharmacists, making the transition from a university education where there is very little exposure to the clinical environment into the work environment. This situation is compounded by a policy landscape which puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. The guidance will also be of use to those involved in the education and mentorship of early career pharmacist.
  18. Content Article
    National audits, such as the National Emergency Laparotomy Audit (NELA), are a powerful tool. They allow us to see what is happening to our ‘real-life’ patients, to identify gaps in our local services, to see which hospitals are doing best and to share best practice. This learning informs guidelines and pathways such as ‘The High-Risk Surgical Patient’ and the forthcoming international enhanced recovery programmes for emergency laparotomy. The linking of good practice with a financial incentive, the Best Practice Tariff, has also acted as a carrot for hospitals to support funding for new models of care. Previously we have seen how audit, linked with guidelines and associated financial incentives, has improved outcomes in hip fracture and now it is encouraging to observe similar results in emergency laparotomy. In this blog, Dr Jugdeep Dhesi, Consultant Geriatrician and Deputy Director for the Centre of Perioperative Care, discusses NELA and older patients, and how we must deliver patient-centred rather than surgical-speciality based pathways and to ensure the best outcomes for all of our patients.
  19. Content Article
    The Care Quality Commission (CQC) were commissioned by the Department for Health and Social Care to conduct a special review of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions taken during the COVID-19 pandemic. This interim report sets out the progress of our review so far and our expectations around DNACPR.
  20. Event
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    Chief executive Joe Rafferty and strategic advisor for digital programmes Jim Hughes, will discuss how Mersey Care Foundation Trust has been part of a region-wide programme to develop shared understanding of covid and other pressures. Joining them on the panel will be Rebecca Malby, professor in health systems innovation at London South Bank University, and Markus Bolton, director of Graphnet Health – which is supporting the event. In a discussion chaired by HSJ contributor Claire Read, they will explore the value of a shared understanding of which pressures and caseloads exist in an area and consider how digital technologies might play a role here. Which parties need to be involved? Which information is most important to which groups? How can worries about information governance be overcome? Register
  21. Content Article
    The All-Party Parliamentary Group (APPG) on Coronavirus was set up in July 2020 to conduct a rapid inquiry into the UK Government's handling of the COVID-19 pandemic. It's purpose is to ensure that lessons are learnt from the UK Government's handling of the coronavirus outbreak to date, and to issue recommendations to the UK Government so that its preparedness and response may be improved in the future. This is the biggest review to date of the UK response to the pandemic. It comes with 71 key findings and 44 recommendations to government. In total, the APPG spoke with 65 witnesses and held 30+ hours worth of public evidence sessions streamed on social media. They received and processed just under 3,000 separate evidence submissions. 
  22. Content Article
    The Health Index is a new tool to measure a broad variety of health outcomes and risk factors over time, and for different geographic areas. This methodology article explains how the Health Index has been constructed.
  23. Content Article
    This Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
  24. News Article
    Do-not-resuscitate orders were wrongly allocated to some care home residents during the COVID-19 pandemic, causing potentially avoidable deaths, the first phase of a review by England’s Care Quality Commission (CQC) has found. The regulator warned that some of the “inappropriate” do not attempt cardiopulmonary resuscitation (DNACPR) notices applied in the spring may still be in place and called on all care providers to check with the person concerned that they consent. The review was prompted by concerns about the blanket application of the orders in care homes in the early part of the pandemic, amid then prevalent fears that NHS hospitals would be overwhelmed. The CQC received 40 submissions from the public, mostly about DNACPR orders that had been put in place without consulting with the person or their family. These included reports of all the residents of one care home being given a DNACPR notice, and of the notices routinely being applied to anyone infected with Covid. Some people reported that they did not even know a DNACPR order had been placed on their relative until they were quite unwell. “There is evidence of unacceptable and inappropriate DNACPRs being made at the start of the pandemic,” the interim report found, adding that the practice may have caused “potentially avoidable death”. Read full story Source: The Guardian, 3 December 2020
  25. News Article
    Trusts have been urged to reflect on their disciplinary procedures, and review them annually where required, following the death of a senior nurse who took his own life after being dismissed. NHS England’s chief people officer Prerana Issar has written to trust leaders to highlight Imperial College Healthcare Trust’s new disciplinary procedures, which were put in place following Amin Abdullah’s suicide. Mr Abdullah, a senior nurse at Charing Cross Hospital in west London, was suspended in September 2015 before being let go from his job that December. He died in February 2016 after setting himself on fire. An independent investigation criticised both the trust and its staff and concluded he had been “treated unfairly”. The summary report produced by the trust was labelled a “whitewash”, which “served to reassure the trust that it had handled the case with due care and attention”, and the delay of three months between the events and hearing were “troubling”. The report, which also criticised the delays as “excessive” and “weak” in their justification, said Mr Abdullah found the delay “stressful” and caused him to become “distressed”. In the letter sent on Tuesday, seen by HSJ, Ms Issar said: “The shared learning from Amin’s experience has demonstrated the need for us to work continuously and collaboratively, to ensure that our people practices are inclusive, compassionate and person-centred, with an overriding objective as to the safety and wellbeing of our people… our collective goal is to ensure we enable a fair and compassionate culture in our NHS. I urge you to honestly reflect on your organisation’s disciplinary procedure…" Read full story (paywalled) Source: HSJ, 3 December 2020
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