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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Care homes will not receive the first batches of the Covid vaccine in Scotland because of problems transporting small doses around the country. The health secretary has said about 65,500 doses of the Pfizer vaccine will arrive in Scotland by next Tuesday. They will initially be stored in freezers in packs of 997 doses. The first people to receive the jab may have to travel to where the doses are being held. Health Secretary Jeane Freeman said that means care homes would have to wait until the issue of breaking down the vaccines packs into smaller doses is resolved. She told the BBC's Good Morning Scotland programme: "The doses come to us in packs of 997 and we need to know to what degree we can pack that down into smaller pack sizes. If we can't, then we absolutely need to bring those who need to be vaccinated to those freezers - to the centres - because there is a limit to how much you can transport the doses once you have defrosted them." "We don't want to waste any of this vaccine so it's not possible at this point to take it in smaller doses into, for example, care homes." Read full story Source: BBC News, 3 December 2020
  2. News Article
    Emergency medics are writing to hospital chief executives warning them that some trusts are being ‘complacent’ about crowding in A&E, they have told HSJ. The Royal College of Emergency Medicine (RCEM) is sending a letter to trust chiefs today calling on them to urgently plan for how they will stop corridor waits and exit blocking ahead of January and February, typically the busiest months. It says some trusts were not treating emergency department crowding as a “high priority”, despite covid risks and pressures. It is also calling for overcrowding in the emergency department (ED) to be classed as a “never event” — a set of major safety risks. RCEM’s concern comes amid apprehension over long ambulance queues at hospitals across the UK, and difficulties enabling social distancing between patients in many EDs. Read full story (paywalled) Source: HSJ, 3 November 2020
  3. Content Article
    This document about the COVID-19 vaccination programme is intended for healthcare staff involved in delivering the programme. It includes detailed information on: the background of the programme the vaccines (as they become available) vaccine recommendations and eligibility contraindications and precautions vaccine administration issues. This document will be updated regularly as more information becomes available.
  4. Content Article
    Pharmacy teams should understand how to minimise the risk and likelihood of dispensing errors, including methods that can be used to evaluate existing processes, as well as how to deal with errors if they happen. This article from Phipps et al., in the Pharmaceutical Journal, builds upon the ideas proposed in ‘Understanding dispensing errors and risk’, and also proposes strategies and methods that should be considered for use in the pharmacy to manage the risk of dispensing errors.
  5. News Article
    Niamh McKenna, Chief Information Officer at NHS Resolution, hosted the recent digital focussed event, ‘2020: A Catalyst for Rapid NHS Digital Transformation’. Panellists from NHS England & Improvement, Health Education England, and Microsoft, looked to dissect the rapid acceleration of digitalisation in our NHS over the last twelve months, and what this means for our sector and our workforce. The two hour event hosted over 100 attendees and live-streamed on YouTube, allowing delegates to hear about the key considerations for the impact of a new digital-first way of working. Looking at the good and the bad from the last twelve months, the panellists shared insight into digital-first training, technology fatigue on the workforce, revolutionary digital approaches from case studies on COVID-19 wards, and much more. One important topic associated with digital is the role of learning for our NHS workforce, and Henrietta Mbeah-Bankas, Head of Blended Learning and Digital Literacy at Health Education England, raised some interesting opportunities, challenges, and considerations around digital learning for the workforce: “Properly defining digital literacy is one of the first vital steps for a digital transformation strategy to succeed, we can’t continue to make assumptions like ‘Millennials are digital-natives’." “There are three groups we need to consider to properly develop an inclusive digital transformation strategy that will be effective – the digitally engaged, digitally ambivalent, and those that say, ‘I don’t do tech’. For me there’s also a fourth group, those who are actually digitally excluded. Until you understand the barriers these people have and consider how they’ll approach digital solutions, you can’t begin to create an inclusive digital strategy that will ensure everyone comes on the journey with you." Niamh's key take-away from the event was that we need to make sure we continue to embrace rapid digital transformation, use it as a catalyst to get stuff done, improve work, improve lives, and improve patient care. We must use all this data available to us to understand the good and the not so good outcomes from the pandemic to shape initiatives for our new future. A recording of this event is now available to watch on demand here, along with downloadable supportive resources shared by the panellists. Read full story Source: Health Tech Newspaper, 30 November 2020
  6. Event
    Release of a major report containing recommendations gathered through the work of the All-Party Parliamentary Group (APPG) on Coronavirus. This report will be the first comprehensive assessment of the UK government’s handling of the pandemic, and consists of 40 recommendations which we will deliver directly to the Prime Minister. From the failure to protect the elderly in care homes, to the over-centralised, outsourced and ineffective test, trace, isolate and support system, the report will make clear the government’s mishandling of the pandemic. There will be a live Q&A on the day of the launch of the report. Register
  7. Content Article
    This survey from the Care Quality Commission (CQC) looks at the experiences of people receiving community mental health services. The 2020 community mental health survey received feedback from 17,601 people who received treatment for a mental health condition between 1 September 2019 and 30 November 2019. This report shows that people are consistently reporting poor experiences of NHS community mental health services, with few positive results. For example, poor experiences were reported for crisis care, accessing care, and involvement. It also found disparity in the experiences of different groups of people, especially among respondents with different diagnoses.
  8. News Article
    The UK has become the first country in the world to approve the Pfizer/BioNTech coronavirus vaccine for widespread use. British regulator, the MHRA, says the jab, which offers up to 95% protection against COVID-19 illness, is safe for rollout next week. Immunisations could start within days for those who need it the most, such as elderly, vulnerable patients. The UK has already ordered 40m doses - enough to vaccinate 20m people. Around 10m doses should be available soon, with the first 800,000 arriving in the UK in the coming days. It is the fastest ever vaccine to go from concept to reality, taking only 10 months to follow the same developmental steps that normally span a decade. Prime Minister Boris Johnson tweeted "It's the protection of vaccines that will ultimately allow us to reclaim our lives and get the economy moving again." Health Secretary Matt Hancock told BBC Breakfast that people will be contacted by the NHS when it is their turn for the jab. Read full story Source: BBC News, 1 December 2020
  9. News Article
    Trusts are carrying out harm reviews after a ‘contamination issue’ affecting hundreds of samples resulted in some staff and patients being wrongly told they had coronavirus, HSJ can reveal. The error happened in mid-October and involved swabs from five trusts in the South East region, which were being processed by the NHS-run Berkshire and Surrey Pathology Services. HSJ understands it is thought that around 100 people across several trusts were given false positive results, and subsequently tested negative. The trusts involved are the Royal Surrey Foundation Trust, Frimley Health Foundation Trust, Royal Berkshire Foundation Trust, Ashford and St Peter’s Hospitals Foundation Trust and Berkshire Healthcare Foundation Trust. Frimley has completed a clinical review and found no harm had been caused, while Royal Berkshire, Ashford and St Peter’s and the Royal Surrey have reviews ongoing. The position for Berkshire Healthcare, a mental health trust, is not known. Read full story (paywalled) Source: HSJ, 2 December 2020
  10. News Article
    The Care Quality Commission (CQC) has raised serious concerns about a major teaching trust’s maternity services and taken action to prevent patients coming to harm. The watchdog has imposed conditions on the registration of Nottingham University Hospitals Trust’s maternity and midwifery services at Nottingham City Hospital and Queen’s Medical Centre and rated them “inadequate”. Following an inspection in October, the CQC identified several serious concerns, including leaders lacking the skills to effectively head up the service, a lack of an open culture where staff could raise concerns, and staff failing to complete patient risk assessments or identify women at risk of deterioration. In its findings, the CQC reported how “fragile” staff wanted to escalate their concerns directly to the regulator, particularly around the leadership’s response to the “verbal outcome of the inspection”. The regulator called this “further evidence of the deep-rooted cultural problems” and escalated these concerns directly to trust CEO Tracy Taylor, who would be “personally overseeing the improvement process required”. Inspectors also found the service did not have enough staff with the right skills, qualifications and experience to “keep women safe from avoidable harm”. The CQC also issued the trust a warning notice over concerns around documenting risk assessments and IT systems. The trust has three months to make improvements. Read full story (paywalled) Source: HSJ, 2 December 2020
  11. News Article
    People with learning disabilities have been "at the back of the queue" during the coronavirus pandemic, a panel of MPs has been told. Those living in supported accommodation were left waiting weeks for guidance on testing and visits. MPs were also told long-term social factors were likely to be more important than biology when it came to ethnic divides in the virus's impact. The panel focused on what lessons could be learned. Read full story Source: BBC News, 1 December 2020
  12. News Article
    Cancer screening programmes designed to save hundreds of lives have been delayed by up to a year as services struggle with staff and equipment shortages, HSJ can reveal. Of the 14 Lung Health Check Programme sites announced last year, four — or just under a third — have either halted programmes they had started or delayed beginning them, with some now expected not to be operational until after March. The areas chosen for the scheme activities, which often involved mobile computed tomography units in vans, have high rates of late diagnosis lung cancer. A study published in the New England Journal of Medicine in February showed CT scanning of high risk groups led to a 26% reduction in deaths in men and between a 39 and 61% reduction in women. NHS England confirmed “activity had resumed” in nine areas while one has started this month, meaning four areas remain out of action. The organisation declined to answer HSJ’s questions on which services were not running and why. Read full story (paywalled) Source: HSJ, 1 December 2020
  13. Content Article
    In this Episode of the 'This Is Nursing' podcast series, Gavin Portier speaks with Kayleigh Evans, a lecturer at Sheffield Hallam University. They talk about nursing homes and the what is has been like during the COVID19 pandemic. Being a registered nurse in a care home/nursing home is an experience like no other and Kayleigh talks about the accountability that comes with the role and the different skills and situations these nurses find them selves in. There's a beautiful account of a good death that is very touching. Kayleigh also talks about the role of a nursing lecturer and we get an insight into the way nursing is being taught during this COVID.
  14. Content Article
    East Lancashire Hospitals NHS Trust (ELHT) is a healthcare provider treating over half a million patients a year in the North West. Back in 2013, they were investigated as part of the Keogh Review and as a result were categorised as an organisation in “special measures”. Morale amongst the staff consequently hit rock bottom, against a backdrop of negative media articles. Staff engagement was identified as a fundamental driver to improve staff and patient experience. However, it was appreciated that the cultural change required would take time to achieve. To gain regular feedback from their staff, they used the Staff Friends and Family Test (Staff FFT), to which they added several local questions. Based on this feedback and information from the NHS Staff Survey, they set about rebuilding ELHT with the clear intention to create a culture where staff felt they belonged. Read their case study.
  15. Content Article
    What does person centred care mean for the role of patients? Fundamentally, it is an ethos that is intended to put users at the heart of services; encouraging a view of them as participants, not patients; active, not passive. This thinking should apply both to people accessing services as individuals and to citizens collectively – and that means the role of patients, and of their voice, is multiple. Chris Graham explores this further in his blog.
  16. Content Article
    Agile working is on the increase and here to stay. This brings its own challenges for people working in a variety of locations and environments. Technology is pervasive and our technical interactions are migrating rapidly to mobile and hand-held devices, keeping us connected and able to work almost anywhere. This inevitably affects our posture and can lead to musculoskeletal issues in the longer term. Adopting the correct posture when sitting, standing and operating mobile devices aids the prevention and management of existing musculoskeletal problems. Regular stretching exercises are even more beneficial.   Osmond Ergonomics provides support tools such as these free guides.
  17. Content Article
    Some patients die after major surgery. Risk prediction tools can help shared decision making with the patient, aiding decisions on whether to operate, how to prepare and use of critical care. An international multi-centre prospective observational cohort study in 274 sites with 22,631 patients compared risk prediction with 30-day mortality. In 88.7% of cases clinicians exclusively used subjective assessment. The best predictions were from the SORT tool combined with clinical assessment. P-POSSUM Surgical Risk Scale, SRS and SORT all over-predicted risk, with SORT performing best. This 10-question SORT model has been updated including clinician assessment and provides an accurate means of predicting perioperative risk.
  18. News Article
    The NIHR-supported PRINCIPLE trial is to start investigating the inhaled corticosteroid budesonide to find out if it can help treat COVID-19 in patients who aren’t in hospital. Led by the University of Oxford, the PRINCIPLE is the UK’s national platform trial for COVID-19 treatments that can be taken at home. It is evaluating treatments that can help people aged over 50 recover quickly from COVID-19 illness and prevent the need for hospital admission. The study, funded by NIHR and UK Research and Innovation (UKRI) has so far recruited more than 2100 volunteers from across the UK with support from NIHR’s Clinical Research Network. Inhaled budesonide is often used to treat asthma and chronic obstructive pulmonary disease, with no serious side-effects associated with short-term use. In some patients with COVID-19, the body’s immune response to the virus can cause high levels of inflammation that can damage cells in the airways and lungs. Inhaling budesonide into the airways targets anti-inflammatory treatment where it is needed most, and can potentially minimise any lung damage that might otherwise be caused by the virus. Patients taking part in the study will be randomly assigned to receive an inhaler in the post, alongside the usual care from their clinician. They will be asked to inhale two puffs twice a day for 14 days with each puff providing a 400 microgram dose of budesonide. They will be followed up for 28 days and will be compared with participants who have been assigned to receive the usual standard-of-care only. Read full story Source: National Institute for Health Research, 27 November 2020
  19. Content Article
    Patient Safety Learning looks at some of the concerns facing people living with Long COVID in this blog for the Patient Information Forum.
  20. Event
    This webcast provides a tutorial on the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Data Entry and Analysis Tool. Speakers will demonstrate how you can enter your SOPS survey data into the tool and it will automatically create tables and graphs to display your survey results. The tool allows healthcare organisations to compare results to the data in SOPS Databases. Register
  21. News Article
    Regulators have apologised to a health manager who went through “five years of hell” while being investigated for misconduct, before being told there was no case to answer. Debbie Moore was a senior manager at the former Liverpool Community Health Trust, where there was a major care scandal in the early 2010s. As head of healthcare at HMP Liverpool, where many of the most serious failings were identified, Ms Moore was suspended in 2014 and referred to the Nursing and Midwifery Council. She was accused of multiple failures to take action or escalate concerns, of failing to investigate deaths, and discouraging staff from reporting incidents. However, in a first public interview about her experience, she told HSJ she was “scapegoated” for the problems at the prison, where she says she worked tirelessly to address the issues and had repeatedly flagged concerns to the LCH management team. External inquiries have found the trust would routinely downgrade risks escalated by divisional managers, as it sought to make drastic cost savings in pursuit of foundation trust status. Read full story (paywalled) Source: HSJ, 30 November 2020
  22. News Article
    Eleven patients have suffered harm after being kept waiting in ambulances outside accident and emergency departments, a review has found. South East Coast Ambulance (SECamb) Service Foundation Trust launched the review after a specific incident at Medway Foundation Trust on Monday 16 November. Although details of the incident have not been released, HSJ has been told one patient waited for nine hours before being seen in the trust’s A&E department that day. The review covered all long waits across SECAmb’s area over the last few weeks. Out of 120 cases examined, 11 patients were found to have suffered some degree of harm, SECAmb’s executive director of nursing and quality Bethan Eaton-Haskins told Kent’s health overview and scrutiny committee last week. However, the trust has not revealed which hospitals were involved. Ms Eaton-Haskins said the ambulance trust was “struggling significantly” with handovers and expecting the recent pressure experienced at Medway FT to affect the county’s other hospitals soon. However, she indicated some other trusts in Surrey and Sussex had also had long delays. Ambulance services have been concerned for some time that handover delays could pose significant problems this winter. They are thought to have contributed to the North West Ambulance Service Trust declaring a major incident earlier this month. HSJ has also been told of waits of several hours in other ambulance trusts. Read full story (paywalled) Source: HSJ, 1 December 2020
  23. News Article
    The safety of maternity services at a major north London hospital has been criticised by the care watchdog after an inspection prompted by the death of a woman. The Care Quality Commission (CQC) has issued the Royal Free Hospital, in Hampstead with a warning notice after inspectors identified serious safety failings in its maternity unit. An unannounced inspection of the hospital’s maternity service took place in October, following the death of Malyun Karama, in February this year. The 34-year-old died while giving birth to her stillborn baby. She suffered a ruptured uterus after being given an overdose of misoprostol to induce her labour. In a report following an inquest into her death Coroner Mary Hassell said: “Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids. The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.” The CQC has yet to publish a full report on its inspection of the hospital but confirmed it had taken enforcement action and issued the trust with a warning notice. The concerns relate to the trust being too slow to investigate and make changes after incidents of harm. It’s understood a panel to investigate Ms Karama’s death did not meet until June this year. Read full story Source: The Independent, 1 December 2020
  24. News Article
    COVID-19 could be causing lung abnormalities still detectable more than three months after patients are infected, researchers suggest. A study of 10 patients at Oxford University used a novel scanning technique to identify damage not picked up by conventional scans. It uses a gas called xenon during MRI scans to create images of lung damage. Lung experts said a test that could spot long-term damage would make a huge difference to Covid patients. The xenon technique sees patients inhale the gas during a magnetic resonance imaging (MRI) scan. Prof Fergus Gleeson, who is leading the work, tried out his scanning technique on 10 patients aged between 19 and 69. Eight of them had persistent shortness of breath and tiredness three months after being ill with coronavirus, even though none of them had been admitted to intensive care or required ventilation, and conventional scans had found no problems in their lungs. The scans showed signs of lung damage - by highlighting areas where air is not flowing easily into the blood - in the eight who reported breathlessness. The results have prompted Prof Gleeson to plan a trial of up to 100 people to see if the same is true of people who had not been admitted to hospital and had not suffered from such serious symptoms. He is planning to work with GPs to scan people who have tested positive for COVID-19 across a range of age groups. The aim is to discover whether lung damage occurs and if so whether it is permanent, or resolves over time. Read full story Source: BBC News, 1 December 2020
  25. News Article
    The government has admitted the NHS in England does not have enough nurses and doctors to keep all its services running if there is a third spike in coronavirus cases as leaked figures show the number of staff off work because of the virus rising. An analysis of the impact of coronavirus, released by Downing Street on Monday, warned that even with a 6% growth in NHS staff since August 2019 and extra funding “there is a trade-off between the NHS’s ability to deliver COVID-19 and non-Covid-19 care in the event that COVID-19 hospitalisations rise”. It also warned of the psychological effects on staff saying: “It would be expected that higher rates of post-traumatic stress disorder (PTSD) would be seen amongst health and social care staff.” New leaked NHS data for England on Monday shows more than 82,000 NHS staff are absent from work with more than two-fifths, 42 per cent, linked to coronavirus either due to sickness or because they need to self-isolate. This includes almost 27,000 nurses and 4,000 doctors absent from NHS wards. Hospital leaders reiterated the strain the NHS was under in a briefing to MPs ahead of the vote on local tier restrictions today. Read full story Source: The Independent, 1 December 2020
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