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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    In October the Faculty of Intensive Care Medicine surveyed their Fellows and Members about their experiences and feelings during the first wave of the COVID-19 pandemic. They have published Voices from the Frontline of Critical Care based on the results of this survey.
  2. Content Article
    This report, co-authored by researchers from organisations including The King's Fund, the Nuffield Trust and The Health Foundation, provides an overview of the impact of COVID-19 so far on people who use and provide long-term care in England, and of the policy and practice measures adopted to mitigate its impact. It finds that the initial policy responses did not adequately consider the social care sector and that the pandemic has laid bare longstanding problems in the long-term care system in England.
  3. Content Article
    In response to the rapid spread of COVID-19, this paper from Tamar Wildwing and Nicole Holt provides health professionals with better accessibility to available evidence, summarising findings from a systematic overview of systematic reviews of the neurological symptoms seen in patients with COVID-19. Implications of so-called Long Covid on neurological services and primary care and similarities with other neurological disorders are discussed. Note: This article is a preprint and has not yet been peer-reviewed.
  4. Content Article
    This guide will support healthcare professionals to integrate prehabilitation services into the cancer pathway.
  5. Content Article
    Patient advocate Vonda Vaden Bates interviews Brandyn Lau, Assistant Professor of Radiology and Health Sciences Informatics, Johns Hopkins School of Medicine, around the importance of venous thromboembolism (VTE) prophylaxis for hospitalised patients.
  6. News Article
    Two hospitals in Cumbria must take "rapid" action "to keep people safe", the health watchdog has announced. There had been "escalating" concerns about Carlisle's Cumberland Infirmary and the West Cumberland Hospital in Whitehaven, the Care Quality Commission (CQC) said. North Cumbria Integrated Care (NCIC) has been issued with a warning. The trust, which was already rated as requiring improvement, admitted the pace of change had been "too slow". The warning notice requires the organisation "to take action to minimise the risk of patients being exposed to harm". During checks in August and September, inspectors found: Emergency department patients "were not always receiving timely and appropriate" treatment Significant delays in admitting people to wards "Insufficient numbers" of qualified, competent and experienced staff Professor Ted Baker, chief inspector of hospitals, said "rapid improvements" were needed. Read full story Source: BBC News, 27 November 2020
  7. News Article
    Nearly 100 trusts have no ‘very senior managers’ (VSM) who are declared to be from a black, Asian or minority ethnic background, HSJ analysis has revealed. According to data obtained from every NHS provider in England, 96 out of 214 (45%) did not have any VSMs declared as being from a BAME background. This includes several large providers, such as The Newcastle upon Tyne Hospitals Foundation Trust — where around 9 per cent of the workforce and 15 per cent of the city’s population are BAME — and Liverpool University Hospitals FT. Jon Restell, chief executive of the Managers in Partnership trade union, said the underrepresentation of BAME staff in leadership positions has “dangerously damaged” the NHS’ response to coronavirus, labelling it the “ultimate wake-up call”. Read full story (paywalled) Source: HSJ, 30 November 2020
  8. News Article
    There are serious concerns over the funding and staffing numbers available for new ‘long-covid’ clinics, while patient groups ‘remain in the dark’ over their locations. Last month, NHS England announced there would be 40 clinics around the country, to start opening at the end of November, with £10m of funding to cover set-up and operational costs until March 2021. But several speakers at HSJ’s inaugural virtual respiratory forum last week said there were still uncertainties and concerns about the capacity to provide the clinics. Dr Jon Bennet, a respiratory consultant and chair of the British Thoracic Society, said staffing the respiratory rehabilitation services within the clinics would be challenging, as “there isn’t at the moment sufficient capacity”. Read full story (paywalled) Source: HSJ, 29 November 2020
  9. Content Article
    As prescription numbers continue to increase, it is necessary to understand the dispensing errors that can occur and how they may happen. This article is the first of two articles from Phipps et al. on dispensing errors and risk. Reducing risk and managing dispensing errors will build on the ideas proposed in this article.
  10. Content Article Comment
    @Swoo Great resources! Thanks so much for sharing. We'll get all these up in Learn.
  11. Event
    A Westminster Health Forum policy conference with: Dr Clifford Mann, National Clinical Director, Urgent and Emergency Care, NHS England and NHS Improvement Dr Katherine Henderson, President, Royal College of Emergency Medicine Jessica Morris, Nuffield Trust; Dr Nick Scriven, The Society of Acute Medicine; Sandie Smith, Healthwatch Cambridgeshire and Peterborough; and Deborah Thompson, NHS Acute Frailty and Ambulatory Emergency Care Networks and NHS Elect Delegates will discuss key developments and challenges in the context of service changes in response to the COVID-19 pandemic, and the ongoing implementation of the NHS Long Term Plan. Register
  12. Event
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    Currently very little is known about the clinical, biological, psychological and socio-environmental impact of COVID-19. While most people may have uncomplicated recoveries, some experience prolonged or new symptoms and complications. The wide range of Long Covid symptoms documented indicates that multiple body systems are involved. Some of the more commonly reported symptoms include fatigue, breathing difficulties, joint pain, chest pain, as well as muscle weakness and neurological symptoms. These are common among both people who were hospitalised in the early phase of COVID-19 and those who were not. Systematic reviews show that people worldwide are experiencing prolonged symptoms of COVID-19. There are implications at an individual level for people’s quality of life and their ability to work, as well as at a socioeconomic level due to the risk of widening health inequalities. As well as breadth of the physical, psychological and social complications, there is a need to understand the causes (aetiology) of the symptoms and complications experienced. It is also vital to be able to identify people at higher risk of Long Covid, as well as interventions that might reduce that risk, and support rehabilitation and recovery. There is an urgent need for robust scientific studies into the long-term impact of COVID-19 in both adults and children, and for healthcare providers to be informed to support prevention, assessment, rehabilitation and interventions to improve recovery and patient outcomes. With this need in mind, ISARIC and GloPID-R are organising the Long Covid Forum on December 9 and 10, 2020 in collaboration with the Long Covid Support. The objectives of the forum will be: to gain a better understanding of Long Covid; the science and the personal impact to define research gaps for funders and researchers to take forward. Register
  13. Content Article
    The government's plans to support people's wellbeing and mental health during the COVID-19 pandemic this winter. This plan sets out the support that will be in place in the immediate term to help support individuals to stay well during the second wave of the coronavirus and winter months ahead.
  14. Content Article
    It was little noticed but the Chancellor in his Spending review on 25 November announced revisions to the Green Book, the Treasury rules for evaluating the costs and benefits of public investments. In this article, Roger Steer takes a look at this re-write of the Treasury rules. The Treasury highlight a string of the common failings in business cases, which those that examine NHS business cases will long recognise. However, this is yet another example of where patient safety doesn't appear in business cases...
  15. Event
    The Chronic Long Covid19 support group presents this international conference for patients. Presenters: Dr David Tuller, Global Public Health Expert, University of Berkeley, California: graded exercise therapy/cognitive behavior therapy treatment approach to ME and why it should not be used for long-covid patients. Nikita Alexandrov biochemist/biohacker, University of Alabama, USA: COVID-19 and the elephants in the room – big misconceptions and important out of the box observations made so far. Secondary infections: why there is no real cytokine storm concern and the issue of mast cell activation. Book your place
  16. News Article
    New Covid guidance for hospitals could see more patients receiving face-to-face visits from loved ones. NHS Wales has given health boards and hospices flexibility to allow visits based on local levels of COVID-19. Until now accompanying people to medical appointments and hospital visits have not been allowed, with a few exceptions. It also allows for pregnant women in low Covid rate areas to take their partners to maternity appointments. The Welsh Government said the new flexibility was "due to the changing picture of coronavirus transmission across Wales, with significant variations in community transmission across different parts of the country and differences in the rate of nosocomial transmission". Read full story Source: BBC News, 30 November 2020
  17. News Article
    Mistakes by Great Ormond Street contributed to the death of a five-year-old boy, the children’s hospital has admitted – just months after it concluded a legal case with his family in which it denied responsibility. The world-renowned children’s hospital failed to flag results of a crucial blood test, showing that Walif Yafi had a dangerous infection, to doctors at King’s College Hospital where he had been receiving treatment. He died a few weeks later, in September 2017. In September this year, Walif’s parents agreed an out-of-court settlement with Great Ormond Street, which admitted negligence but denied liability for the boy’s death. However, this week the hospital admitted an expert had reviewed the case ahead of the settlement and concluded its actions did contribute to Walif’s death. The hospital said it had been under no duty to share these results with Walif’s parents at the time. Walif had a liver transplant in 2012 after suffering cancer shortly after his birth, and was being overseen by Great Ormond Street as an outpatient, as well as by the transplant team at King’s College Hospital, in south London. On 24 August 2017, he had a routine blood test at Great Ormond Street, which showed he had an adenovirus infection – something that is common in children whose immune system is being suppressed by drugs, as Walif’s was because of his transplant. If untreated, the infection can be deadly. But the blood test result was not communicated to the team at King’s College Hospital. Shortly afterwards, Walif’s health deteriorated and he was admitted to hospital. He was transferred to King’s College Hospital a week later, and it was not until 7 September that the infection was confirmed. By this stage, he was severely unwell and, though he began anti-viral therapy, Walif suffered multiple organ failure from the spread of the infection. On 30 September, he suffered cardiac arrest and died. It was only when approached by The Independent this week that the trust revealed its expert had, in the course of negotiating the settlement with Walif’s parents, determined the hospital did materially contribute to the child’s death. Read full story Source: The Independent, 29 November 2020
  18. News Article
    Health inspectors in England have been moving between care homes with high levels of COVID-19 infection without being tested, raising fears they have put more residents at risk of catching the virus, leaks to the Guardian have revealed. In recent weeks all care home inspections carried out in the north of England have been of infected homes, including a facility where 38 of the 41 people receiving care and 30 staff – almost half of the workers – had tested positive, internal documents from the Care Quality Commission (CQC) show. Over the last two months inspectors have been checking infection control procedures and care standards in up to 600 care homes, many of which were dealing with outbreaks of COVID-19, but the Department of Health and Social Care (DHSC) has yet to provide testing. The CQC said on Friday it was expecting to start testing inspectors “in the coming weeks”. Weekly Covid deaths in care homes have been rising. In the week to 20 November, 398 people were notified to the CQC as having died from Covid, up from 138 a month earlier. The death toll remains lower than at the peak of the pandemic, when more than 2,500 people were dying a week in late April. The situation has sparked “very real anxieties about contracting the disease” and spreading it between infected homes, the leaked memos reveal. One inspector described work to his managers as like “going into the eye of the storm”. Read full story Source: The Guardian, 27 November 2020
  19. News Article
    A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign. On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000. The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case. A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns. This included staff changing records after his death to suggest he had a full care plan in place when he didn’t. Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS. The trust has admitted Matthew’s care fell below acceptable standards. In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years. Read full story Source: The Independent, 29 November 2020
  20. News Article
    The Care Quality Commission (CQC) has criticised a new trust’s leadership after issuing it with a warning notice to improve care in its two emergency departments. The watchdog warned North Cumbria Integrated Care Foundation Trust that patients were not always receiving timely and appropriate care, while delayed transfers of care had “resulted in significant delays in admitting patients on to wards”. The CQC — which carried out focused inspections at the trust in August and September after concerns were raised about risks to patient and staff safety — added there was evidence of “insufficient numbers of suitably qualified, skilled, competent and experienced clinical staff”. The CQC also said there was a lack of an effective system to mitigate risks, including infection control in the emergency department escalation areas and on some medical wards. Of the trust’s Cumberland Infirmary and West Cumberland hospitals, the CQC said: “People could not access the urgent and emergency care and medicine service when they needed them and often had long waits for treatment.” The CQC’s inspection report, published today, also said the trust had an “inexperienced leadership team” which “did not always have the necessary skills and abilities to lead effectively”. It added there were “few examples of leaders making a demonstrable impact on the quality or sustainability of services”. Read full story (paywalled) Source: HSJ, 30 November 2020
  21. Content Article
    In this review, Jane Carthey and colleagues discuss human factors research in cardiac surgery and other medical domains. The authors describe a systems approach to understanding human factors in cardiac surgery and summarise the lessons that have been learned about critical incident and near-miss reporting in other high technology industries that are pertinent to this field.
  22. Content Article
    Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research has demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners (GPs) in a pharmacist-led intervention. This study aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion.
  23. Content Article
    Letter to the Chief Executives of all NHS trusts and foundation trusts from the Covid-19 Vaccination Deployment Programme.
  24. Event
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    The Nursing Times awards are free to attend and will give you the chance to highlight and reward innovation in workforce planning and management that will contribute to sustaining a workforce fit for the future. The summit will take place over two days, connecting nurses responsible for the recruitment, retention and development of the workforce to meet with solution providers and workforce experts. Book tickets
  25. Event
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    Normally each year the Academy of Fabulous Stuff has a FabAwards Show, shares to the website are shortlisted and voted on and at the awards show the winner announced. This is no ordinary year. Given the amazing work that NHS/Health and Social care staff are doing during the pandemic, now is NOT the time to judge peoples work and vote for winners. Right NOW is a time to say thank You. This is a fabulous free event for everyone working in health and social care. Further information
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