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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The collapse of healthcare services round the world, the behaviour of some of the “agencies” enforcing quarantining, and high levels of patient harm during the COVID-19 pandemic, undoubtedly warrant a strong response. We need a new agenda for change if we are to address the current threat to patient centred healthcare and patient safety globally. Kawaldip Sehmi, CEO International Alliance of Patient Organizations, summarises the key messages and actions from the 9th biennial Global Patients Congress 2020, 
  2. News Article
    A drug used to treat rheumatoid arthritis appears to help patients who are admitted to intensive care with the most severe coronavirus infections, researchers say. Tocilizumab, a medicine that dampens down inflammation, improved outcomes for critically ill patients, according to early results from an international trial investigating whether the drug and others like it boost survival rates and reduce the amount of time patients spend in intensive care. The findings have not been peer-reviewed or published in a journal, but if confirmed by more trial data, the drug will be on track to become only the second effective therapy for the sickest Covid patients, following positive results for the steroid dexamethasone earlier this year. “We think these are very exciting results, we are encouraged by them,” said Prof Anthony Gordon, of Imperial College London, the UK’s chief investigator on the REMAP-CAP trial. “It could become the standard of care once we have all the data reviewed by guidelines groups, and also drug regulators.” Read full story Source: The Guardian, 20 November 2020
  3. News Article
    People aged 50 to 64 in England will be able to get a free flu jab from 1 December in an attempt to fight the "twin threats" of flu and COVID-19. The group has been added to a list of people who are already eligible for a flu jab in England, such as those over 65 and health and social care workers. Thirty million people are being offered the vaccine in England's largest flu-immunisation programme to date. Health Secretary Matt Hancock said it was a winter "like no other". "We have to worry about the twin threats of flu and COVID-19," he said, adding that the coronavirus pandemic meant it was "more important than ever" that people got their flu jabs. Mr Hancock told BBC Breakfast that all over 50s would be able to get the vaccine by January. Read full story Source: BBC News, 20 November 2020
  4. News Article
    The NHS is going into this winter with 5,500 fewer general acute beds than last year, NHS England data has revealed. The numbers of general and acute beds open overnight from July to September this year was 94,787 compared with 100,370 for the same period in 2019, a fall of 5.6% or 5,583 beds. The reduction in bed numbers is thought to be partly because of covid infection control measures, such as creating more distance between beds. HSJ reported this week that Cambridge University Hospitals Foundation Trust had taken nearly 100 beds out of use to allow for better social distancing. The figures showed significant regional differences. London had 8% fewer beds available compared with last year, while the East of England and the North East only had 3.4% fewer. The North West, which has been badly affected by the second wave of covid, had 6.6% fewer beds than last year. NHS Providers deputy chief executive Saffron Cordery said: “We have been arguing for some time that the NHS is short of beds as we head into winter… This is a real problem as trusts deal with pressures posed by the virus, growing demand for urgent and emergency care and the work to recover the backlog of routine operations.” Nuffield Trust deputy director of research Sarah Scobie said: “This drop in the number of beds available bears out our warning that infection control will mean a loss of capacity even between waves of the virus. Many of these will have been beds too close to others for physical distancing. This is why it will be so difficult to return to previous rates of activity while the virus remains at large, worsening waiting times and forcing difficult decisions about who gets priority." Read full story (paywalled) Source: HSJ, 19 November 2020
  5. News Article
    Death rates for a major emergency abdominal surgery are almost eight times higher at some outlier hospitals compared with top performers, a national report has found. A review of emergency laparotomies in England and Wales has identified six hospitals as having much higher-than-average 30-day mortality rates for the surgery between December 2018 and November 2019. Hospitals identified by the annual National Emergency Laparotomy Audit as having the best outcomes, such as Stepping Hill Hospital and Salford Royal Hospital, had mortality rates of around 2.5%. But the review, published this month, found some hospitals, such as George Eliot Hospital, had 30-day mortality rates for emergency laparotomies as high as 19.6% The national 30-day mortality rate for emergency laparotomies in England and Wales was 9.3% last year and has fallen consistently since the review started in 2013. Some trusts told HSJ that data collection issues were partly to blame for the high mortality rates recorded in the review. Read full story (paywalled) Source: HSJ, 20 November 2020 .
  6. Content Article
    Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Robyn Begley, Chief Executive Officer, American Organization for Nursing Leadership (AONL), and Senior Vice President and Chief Nursing Officer, AHA, around her most recent discoveries in the COVID-19 pandemic. The team conducted a study with over 1,800 participants, ranging from nursing staff to hospital administrators, on the effects of COVID-19 and the challenges and fallbacks that occurred during three periods of the pandemic. After discussion of results, recommendations are proposed for supporting hospitals and healthcare workers.
  7. Content Article
    Losing your sense of smell or having it 'disturbed' is not as rare as you might think: one in 20 people experience it at some point in their lives. It can happen as a result of chronic sinusitis, damage caused by cold viruses, or even a head injury. It is sometimes also a precursor of nervous system diseases such as Parkinson’s and Alzheimer’s. But compared with hearing and sight loss, it receives little research or medical attention. Carl Philpott, Professor of Rhinology and Olfactory at the University of East Anglia, wanted to better understand the issues people with smell disorders face, so him and his team analysed written, personal accounts of anosmia (loss of sense of smell) by 71 sufferers. The texts revealed several themes, including feelings of isolation, relationship difficulties, impact on physical health and the difficulty and cost of seeking help. Many people also commented on the negative attitude from doctors about smell loss, and how they found it difficult to get advice and treatment for their condition.
  8. Content Article
    The Center for Outcomes and Patient Safety in Surgery (COMPASS) in the USA combines clinical collaboration and data to ensure, amongst all surgical and procedural colleagues, the safest, most appropriate and effective and highest quality procedure for every patient, every time. It aims to continuously strengthen the care that our patients receive through the measurement and analysis of surgical outcomes and data. COMPASS is composed of clinicians representing all Massachusetts General Hospital surgical specialties.
  9. Content Article
    Harm reviews give assurance to patients, patient groups, commissioners and the public as to whether patients have been harmed, or are at risk of harm, as well as helping to avoid future harm to patient. Patients may be harmed not only by clinical treatment, but also as a result of the need to be on a waiting list for clinical treatment, as this may result in deterioration of their physical or mental condition.  Royal Cornwall Hospitals standard operating procedure (SOP) identifies a standardised approach to harm reviews for all specialities at the Trust that support the Trusts' governance and assurance processes and maintains practice in line with national expectations.
  10. Content Article
    The Berwick report asks the NHS to change its culture and continuously improve patient safety, but this is not always easy. It takes Herculean will-power from right-minded leaders, constant coaching of the middle managers and it takes time. In this Health Foundation article, Stephen Singleton, a former NHS medical director and Chief Executive, and a former member of the Don Berwick advisory group, asks is it the sheer hardness of the challenge that allows us to tolerate doctors and nurses who are poor role models, incompetent managers and bullies? Or is it something else?
  11. Event
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    The advancing mental health equalities strategy published in September 2020 outlines the core enabling actions NHS England and NHS Improvement will take with the support of the Advancing Mental Health Equalities Taskforce – an alliance of sector experts, including patients and carers, who are committed to creating more equitable access, experience and outcomes in mental health services in England. It sits alongside the NHS Mental Health Implementation Plan 2019/20–2023/24 and as such is similarly focused in scope. This strategy is also an important element of the overall NHS plans to accelerate action to address health inequalities in the next stage of responding to COVID-19. This webinar lead by Dr Jacqui Dyer MBE will introduce advancing mental health equalities strategy and summarise 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. Register
  12. Content Article
    In this blog, Patient Safety Learning reflects on the recent steps taken by the healthcare system in the UK to increase provision and support for people living with Long COVID. It then goes on to consider the importance of engagement and information sharing with patients, outlining suggestions where Patient Safety Learning feel the current NHS approach could be improved. 
  13. Content Article
    SSKIN is a five step approach to preventing and treating pressure ulcers. Wirral University Teaching Hospital is sharing their version of the SSKIN bundle as part of Stop The Pressure Day. They have worked with their Allied Health Professional colleagues on refreshing the bundle for local use.
  14. News Article
    PRESS RELEASE (London, UK, 19 November 2020) – The charity Patient Safety Learning and the Royal College of GPs have published new guidance to help patients with post COVID-19 syndrome (also known as Long COVID) understand the support they can expect from their GP. This guidance draws on the RCGP's recent summary and top tips for GPs caring for patients with post COVID-19 syndrome. Both these documents have been produced in advance of more detailed national guidance being developed by the National Institute of Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of GPs, due to be published in December 2020. Helen Hughes, Chief Executive of Patient Safety Learning, said: “We have used the RCGP’s guidance to produce a simple patient-friendly guide to help support people living with Long COVID in the interim period before more detailed guidance is produced by NICE. We hope that this guidance will empower and inform patients, providing them with an evidence-based document that can be shared with those around them. We believe that this will also help raise awareness of the health challenges these patients are facing so that their health and recovery needs can be better met.” Professor Martin Marshall, Chair of the Royal College of GPs, said: “It’s important that patients experiencing debilitating prolonged effects of Covid-19, which we know affect a small but significant number of people who have had the virus, feel that they have the understanding and support of the GPs and other healthcare professionals delivering their care. To this end we hope this guidance is helpful for them. The RCGP is working hard to ensure that the long term effects of Covid-19 are recognised, especially in those who were never admitted to hospital, and that our GP members have interim guidance whilst waiting for formal national guidance, currently being developed by NICE, SIGN and the College, to be published.” Notes to editors: 1. The new Patient Safety Learning and RCGP guidance can be found here: Post COVID-19 syndrome: What support can patients expect from their GP? 2. Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable. 3. The RCGP guidance for GPs can be found here: RCGP, Management of the long term effects of COVID-19. The RCGP response and top tips for caring for our patients, V1 30 October 2020.
  15. News Article
    An Essex maternity department has been served with further warnings by the Care Quality Commission (CQC) and again rated “inadequate”. Serious concerns were raised about the services at Basildon University Hospital in the summer, after several babies were found to have been starved of oxygen and put at risk of permanent brain damage. Despite the CQC issuing warning notices to Mid and South Essex Foundation Trust in June 2020, a subsequent visit on 18 September found multiple problems had persisted. The CQC’s findings at Basildon included: the service was short-staffed and concerns were not escalated appropriately multidisciplinary team working was “dysfunctional”, which sometimes led to safety incidents doctors, midwives and other professionals did not support each other to provide good care. Read full story (paywalled) Source: HSJ, 19 November 2020
  16. News Article
    A hospital trust in Bristol has been accused of risking lives after raising its patient-to-nurse ward ratio to dangerously high levels, having allegedly dismissed staff concerns and national guidance on safe staffing. University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) has introduced a blanket policy across its hospitals that assigns one nurse to 10 patients (1:10) for all general adult wards. This ratio, which previously stood at 1:6 or 1:8 depending on the ward, rises to 1:12 for nights shifts. The new policy, which is applicable to Bristol Royal Infirmary (BRI) and Weston General Hospital, also extends to all specialist high-care wards, which treat patients with life-threatening conditions such as epilepsy and anaphylaxis. Nurses at the trust have expressed their anger over the decision, saying they were never fully consulted by senior officials. Many are fearful that patient safety will be compromised as the second coronavirus wave intensifies, culminating in the unnecessary loss of life. “Patients who would have extra nursing staff because they are very acutely unwell and need close observation I think are going to unnecessarily die,” one nurse at BRI told The Independent. “Or if they survive, they’ll suffer long-term conditions because things were missed as they don’t have the staff at their bed side to watch the deterioration.” Read full story Source: The Independent, 18 November 2020
  17. Content Article
    It is estimated that across the UK, a third of healthcare improvement projects never spread beyond their particular unit, a further third are embedded across their organisation but never spread further than that, and only the final third are spread across their own and other similar organisations. Successfully spreading improvements and ensuring changes are sustained requires overcoming numerous challenges, such as: Creating an awareness of why the change is needed Ensuring those involved have a desire to support and participate in the change Knowledge of how to bring about change The skills and resources to bring about the change Ensuring processes to sustain the change This new guide from the West of England AHSN sets out suggestions to be considered for the successful adoption and spread of innovation and improvement projects.
  18. Content Article
    The Professional Record Standards Body (PRSB) has published a new report on lessons learned from the pandemic to support the future of digital change in health and care. Following a consultation process with 100 of its members, PRSB has published the report examining the digital transformation of services during the pandemic and it recommends how the system can use the lessons in the future.  The Digital Health and Care and COVID-19 report recommendations include building on the enthusiasm for digital but reviewing and evaluating safety implications, particularly for remote and virtual consultation where both clinical risk and patient access need to be addressed. The report also includes a focus on quality in practice, including the use of apps and other digital technologies. 
  19. Content Article
    Those who have read Professor Edmondson's book "The Fearless Organization" will know that psychological safety is required for team high-performance. Psychological safety is defined as "a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes". If you do not feel safe in a group, you are likely to keep ideas to yourself and avoid speaking up, even about risks. Furthermore, if mistakes are held against you, you then look to avoid making mistakes and so stop taking risks, rather than making the most out of your talents. Low psychological safety, therefore, gets in the way of both team performance, innovation, learning, and personal success. For you to be successful in your team, and "as a team", psychological safety is the enabler. In collaboration with professor Amy C. Edmondson, The Fearless Organization has developed 'The Fearless Organization Scan'. This scan maps how team members perceive the level of psychological safety in their closest context. To improve team performance, it helps to know the Psychological Safety levels in your team, as this is a critical predictor of how your team will learn and work together. By improving the level of psychological safety, you significantly increase the likelihood of team success.
  20. Event
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    This webinar will be chaired by Dr Joanne Fillingham, Deputy Chief Allied Health Professions (AHPs), NHS England & NHS Improvement and will include presentations from: Sarah Cooper, Senior Programme Manager- Post Covid Syndrome, Clinical Policy Unit, NHS England & NHS Improvement Sarah Duncan, Head of Clinical Policy Unit, Medical Directorate, NHS England & NHS Improvement Gordon Bigham, Interim Regional Chief Allied Health Professional Lead – Midlands, NHS England & NHS Improvement The webinar will cover: NHS five-point plan for managing long COVID NICE Guidance and clinical definitions of long COVID Educational resources and materials from HEE Post COVID assessment clinics This webinar will be hosted on Microsoft Teams as a live event and can be accessed using this link at 2:00pm on Tuesday the 24th of November.
  21. Content Article
    The Patient Safety Authority has put together information and tips for patients on a range of topics.
  22. Event
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    Discover how Wirral University Teaching Hospitals maintains their quality accreditation programme during a pandemic. The webinar will feature a presentation, followed by a discussion, and concluded with a Q&A from the audience. Les Porter and Jenine Kelly from Wirral University Teaching Hospital will be joined by Helen Hughes from Patient Safety Learning Register
  23. News Article
    Covid patients could be left to languish in hospital and block NHS beds amid delays in setting up “hot” care homes dedicated to receiving them, health chiefs have warned. A plan to reduce care home coronavirus outbreaks by setting up “hot homes” to receive infected people discharged from hospital is running late after dozens of councils missed a government deadline to nominate locations. By the end of October every area of England was supposed to have at least one facility approved for Covid-positive discharges, the government pledged last month. It was part of an attempt to prevent a repeat of the spring pandemic, which killed more than 18,000 residents after thousands of patients were discharged into care homes without tests. But as hospital admissions with Covid continue to rise, only 67 out of 151 local authorities have one set up, according to figures from the Care Quality Commission (CQC). NHS Providers, which represents NHS trusts, said the delays were adding to discharge problems, causing increasing patient stays and a growing number of “super-stranded” patients. “While the new discharge requirements are well-intentioned and aimed at protecting the most vulnerable in care homes, the challenge of implementing the changes has created blockages across mental health, acute and community beds,” said Miriam Deakin, the director of policy and strategy at NHS Providers. Read full story Source: The Guardian, 18 November 2020
  24. News Article
    A coroner has urged ministers to revisit plans to make it possible to hold inquests into babies that are stillborn after a baby died due to “excessive force” during an attempted forceps delivery. Senior coroner Caroline Beasley-Murray has written to the Ministry of Justice after she was forced to stop hearing evidence into the death of baby Frederick Terry, known as Freddie, who died under the care of the Mid and South Essex Hospitals Trust on 16 November, last year. An inquest into his death was started in September where Freddie was found to have died after suffering hypovolaemic shock as a result of losing a fifth of his blood when his skull was fractured during a traumatic birth attempt. In a report on the case the coroner said: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts." "The evidence showed that baby Freddie's very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby." The coroner said the injuries he sustained implied “an excessive degree of force” in the application of the forceps, which are curved metal instruments that fit around a baby’s head and are designed to help deliver the baby. The inquest had to be stopped from hearing any more evidence because coroners are not able to investigate stillborn babies. As part of her report, the coroner said: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. "Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, the Government issued a consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.” Read full story Source: The Independent, 17 November 2020
  25. News Article
    A top teaching hospital has blamed covid measures for a dramatic rise in the number of trolley waits in its accident and emergency department. In October, 111 patients at Cambridge University Hospitals (CUH) Foundation Trust, which runs Addenbrooke’s Hospital, waited more than 12 hours for admission, despite the region’s relatively low covid rates. CUH recorded just nine 12-hour waits in September and 27 in August. It had no 12-hour waits in either June or July this year, and in October 2019, it had only one. The trust also had 761 patients who waited more than four hours from the decision to admit to admission last month, out of a total of 2,998 emergency admissions. CUH director of operations Holly Sutherland said: “We have had to reorganise the hospital to meet infection control requirements and to reduce the risk of covid-19 transmission. With limited side room availability due to the age of our facilities, this has reduced the number of beds in the hospital by around 100 and has impacted on patient flow from the emergency department." “We would like to apologise to anyone affected by this, and to reassure our patients that their safety is our utmost priority and we are doing everything we can to treat them as quickly as possible.” Read full story (paywalled) Source: HSJ, 18 November 2020
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