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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The chief inspector of hospitals has warned that patient safety is at risk if the NHS winter crisis is worsened by coronavirus – and ministers must act now in emergency departments to prevent a catastrophe. Professor Ted Baker, speaking to The Independent in his first interview since the COVID-19 outbreak hit Britain, warned that the NHS could not carry on as before as hospitals across the country struggle to return to normal care while the crisis continues. “If we are going to do something about it, we need to act now, not at the beginning of winter,” he warned, adding the Care Quality Commission (CQC) was also worried about patients being “forgotten” as NHS waiting lists surge to an expected 10 million later this year. "We will be going into winter and all the difficulties of the winter viruses that we normally face, together with Covid. I think next winter is going to be very difficult, unless emergency departments and the whole system supporting emergency departments do things very differently.” He warned providing care in the NHS under the shadow of coronavirus was “a formidable challenge … probably bigger than the challenge we faced at the height of the pandemic”. Prof Baker also told The Independent that the CQC was investigating a number of reports that some hospital patients were discharged unsafely to care homes following a staggering 55% rise in whistleblowing complaints, particularly in care homes, with 2,612 calls between March and May. Read full story Source: The Independent, 17 June 2020
  2. News Article
    There should be independent reviews of the NHS’ readiness for a potential second major outbreak of coronavirus in the UK, senior doctors are arguing. The Royal College of Anaesthetists said a series of reviews should be carried out, overseen by an independent group formed from clinical royal college representatives, independent scientists and academics. It would encompass investigation of what happened to care quality during the peak of infection and demand through March, April and May — there are major concerns that harm and death was caused by knock of effects, with some health services closed and people being afraid to use others. Hospitals were unable to provide many other services as staff, including most anaesthetists, were redeployed to help with critical care. Ravi Mahajan, president of the Royal College of Anaesthetists, told HSJ areas such as capacity, workforce and protective equipment were key issues to be reviewed. He said: “We can’t wait for [the pandemic] to finish and then review. [The reviews] have to be dynamic, ongoing, and the sooner they start the better. Read full story Source: HSJ, 17 June 2020
  3. News Article
    A leading surgeon has said NHS staff must be routinely tested for coronavirus up to twice a week. Prof Derek Alderson, president of the Royal College of Surgeons, said it was vital, to reassure patients staff were not unwittingly carrying the virus. But hospital trust bosses say they are still waiting for clarity on plans for regular testing. The Department for Health and Social Care (DHSC) said it was focusing on routine testing in care homes. Prof Alderson was speaking at a Health Select Committee meeting about the necessary steps to get all NHS services back up and running. He said: "It's absolutely essential to regain public confidence that we are able to test our staff regularly." It would be "pragmatic" for testing to take place "about twice weekly", he added, because it was known that the available tests were not perfect. Read full story Source: BBC News, 17 June 2020
  4. Content Article
    Investigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
  5. Content Article
    Since the seminal report by the Institute of Medicine, To Err Is Human, was issued in 1999, significant efforts across the health care industry have been launched to improve the safety and quality of patient care. Recent advances in the safety of health care delivery have included commitment to creating high-reliability organisations (HROs) to enhance existing quality improvement activities. This article will explore key elements of the HRO concept of deference to expertise, describe the structural elements that support nurses and other personnel in speaking up, and provide examples of practical, evidence-based tools to help organizations support and encourage all members of the health care team to speak up.
  6. Content Article
    Some innovations spread fast. How do you speed the ones that don’t? Atul Gawande, a professor of public health and a surgeon, is the founder and chair of Ariadne Labs, takes a look at the history of medicine and why some innovative ideas and treatments take off and others don't. 
  7. Content Article
    Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and healthcare expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review from Conn et al. determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, the authors tested whether effects vary depending on intervention, sample, and design characteristics. Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence.
  8. Content Article
    Many people sense that the way organisations are run today has been stretched to its limits. In survey after survey, business people make it clear that in their view, companies are places of dread and drudgery, not passion or purpose. Organisational disillusionment afflicts government agencies, nonprofits, schools, and hospitals just as much. Further, it applies not just to the powerless at the bottom of the hierarchy. Behind a facade of success, many top leaders are tired of the power games and infighting; despite their desperately overloaded schedules, they feel a vague sense of emptiness. In this article, Frederic Laloux discusses and gives examples of 'teal' organisations.
  9. News Article
    A patient almost died after being misdiagnosed and sent home from hospital on the first day of the lockdown as the NHS curtailed many normal services to focus on COVID-19. The NHS trust involved has admitted that its failings led to the man suffering excruciating pain, developing life-threatening blood poisoning, and contracting the flesh-eating bug necrotising fasciitis. He needed eight operations to remedy the damage caused by his misdiagnosis. The man, his wife and his GP spent three weeks after his discharge trying to get him urgent medical care. However, St Mary’s hospital on the Isle of Wight rejected repeated pleas by them for doctors to help him, even though his health was deteriorating sharply. The man, who does not want to be named, said his experience of seeking NHS care for something other than COVID-19 during the pandemic had been “debilitating and exhausting” and that feeling the NHS “was not there” for him had been “very distressing” for him and his wife. Mary Smith, of the solicitors Novum Law, who are representing the man in his complaint against the trust, said his plight highlighted the growing number of cases that were emerging of people whose health had suffered because they could not access normal NHS care in recent months. Read full story Source: The Guardian, 16 June 2020
  10. Content Article
    The response to COVID-19 has created an outstanding amount of change to the NHS and we must learn from this, says Samantha Machen, Improvement Facilitator at Central London Community Healthcare NHS Trust and PhD Improvement Fellow at the Health Foundation.
  11. News Article
    Care homes have been ordered to destroy a batch of faulty COVID-19 test kits after it was discovered that the swabs could break off while being used to gather samples from residents’ tonsils and noses. Care home managers were told on Sunday not to use the tests because they had “brittle stems at risk of snapping”. The kits were manufactured by Citotest, a company based in China, and were distributed by the government’s COVID-19 care home testing programme. It is tasked with providing tests for all staff and residents in care settings, not just people displaying symptoms. The affected batch should be destroyed or kept in a safe area clearly marked with warnings not to use them, officials said, adding that the problem emerged on Saturday and they were working as quickly as possible to resolve it. The Department of Health and Social Care (DHSC) said the batch could have contained tens of thousands of tests and that a complaint had been raised with the manufacturer, with whom discussions were ongoing. “We are aware of an issue with one batch of swab sticks which are being replaced where needed but this does not affect any tests, or the results of tests, previously taken,” a DHSC spokesperson said. “Testing is unaffected and people should still arrive for their booked tests.” Read full story Source: The Guardian, 15 June 2020
  12. News Article
    A woman whose father died in a care home has launched a judicial review case in the High Court over the government’s “litany of failures” in protecting the vulnerable elderly residents who were most at risk from COVID-19. Cathy Gardner accuses England’s health and social care secretary, Matt Hancock, NHS England, and Public Health England of acting unlawfully in breaching statutory duties to safeguard health and obligations under the European Convention on Human Rights, including the right to life. Her father, Michael Gibson, who had Alzheimer’s disease, died aged 88 of probable COVID-19 related causes on 3 April at Cherwood House Care Centre, near Bicester, Oxfordshire. She claims that before his death the care home had been pressured into taking a hospital patient who had tested positive for the virus but had not had a raised temperature for about 72 hours. “I am appalled that Matt Hancock can give the impression that the government has sought to cast a protective ring over elderly residents of care homes, and right from the start,” Gardner said. “The truth is that there has been at best a casual approach to protecting the residents of care homes. At worst the government has adopted a policy that has caused the death of the most vulnerable in our society.” Read full story Source: BMJ, 15 June 2020
  13. News Article
    Demand for oxygen from COVID-19 patients recovering at home is set to place the NHS under strain, the health service has warned. NHS England has issued guidance to out-of-hospital health providers on the extra demands likely to be placed on them given the number of people recovering after a hospital stay with the coronavirus. It warns that the provision from its home oxygen services and community respiratory teams across the NHS is expected to be an issue as the scale of demand increases. Andrew Whittamore, a practising GP and clinical lead for the Asthma UK and British Lung Foundation partnership, said concerns about the potential for hospitals to be overwhelmed in the early part of the pandemic had led to community oxygen teams being primed to take on more patients – but he described that ramping up as “a short-term fix”. “We don’t know how long people are going to need oxygen or other services for,” he said. “There are definitely going to be extra patients added on to our community teams’ workloads.” The Taskforce for Lung Health – of which the British Lung Foundation is a member – has raised particular concerns about access to pulmonary rehabilitation. An education- and exercise-based treatment, which is proven to be more effective for lung patients than many drug-based treatments, and face-to-face classes have been suspended during the pandemic. It may be that such treatment would also be helpful for some patients recovering from COVID-19. Jackie Eagleton, policy officer at the British Lung Foundation, said there had been issues with access to pulmonary rehabilitation for a long time, but the need to offer this form of support to people with lung conditions “has never been more pressing than it is now”. Read full story Source: The Independent, 16 June 2020
  14. News Article
    The architects behind the new NHS Race and Health Observatory have vowed that it will deliver actionable recommendations within months to tackle the structural racism that exists throughout healthcare. Victor Adebowale and Mala Rao called for an observatory to tackle the ethnic health inequalities in the UK in a special issue of The BMJ that they co-edited in February (bmj.com/racism-in-medicine) and NHS England confirmed at the end of the May that the centre would go ahead. Speaking at a meeting to discuss the aims of the observatory on 12 June, Adebowlae told more than 20 assembled stakeholders that he wanted the new centre “to fire on all cylinders,” making recommendations for changes to services that are likely to affect the health outcomes of people from black and ethnic minority backgrounds “within a couple of months.” Read full story Source: BMJ, 15 June 2020
  15. Content Article
    Charts are useful for collecting and charting data over time, you can find trends or patterns in the process. NHS Education for Scotland has provided resources and guidance on a number of different charts you could use for quality improvement.
  16. Content Article
    A process map is a planning and management tool that visually describes the flow of work. Using process mapping software, process maps show a series of events that produce an end result.
  17. News Article
    When Dan Scoble came down with the coronavirus in March, all the classic symptoms landed in one fell swoop. “I had everything under the sun: a fever, temperature, fatigue and chest pain,” he said. “My head felt like a balloon.” The 22-year-old, a personal trainer from Oxford who normally breezed through 10-mile runs, suddenly found himself bed-bound. He presumed it would soon blow over, but 12 weeks after falling ill as the country went into lockdown, he is still not back to normal. Dan has left his house just five times in three months — twice to see his GP and three times to hospital. He still suffers from crippling fatigue, recurrent migraines and a persistent sore throat, as well as abdominal and musculoskeletal pain. Read full story (paywalled) Source: The Times, 14 June 2020
  18. Content Article Comment
    Dr Rick Fraser asked us to post his response to this blog: Good to hear about the work you are doing. An open/transparent culture of speaking up is something I am really interested in for so many important reasons - I have found the IHI model of safe, reliable and effective care is enormously helpful in linking patient safety and culture. When an organisation has a culture where psychological safety is clearly evident then staff, patients, family & others all feel able to speak up and raise concerns as & when they occur. The organisational response is crucial and needs to be absolutely linked to patient safety as that cannot be disputed and is always the common ground we look for when trying to connect across systems and with others eg staff. An authentic, consistent approach that is humane, proportionate and transparent is crucial and must be led from the Board all the way through the organisation. Included in this humane approach are kindness, forgiveness, fallibility and equality. Some of these will come naturally and others have to be nurtured within individuals and the organisation. Some may criticise and call it 'woolly' or 'fluffy' however when the evidence can link all of these culture based approaches patient safety and outcomes then there can be no dispute. That’s what is so elegant about the IHI model (below) as it links all these aspects of the system together and allows for development of culture & learning system and then ongoing monitoring from Board to Ward. As a Dr this makes perfect sense as it combines the science/evidence with the learning system/culture to ensure patient care is optimal and safe every time. Dr Rick Fraser, Chief Medical Officer
  19. Content Article
    This second comprehensive edition of these Principles is to help public authorities, industry and communities worldwide anticipate accidents involving hazardous substances resulting from technological and natural disasters, as well as sabotage. It addresses the following issues: preventing the occurrence of chemical accidents and near-misses; preparing for accidents through emergency planning, public communication, etc.; responding to accidents and minimising their adverse effects; and following-up to accidents, regarding clean-up, reporting and investigation.
  20. Content Article
    The purpose of this guide is to help leaders and managers in businesses and organisations make their office workspaces safe for staff returning to work and reduce the transmission of the COVID-19 virus. This process begins with putting together a competent team and undertaking a risk assessment and staff survey to inform decision-making. Businesses are encouraged to consider the workplace as a whole system so that in mitigating a risk in one part of the work system, unintended consequences are not created in another. For example, new ways of work lead to increased workload/stress and reduced collaborative working.
  21. Event
    until
    Hear reflections on patient safety from healthcare professionals involved in delivering care at the Nightingale Hospital London. This webinar will explore the challenges of establishing a quality and safety infrastructure in a hospital built over a few days. You will be joined by Dr Andrew Wragg, Consultant Cardiologist and Director of Quality and Safety at St Bartholomew’s Hospital, Dr Jonathan Behar, Locum Consultant Cardiologist at the Royal Brompton Hospital and Johanna Cade, Staff Nurse, all of whom have worked at the Nightingale Hospital London. Further information and registration
  22. News Article
    Unlawful 'do not resuscitate' orders are being placed on patients with a learning disability during the coronavirus pandemic without families being consulted. National charities have successfully challenged more than a dozen unlawful do not resuscitate orders (DNRs) that were put in place because of the patient’s disability rather than due to any serious underlying health risk. Turning Point said it had learned of 19 inappropriate DNRs from families while Learning Disability England said almost one-fifth of its members had reported DNRs placed in people’s medical records without consultation during March and April. In one example, a man in his fifties with sight loss was admitted to hospital after a choking episode and was incorrectly diagnosed with coronavirus. He was discharged the next day with a DNR form giving the reason as his “blindness and severe learning disabilities”. Marie-Anne Peters, whose brother Alistair has epilepsy but no other health conditions, overturned a DNR on her brother which included instructions for him not to be taken to hospital. Both charities fear other people with learning disabilities who are vulnerable could be wrongly denied life-saving treatment. They have now launched a new checklist for families and care workers to challenge illegal DNRs. Read full story Source: The Independent, 13 June 2020
  23. News Article
    Dozens of hospitals are running short of scrubs in the latest problem to hit the NHS over the supply of personal protective equipment (PPE) during the coronavirus pandemic. The shortages are revealed in a survey of UK doctors undertaken by the Doctors’ Association UK (DAUK), which found that 61% said that the hospital where they worked was facing a shortage of scrubs. In recent months, many more NHS staff have begun wearing scrubs, which are usually used mainly by surgical staff, to protect themselves against COVID-19. The prevalence of coronavirus in hospitals has prompted many to switch from wearing their own clothes at work to using scrubs, and handing them in to be washed at the end of their shift. However, the big increase in demand for scrubs from doctors, nurses, physiotherapists and occupational therapists has left many hospitals unable to keep up and also put unprecedented pressure on hospital cleaning services. Some staff have even worn pyjamas intended for patients when scrubs have run out. “Protective clothing must be considered to be at a par with other PPE by Public Health England and must be provided to staff by the NHS," said said Dr Samantha Batt-Rawden, the president of the DAUK. She added: “A failure to adequately supply scrubs to staff may risk further community spread of Covid-19.” Read full story Source: The Guardian, 15 June 2020
  24. News Article
    Ambulance services have been urged to look at how suspected overdose and poisoning cases are prioritised after paramedics took 45 minutes to reach a woman with known mental health problems. Helen Sheath, 33, had been discharged from a mental health unit in early July last year and was still waiting for an outpatient appointment with a psychological assessment and treatment service when she took a fatal dose of sodium nitrate on 20 August. Her father called an ambulance at 6.20pm when she had locked herself in a bathroom and was threatening to take the sodium nitrate. But Bedfordshire and Luton senior coroner Emma Whitting said her father could not tell whether or not she had taken it, and that in view of her history of suicidal ideation, the call should have been treated as a category two – with an 18 minutes response target – rather than a category three incident. The first ambulance which was sent to her was diverted on route and it was only after a second call to the East of England Ambulance Service at 6.48pm, that the call was upgraded to category two – when the call handler selected a different set of questions, after being told she had ingested the chemical. A rapid response vehicle arrived at 7.05pm and the mental health street triage team attended six minutes later. Shortly afterwards she became acutely unwell and was taken to Bedford Hospital, where she received treatment but died shortly afterwards. In a prevention of future deaths report Ms Whitting said: “If the first call had been coded as a category two, it seems likely that the rapid response vehicle, mental health street triage team (and even possibly the double staffed ambulance) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.” The case comes just months after two other ambulance trusts were criticised in cases involving suspected or threatened overdoses. The prevention of future deaths report was sent to the Association of Ambulance Chief Executives and the emergency call prioritisation advisory group, which is run by NHS England. Neither would comment other than saying they would respond to the coroner. Read full story Source: HSJ, 15 June 2020
  25. News Article
    A leading doctor has warned that trusts will struggle to get back to anything like pre-covid levels of endoscopy services and will need to prioritise which patients are diagnosed. Endoscopy procedures are part of the diagnostic and treatment pathway for many conditions, including bowel cancer and stomach ulcers. Most hospitals have not done any non-emergency procedures since the middle of March because they are aerosol generating — meaning a greater covid infection risk and need for major protective equipment. Although some areas are now starting to do more urgent and routine work, capacity is severely limited. Kevin Monahan, a consultant gastroenterologist at St Marks’s Hospital, part of London North West Healthcare Trust, and a member of the medical advisory board for Bowel Cancer UK, said the time taken for droplets to settle in rooms after a procedure can be up to an hour and three quarters, depending on how areas are ventilated. Only then can the room be cleaned and another patient seen. Dr Monahan said his trust had restarted some endoscopy work and was currently doing around 17 per cent of its pre-covid activity. “We can provide a maximum of about 20 per cent of normal activity — and that is using private facilities for NHS patients,” he said. “I am not at all confident we will be able to double what we are doing now, even in three to four months’ time." Read full story Source: HSJ, 12 June 2020
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