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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Ministers are facing a high court legal challenge after they refused to order an urgent investigation into the shortages of personal protective equipment faced by NHS staff during the coronavirus pandemic. Doctors, lawyers and campaigners for older people’s welfare issued proceedings on Monday which they hope will lead to a judicial review of the government’s efforts to ensure that health professionals and social care staff had enough personal protective equipment (PPE) to keep them safe. They want to compel ministers to hold an independent inquiry into PPE and ensure staff in settings looking after Covid-19 patients will be able to obtain the gowns, masks, eye protection and gloves they need if, as many doctors fear, there is a second wave of the disease. About 300 UK health workers have so far died of COVID-19, and many NHS staff groups and families claim inadequate PPE played a key role in exposing them. Read full story Source: The Guardian, 8 June 2020
  2. News Article
    Northern Ireland faces a massive challenge rebuilding health and social care in the wake of the first COVID-19 wave, Health Minister Robin Swann has said. Speaking at the Northern Ireland Assembly on Tuesday, Mr Swann said that the rebuilding process can secure better ways of delivering services but will require innovation, sustained investment and society-wide support. He said that services will not be able to resume as before and that rebuilding will be significantly constrained by the continuing threat from COVID-19 and the need to protect the public and staff from the virus. “Our health and social care system was in very serious difficulties long before Coronavirus reached these shores. The virus has taken the situation to a whole new level. The Health and Social Care system has had its own lockdown – services were scaled back substantially to keep people safe and to focus resources on caring for those with COVID-19." The Health Minister said that despite the pressures, there are opportunities to make improvements. “I have seen so many examples of excellence, innovation and commitment as our health and social care staff rose to the challenges created by COVID-19. Decisions were taken at pace, services were re-configured, mountains were moved. Staff have worked across traditional boundaries time and time again. I cannot thank them enough. We must build on that spirit in the months and years ahead. Innovations like telephone triage and video consultations will be embedded in primary and secondary care.” Mr Swann added that the health system can't go back to the way it was and that it must be improved. Read full story Source: Belfast Telegraph, 9 June 2020
  3. News Article
    "Structural racism and social inequality" should be taken into account when looking at the impact of COVID-19 on Britain's black, Asian and minority ethnic, according to an expert involved in a recent review. Professor Kevin Fenton was a major part of a Public Health England (PHE) report ordered by the government into why the BAME community has been disproportionately affected by coronavirus. It found people from BAME groups were up to twice as likely to die with COVID-19 than those from a white British background. The review was also meant to offer recommendations, but sources have told Sky News that these were "held back" by the government. Health Secretary Matt Hancock said coming from a non-white background was a Speaking at a public meeting for Hackney Council, Prof Fenton said: "Over the last six weeks I've worked with over 4,000 individuals to understand what are some of the contextual issues that are driving the excess risk amongst, black, Asian and minority ethnic groups." "Some of the structural issues, like racism, discrimination, stigma, distrust, fair, these are real issues that are challenging for the communities and are seen as underpinning some of the disparities we see for COVID. Any conversation about what we need to do, should take into consideration these things." Read full story Source: Sky News, 9 June 2020
  4. News Article
    As the death toll from the virus soars above 40,000, slowly the horrendous toll on non-Covid patients is emerging. These are patients who are not afflicted by coronavirus, but who have had their treatment or diagnosis for other potentially deadly conditions postponed or cancelled, as hospitals scrambled to make way for an overwhelming burden of COVID-19 patients. Sherwin Hall, a 27-year-old from Leeds, had tried 13 times in one month during the lockdown to get a proper diagnosis for the crippling pain in his groin. He was initially told it might be a sexually transmitted disease. Eventually he was given the all clear of any STD after multiple blood tests and begged for an MRI scan. But he claims he was told no scans would be available because of the COVID-19 emergency. Finally he got a scan which confirmed a 14 cm tumour near his pelvis. He clams his consultant confirmed the delay in diagnosis and therefore cancer treatment may have serious consequences on his chances of survival. He told ITV news "I am very angry at the way I have been treated due to COVID-19 and the delay on my cancer treatment and now I am fighting for my life." His lawyer, Mary Smith, who specialises in medical negligence at Novum Law in Bristol, says she is worried there will be a spike in cases involving delayed diagnosis or treatment coming across her desk. She wants an urgent overhaul of the management of this crisis, now its peak appears to have passed. Read full story Source: ITV News, 9 June 2020
  5. Event
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    This seminar will explain the Seven Key Steps to creating a safe workplace during and beyond the current pandemic. 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. From establishing a response team to encouraging behavioural change and implementing control measures, we talk you through our new 32-page guide which outlines important steps to identify and reduce risks whilst maintaining performance and productivity. The Chartered Institute of Ergonomics and Human Factors CEO Noorzaman Rashid will be joined on this webinar by Kirsty Angerer and Ed Milnes, co-authors of the guide, to discuss the benefits of applying a human factors approach at this critical time. Further information and registration
  6. Content Article
    The government has unveiled a COVID-19 test and trace strategy for England, but it wasted valuable time in recognising what needed to be done after the lockdown was imposed and has been playing catch up ever since writes Chris Ham in a BMJ Opinion article. Chris says responding effectively to COVID-19 requires a blend of national and local leadership. Tragically, the government has been slow to recognise this, no more so than in plans to resume community testing and contact tracing as the lockdown is relaxed. These plans are essential to identify further outbreaks when they occur and to contain their impact. The challenge now is to ensure that every area of England has effective arrangements in place ahead of further relaxations of the lockdown in June. These arrangements must involve people being able to access tests in convenient locations, including their own homes, and for tests to be analysed rapidly. Agreement is needed on sharing test results with GPs and contact tracing staff to enable effective follow up.
  7. Content Article
    The Patient Safety Movement Foundation (PSMF) surveyed their community members from April 20 to May 4, 2020 and share the results in this report. They collected a total of 195 complete responses worldwide. This included 71% respondents from the US, 13% from EMEA, 7% from Mexico, 4% from the rest of LATAM, 3% from JAPAC, 2% from Canada, and 1% from India. The community sample also comprised of approximately a quarter of nurses, a quarter of other medical professionals (doctors, pharmacists), and significant representation of administrators, vendors, advocates, quality control, as well as many other backgrounds and occupations. 
  8. Content Article
    The call for meaningful patient and family engagement in healthcare and research is gaining impetus. Healthcare institutions and research funding agencies increasingly encourage clinicians and researchers to work actively with patients and their families to advance clinical care and research. Engagement is increasingly mandated by healthcare organizations and is becoming a prerequisite for research funding. In this article, Burns et al. review the rationale and the current state of patient and family engagement in patient care and research in the ICU. The authors identify opportunities to strengthen engagement in patient care by promoting greater patient and family involvement in care delivery and supporting their participation in shared decision-making. They also identify challenges related to patient willingness to engage, barriers to participation, participant risks, and participant expectations. To advance engagement, clinicians and researchers can develop the science behind engagement in the ICU context and demonstrate its impact on patient- and process-related outcomes. In addition, the authors provide practical guidance on how to engage, highlight features of successful engagement strategies, and identify areas for future research. At present, enormous opportunities remain to enhance engagement across the continuum of ICU care and research.
  9. Content Article
    If psychological safety is the number one variable in team performance then how do you improve it? Where do you start? What are the key actions you can take to increase the level of psychological safety in your environment? This guide from Leader Factor has 120+ behaviours you can use to have a higher level of psychological safety. You can download the guide by filling in the online form.
  10. Content Article
    The goal of this virtual discussion is to explore practical solutions for keeping seniors safe. The ideas are drawn from real life experiences noting how COVID-19 impacted seniors, their loved ones as well as healthcare workers and leaders.  The focus of the discussion is on identifying safety risks together with practical solutions for seniors who live at home, in residences and long-term care facilities. Watch the webinar on demand and download the slides.
  11. News Article
    Almost three quarters of GP partners are concerned about how to keep colleagues safe as numbers of patients attending practices return to pre-pandemic levels - with access to PPE a major worry, a GPonline poll has found. Half of the 185 GP partners responding to the poll said that they were either 'very worried' or 'slightly worried' about the government's ability to supply the PPE that GPs and practice staff needed to keep them as safe as possible through the rest of the pandemic. Only 9% said they were 'very confident' that the government would be able to supply adequate PPE, with a further 20% saying they were 'slightly confident'. Some 73% of GP partners said that they were concerned about how to ensure the safety of practice staff as the number of patients attending the surgery begins to rise. BMA GP committee chair Dr Richard Vautrey said keeping staff safe was 'a challenge for everyone in the NHS'. He told GPonline: 'Even months now into this crisis the government still hasn’t sorted out PPE in a way that means people have absolute confidence that they will have enough to meet their needs, and the growing needs of practices as they will need to be seeing more patients face-to-face for important procedures that can’t be done remotely. Read full story Source: GPonline, 8 June 2020
  12. News Article
    Senior doctors repeatedly raised concerns over safety and staffing problems at a mental health trust before a cluster of 12 deaths, an HSJ investigation has found. The deaths all happened over the course of a year, starting in June 2018, involving patients under the care of the crisis home treatment services at Birmingham and Solihull Mental Health Trust. The causes of the deaths included suicides, drug overdoses, and hanging. Coroners found several common failings surrounding the deaths and have previously warned of a lack of resources for mental health services in the city. HSJ has now seen internal documents which reveal senior clinicians had raised repeated internal concerns about the trust’s crisis home treatment teams during 2017 and early 2018. The clinicians warned of inadequate staffing levels, long waiting lists, and a lack of inpatient bed capacity. In the minutes of one meeting in February 2018, just two months before the first of the 12 deaths, a consultant is recorded as saying he had “grave concerns over safety in [the home treatment teams]”. Read full story Source: HSJ, 9 June 2020
  13. Content Article
    Knight et al. in a study published in the BMJ describe a national cohort of pregnant women admitted to hospital with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the UK, identify factors associated with infection, and describe outcomes, including transmission of infection, for mothers and infants. Most pregnant women admitted to hospital with SARS-CoV-2 infection were in the late second or third trimester, supporting guidance for continued social distancing measures in later pregnancy. Most had good outcomes, and transmission of SARS-CoV-2 to infants was uncommon. The high proportion of women from black or minority ethnic groups admitted with infection needs urgent investigation and explanation.
  14. News Article
    The high proportion of pregnant women from black and ethnic minority (BAME) groups admitted to hospital with COVID-19 "needs urgent investigation", says a study in the British Medical Journal. Out of 427 pregnant women studied between March and April, more than half were from these backgrounds - nearly three times the expected number. Most were admitted late in pregnancy and did not become seriously ill. Although babies can be infected, the researchers said this was "uncommon". When other factors such as obesity and age were taken into account, there was still a much higher proportion from ethnic minority groups than expected, the authors said. But the explanation for why BAME pregnant women are disproportionately affected by coronavirus is not simple "or easily solved," says Professor Knight, lead author. "We have to talk to women themselves, as well as health professionals, to give us more of a clue." Gill Walton from the Royal College of Midwives says, "Even before the pandemic, women from black, Asian or ethnic minority backgrounds were more likely to die in and around their pregnancy," She said they were "still at unacceptable risk" and getting help and support to affected communities was crucial. Ms Walton added: "The system is failing them and that has got to change quickly, because they matter, their lives matter and they deserve the best and safest care." Read full story Source: BBC News, 8 June 2020
  15. Content Article
    The BMA has provided clarification on PPE use in primary and secondary care, including procurement, use, safe working and CPR.
  16. News Article
    What will the next six months bring for the NHS? HSJ has spoken to the service’s most senior figures and makes a number of predictions. Read full story Source: HSJ, 8 June 2020
  17. Content Article
    Human factors understanding focuses on optimising human performance through better understanding the behaviour of individuals, their interactions, with each other and with their environment. Inhealth care, it underpins patient safety, offering an integrated approach to quality improvement and clinical excellence. In this episode, we are in conversation with Health Education England's deputy dean and physician Jo Szram, surgeon Peter Brennan, BA pilot Graham Shaw and Obs & Gynae trainee Ruth-Anna Macqueen to explore what human factors are, their importance in the health care setting and how knowledge of human factors can help both trainees and supervisors.
  18. Event
    Recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  19. Event
    This conference focuses on the prevention and management of pressure ulcers including monitoring, reporting and improvement. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  20. Event
    This masterclass, facilitated by Faisal Ahmed, Governance Specialist Trainer, provides knowledge and skills in addressing and managing risks within a health Organisation. All staff who report and manage risks should attend. Risks are inherent in all organisations – implementing and managing control measures is pivotal to managing risk in order to prevent an incident taking place. By exploring drivers behind why risks happen we can understand how to mitigate and reduce the likelihood and severity of further risks and the occurrence of incidents. A risk can be viewed as a precursor to an incident. Prevention through the risk management process can be an effective mechanism for organisations to manage their risks. All staff have a duty to identify and escalate risk within an organisation. This masterclass will explore the key components of the risk management process that must be followed to reduce the likelihood and severity of the risk. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  21. Event
    This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  22. Event
    This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  23. Event
    This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  24. Event
    This masterclass, facilitated by Faisal Ahmed, Governance Specialist Trainer, provides knowledge and skills on how to report and investigate an incident in light of the most prevalent incidents, for example medication and patient falls. We ensure that there is a comprehensive investigation, identifying lessons learned and the development of action plans. Attendees will gain an understanding of how to record findings and collate information to prevent recurrence and the severity of incidents. All staff who report and investigate incidents should attend. hub members can receive a 10% discount with code hcuk10psl. Further information and registration
  25. Content Article
    As the number of COVID-19 hospital admissions gradually declines, policy attention is turning to how the NHS can restart some more routine activities. But doing this while living alongside COVID-19 will involve major practical challenges that will need to be overcome. This new discussion paper by Nigel Edwards looks at the realities the health and care systems will now begin to face.
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