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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The UK NHS has risen to the challenge posed by COVID-19 through Herculean efforts to expand capacity. This has included doubling or trebling intensive care (ICU) capacity within hospitals, augmenting this with Nightingale Hospitals, cancelling all non-emergency surgery and redeploying staff and equipment to focus on a single disease. At the same time, government and population efforts have – through social distancing then lockdown – successfully flattened the epidemic curve and so reduced demand. Together, these actions have enabled treatment of all those needing hospital care for COVID-19 and avoided the unfettered increase in mortality that would have accompanied an overwhelmed healthcare service. However, this has been achieved ‘by the skin of our teeth’ and until very recently, the threat of insufficient ICU beds ventilators, and the need for triage were all anticipated: a few hospitals were overcome by the surge of critically ill patents. Now, political and social thoughts and actions are turning to loosening lockdown and determining what ‘post-pandemic normality’ will look like. In this Editorial, William Harrop‑Griffiths and Tim Cook discuss the prospects and challenges of ‘planned surgery’ – both time-critical and wholly elective procedures.
  2. Content Article
    Pharmacy Times® interviewed Allison Hanson, PharmD, BCPS, 2019-2020 Institute for Safe Medication Practices (ISMP) International Medication Safety Management Fellow, to discuss medication safety during the coronavirus disease 2019 (COVID-19) pandemic, including key medication safety takeaways from the pandemic and current advancement efforts in the promotion of knowledge around medication safety.
  3. Content Article
    An update on how Care Quality Commission is monitoring the Mental Capacity Act and people who are subject to the Deprivation of Liberty Safeguards (DoLS) during the coronavirus pandemic.
  4. Content Article
    Patient Safety Learning interviews Jules Mckoy, a Specialist Perinatal Mental Health Midwife. In this interview, Jules highlights how the COVID-19 pandemic is impacting on the mental health of women during their pregnancy and after birth. She describes some of the ways they are trying to alleviate anxiety locally and raises concerns about the longer term implications of a rise in postnatal depression.
  5. Content Article
    Malcolm Kendrick, an NHS doctor, has seen people die and be listed as a victim of coronavirus without ever being tested for it. In his blog, Malcolm says if we do not diagnose deaths accurately we will never know how many died of COVID-19, or ‘because of’ the lockdown. Accurate statistics are vital for planning for the future. We have to accurately know what happened this time, in order to plan for the next pandemic, which seems almost inevitable as the world grows more crowded. What are the benefits of lockdown, what are the harms? What should we do next time a deadly virus strikes?
  6. News Article
    A trial has been launched in the UK to test whether ibuprofen can help with breathing difficulties in COVID-19 hospital patients. Scientists hope a modified form of the anti-inflammatory drug and painkiller will help to relieve respiratory problems in people who have more serious coronavirus symptoms but do not need intensive care unit treatment. Half the patients participating in the trial will be administered with the drug in addition to their usual care, while the other half will receive standard care to analyse the effectiveness of the treatment. Read full story Source: The Independent, 3 June 2020
  7. News Article
    The COVID-19 pandemic has dramatically curtailed the provision of health services for non-communicable diseases, says a survey of 155 countries by the World Health Organization conducted over three weeks in May. In the survey poorer countries were the most likely to report disrupted services, but some 94% of responding countries had reassigned health ministry staff from work on NCDs to dealing with the pandemic. Hypertension treatment has been partially or completely disrupted in 53% of the countries surveyed, diabetes treatment in 49%, cancer treatment in 42%, and cardiovascular emergency responses in 31% of countries, the survey found. In the Netherlands, new cancer diagnoses have fallen by 25% since the pandemic lockdown began. In rural India, 30% fewer cardiac emergencies reached health facilities in March 2020 than the previous year. Rehabilitation services, which are often key to a healthy recovery after severe COVID-19, have been disrupted in 63% of countries surveyed. Screening campaigns have been put on hold in more than half. WHO’s director general, Tedros Adhanom Ghebreyesus, said, “The results of this survey confirm what we’ve been hearing from countries for a number of weeks now. Many people who need treatment for diseases like cancer, cardiovascular disease, and diabetes have not been receiving the health services and medicines they need since the COVID-19 pandemic began. It’s vital that countries find innovative ways to ensure that essential services for NCDs continue, even as they fight COVID-19.” Read full story Source: BMJ, 3 June 2020
  8. News Article
    The use of electroconvulsive therapy (ECT) to treat depression should be immediately suspended, a study says. ECT involves passing electric currents through a patient's brain to cause seizures or fits. Dr John Read, of the University of East London said there was "no place" for ECT in evidence-based medicine due to risks of brain damage, but the Royal College of Psychiatrists said ECT offers "life-saving treatment" and should continue in severe cases. The National Institute for Health and Care Excellence (NICE) currently recommends the use of ECT for some cases of moderate or severe depression as well as catatonia and mania. However, peer-reviewed research published in the journal Ethical Human Psychology and Psychiatry concludes "the high risk of permanent memory loss and the small mortality risk means that its use should be immediately suspended". In response to the study, the Royal College of Psychiatrists said ECT should not be suspended for "some forms of severe mental illness". Dr Rupert McShane, chair of the college's Committee on ECT and Related Treatments, said there was evidence showing "most people who receive ECT see an improvement in their condition". "For many, it can be a life-saving treatment," he said. "As with all treatments for serious medical conditions - from cancer to heart disease - there can be side-effects of differing severity, including memory loss." Read full story Source: BBC News, 3 June 2020
  9. News Article
    The government removed a key section from Public Health England’s review (published Tuesday) of the relative risk of COVID-19 to specific groups, HSJ has discovered. The review reveals the virus poses a greater risk to those who are older, male and overweight. The risk is also described as “disproportionate” for those with Asian, Caribbean and black ethnicities. It makes no attempt to explain why the risk to BAME groups should be higher. An earlier draft of the review which was circulated within government last week contained a section which included responses from the 1,000-plus organisations and individuals who supplied evidence to the review. Many of these suggested that discrimination and poorer life chances were playing a part in the increased risk of COVID-19 to those with BAME backgrounds. HSJ understands this section was an annex to the report but could also stand alone. Typical was the following recommendation from the response by the Muslim Council of Britain, which stated: “With high levels of deaths of BAME healthcare workers, and extensive research showing evidence and feelings of structural racism and discrimination in the NHS, PHE should consider exploring this in more detail, and looking into specific measures to tackle the culture of discrimination and racism. It may also be of value to issue a clear statement from the NHS that this is not acceptable, committing to introducing change.” One source with knowledge of the review said the section “did not survive contact with Matt Hancock’s office” over the weekend. Read full story Source: HSJ, 2 June 2020
  10. News Article
    At least 25 people have died at a care home amid claims from an industry body that a council's actions "caused" or "increased COVID-19 deaths". Melbury Court in Durham is thought to be the care home with the highest number of deaths in the UK. County Durham has had the highest number of care home deaths in England and Wales. Durham County Council said it "strongly refuted" the claim by the County Durham Care Home Association (CDCHA). Some patients went from the nearby University Hospital of North Durham to Melbury Court without being tested for coronavirus or after a positive test. A BBC investigation has discovered that in a conference call in late March, council officials were told plans to move hospital patients into care homes without testing would be disastrous. The CDCHA offered to find a specific home or homes where COVID-19 positive or untested people could be cared for rather than have them spread around the network, but this was never acted on and now the CDCHA has calculated there has been an outbreak of coronavirus in 81 of the county's 149 care homes. Maria Vincent, who runs Crosshill Care Home in Stanhope, told the council in March that care homes were not set up to accept COVID-19 patients, and described it as "neglect pure and simple". Read full story Source: BBC News, 2 June 2020
  11. Content Article
    Public Health England (PHE) has published data on the disparities in the risk and outcomes from COVID-19. This review presents findings based on surveillance data available to PHE at the time of its publication, including through linkage to broader health data sets. It confirms that the impact of COVID-19 has replicated existing health inequalities and, in some cases, has increased them. These results improve our understanding of the pandemic and will help in formulating the future public health response to it. 
  12. News Article
    The government’s top scientific advisers discussed care homes only twice between January and May, according to newly published minutes. Records for meetings of the Scientific Advisory Group for Emergencies, or Sage, which is the key group of experts advising ministers on how to react to the COCID-19 outbreak, reveal a lack of discussion about the risks facing care homes. Between January and May, Sage minutes mention care homes only twice, before the start of lockdown in the UK and weeks before the numbers of deaths made headlines across the country. Shadow care minister Liz Kendall said she was concerned not enough action had been taken and added: “It is clear that social care and the NHS were not treated equally, nor as two sides of the same coin.” James Bullion, president of the Association of Directors of Social Services said the publication of the minutes "appears to reinforce the impression that social care has been an afterthought – a secondary consideration after the NHS. This cannot continue." Read full story Source: The Independent, 1 June 2020
  13. News Article
    The Care Quality Commission (CQC) have looked at how the number of people who have died during the coronavirus outbreak this year compares to the number of people who died at the same time last year. They looked at information about services that support people with a learning disability or autism in the 5 weeks between 10 April to 15 May in 2019 and 2020. These services can support around 30,000 people. They found that in that 5 weeks this year, 386 people with a learning disability, who may also be autistic, died. Data for the same 5 weeks last year found that 165 people with a learning disability, who may also be autistic, died. This information shows that well over twice as many people in these services died this year compared to last year. This is a 134% increase in the number of death notifications this year. This new data should be considered when decisions are being made about the prioritisation of testing at a national and local level. Kate Terroni, Chief Inspector of Adult Social Care at the Care Quality Commission (CQC) said: "Every death in today's figures represents an individual tragedy for those who have lost a loved one." "While we know this data has its limitations what it does show is a significant increase in deaths of people with a learning disability as a result of COVID-19. We already know that people with a learning disability are at an increased risk of respiratory illnesses, meaning that access to testing could be key to reducing infection and saving lives." "These figures also show that the impact on this group of people is being felt at a younger age range than in the wider population – something that should be considered in decisions on testing of people of working age with a learning disability." Read full story Source: Care Quality Commission, 2 June 2020
  14. News Article
    Care homes are the focus of the COVID-19 outbreak in England and Wales. At least 40% of all coronavirus deaths have occurred in the very places dedicated to keeping people safe in their later years. The under-reporting of deaths, the lack of personal protective equipment (PPE) and testing available to staff, and the total focus on the NHS at the expense of the social care sector have all contributed to an estimated 22,000 deaths in care homes – places that government had originally advised were “very unlikely” to experience infection. But how could care homes have been failed so badly, and what checks and balances should have been in place to prevent this? Care homes in England are regulated by the Care Quality Commission (CQC). One of its key responsibilities is to carry out inspections and visits to ensure providers meet fundamental standards of quality and safety; however, as of 16 March, the regulator stopped all routine inspections to “focus on supporting providers to deliver safe care during the pandemic”. Had the CQC continued its inspections, it would have been in a position to challenge cases where PPE was being diverted away from care homes to the NHS, and to aid struggling homes in their battle to secure tests for staff and residents. Instead, care homes have effectively been left to fend for themselves. On top of this, the CQC joined similar bodies in Wales, Scotland and Northern Ireland in refusing to publish detailed data on care home deaths, arguing instead for a need to “avoid confusion” and to protect “the privacy and confidentiality of those who have died and their families”. Families and the wider public have a right to know when and where COVID-19 outbreaks are happening, and this lack of transparency is deeply troubling. Read full story Source: The Guardian, 1 June 2020
  15. News Article
    DigitalHealth.London is helping health and care professionals turn the idea of digital innovation into tangible improvements in experience and outcomes for patients. Our work is instrumental in giving health and care stakeholders across London insight into the best digital health interventions and tools on the market. DigitalHealth.London is a collaborative programme delivered by MedCity, and London’s three Academic Health Science Networks – UCLPartners, Imperial College Health Partners, and the Health Innovation Network. Closing date: Midnight, Sunday 5 July 2020 Read more
  16. Content Article
    The rapid transmission of COVID-19 has resulted in an international pandemic with the cumulative death rate expected to further escalate in the months to come. The majority of deaths to date (May 2020) have been highly concentrated in certain geographic areas, placing tremendous stress on local healthcare systems and associated workforces. Healthcare is a fundamentally human endeavor; its reliability and the capacity to provide it are tested under stressful conditions and the COVID-19 pandemic is proving to be an especially difficult test for healthcare systems. Consideration of the humanness of care in the broader context of patient safety can raise awareness of how human weaknesses impact individual clinicians and care teams in ways that could degrade patient safety and quality of care and increase risk for both patients with COVID-19 and the staffs that care for them. These weaknesses are exacerbated by fatigue and burnout, absence of team trust, lack of time, medical illness, and poor psychological safety, each of which can result in reduced performance and contribute to failures such as misdiagnoses and adverse events. This article published on AHRQ's PSNet explores these weaknesses.
  17. Content Article
    In this guest blog for the Professional Standards Authority, Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA), sums up what progress has been made since the introduction of the organisational and professional duties of candour, but also questions what difference they have made. Peter remains hopeful, that the duty of candour will become much more than just a box-ticking exercise and believes, if we can get it right, it will be the biggest and most overdue advance in patients’ rights and patient safety that we have ever seen in health and social care.
  18. News Article
    World leaders in infection control and disease prevention convened online at the inaugural iClean 2020 conference on 28 May to discuss innovative infection control reform in hospitals and aged-care facilities in the wake of the COVID-19 crisis. Keynote speaker Professor Didier Pittet* said there has never been a more pertinent time to address infection control in our healthcare systems. “During this devastating COVID-19 pandemic, up to one in five people who contracted the virus globally are healthcare workers, and we saw similar numbers in the SARs and MERS outbreaks." “Furthermore, aged-care residents accounted for 29% of COVID-19-related deaths in Australia, and this rate is even higher in Europe, the United States and the United Kingdom, who have been hardest hit by the pandemic,” Professor Pittet said. “We are therefore calling for urgent reform in our approach to cleaning and disinfection in hospitals and aged-care homes.” Professor Pittet explained that Clean Hospitals — an initiative aiming to create better procedures, training, auditing and management processes — would allow cleaning and infection control managers around the world to improve quality and outcomes. Read more Source: Hospital Healthcare, 1 June 2020
  19. News Article
    About 2.4 million people in the UK are waiting for cancer screening, treatment or tests, as a result of disruption to the NHS during the past 10 weeks, according to Cancer Research UK. It estimates 2.1 million have missed out on screening, while 290,000 people with suspected symptoms have not been referred for hospital tests. More than 23,000 cancers could have gone undiagnosed during lockdown. Chief executive Michelle Mitchell said COVID-19 has placed an "enormous strain on cancer services". "The NHS has had to make very hard decisions to balance risk," she said. "...there have been some difficult discussions with patients about their safety and ability to continue treatment during this time. Prompt diagnosis and treatment remain crucial to give people with cancer the greatest chances of survival and prevent the pandemic taking even more lives." To ensure no-one is put at risk from the virus now that cancer care is returning, Cancer Research UK said "frequent testing of NHS staff and patients, including those without symptoms" was vital. Read full story Source: BBC News, 1 June 2020
  20. Event
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    Join West Midlands Academic Health Science Network (WMAHSN) for the third session in a four-part series, offering health & social care workers an opportunity to socially connect through Appreciative Inquiry. During these clarifying times where people have been asked to physically distance, and there are increased demands on the health and social care sectors to respond to COVID-19, the West Midlands Academic Health Science Network (WMAHSN) offers health and social care workers an opportunity to socially connect through a four week webinar series focusing on the use of Appreciative Inquiry. The series will look to provide participants with an opportunity to: Understand Appreciative Inquiry and how it can be used to co-create new ways of working in both health and social care sectors. Explore tools, techniques and practices that can be used to support existing practice. Hear from topical experts who are already applying Appreciative Inquiry to both their professional and personal lives. Connect socially in the development of a community of discovery that can continue to share learning. Inquire into appreciative conversations and apply questions and reframes to enable resiliency growth. Further information and registration
  21. Content Article
    This guide from the Clinical Human Factors Group is to help staff working in procurement or with medical devices and equipment, to use Human Factors to specify and select the best and safest products to use in healthcare. This is important because conformity with Regulations and Standards does not always guarantee safe outcomes when products are used in practice. This guide is particularly relevant to medical devices but can be used for other healthcare products.
  22. Content Article
    The world today is highly complex and fast changing. New technologies become available and change the way we work, communicate and live our lives. The complex socio-economic and socio-political systems can make it difficult to anticipate the needs and requirements of tomorrow. This article discusses issues organisations have to deal with and the benefit of becoming more human-centred with help of a model aiming to influence organisations on policy level.
  23. News Article
    NHS pathology labs were given just two days to roll out thousands of antibody tests, amid a push to reach a COVID-19 testing target set out by Boris Johnson. Earlier this month the Prime Minister set a target of having a testing capacity of 200,000 per day by the end of May. Capacity currently stands at 161,000, Matt Hancock has said. Until now there has been very limited use of antibody tests, with most capacity used to deliver PCR tests that indicate whether someone currently has the virus. Antibody tests are intended to identify whether someone has previously had the virus. On 27 May, NHS England and Improvement wrote to local leaders giving them two days’ notice to put in place testing capacity for, and deliver, thousands of antibody tests of staff and patients. In one letter to leaders in the south east, seen by HSJ, the regulator said labs were expected to establish capacity and deliver 6,000 tests daily by 29 May. A senior source from London confirmed to HSJ the region had also been given a target of 6,000. There are seven local regions in the NHS, which would indicate around 42,000 tests per day, which if PCR testing continued at the current levels, could enable the government to meet the 200,000 target. One head of pathology at a trust said: “There is one obvious answer as to why there is suddenly such an urgency to roll this out. While it will be interesting to have the results, there is nothing meaningful we can do with this test data at the moment.” Another trust director involved in the scheme described the antibody tests as having “no clinical value”. Read full story Source: HSJ, 29 May 2020
  24. Event
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    Risky Business Events, in collaboration with The BMJ and Great Ormond Street Hospital, supported by the Medical Protection Society, have partnered to create this free, virtual conference for the multidisciplinary teams in the pandemic frontline. The idea of the event is to provide front-line clinical professionals who have been working flat out and exhausted with a succinct latest update on the science, the medicine, the technology and the people (well being) with respect to the COVID-19 crisis. Book
  25. Content Article
    North Tees and Hartlepool NHS Foundation Trust has achieved more than double its medicines savings target, delivering the best value for the North Tees and Hartlepool region and the wider NHS. The Trust’s Pharmacy and Medicines Optimisation team together in collaboration with the multidisciplinary medical and nursing teams, finance department and commissioners developed several work streams for medicines efficiencies and quality improvement initiatives. Getting best value for medicines is one of the core business priorities for the Pharmacy & Medicines Optimisation team, through significant collaboration with the multidisciplinary teams of senior medical, nursing, finance, and wider commissioning teams. The project has significantly benefited the organisation and the wider system, through exceeding the expectation of efficiency target, it has contributed directly to improving the quality of patient care and experience as well as ensuring the financial sustainability of the organisation.
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