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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The International Pharmaceutical Federation (FIP) has set up a FIP COVID-19 information hub with guidance to support pharmacists and the pharmacy workforce in responding to the pandemic. The updated guidance document takes into account newly available evidence and recommendations.
  2. Content Article
    In September 2015, the Institute of Medicine (IOM) issued the report “Improving Diagnosis in Health Care,” which focused on the underappreciated problem of diagnostic error in medicine. This report builds on the IOM’s 2000 landmark report, “To Err is Human”, which specifically highlighted opportunities for improvement in diagnostically focused fields, such as radiology and pathology. One of the major recommendations of the report is that “health care organizations should adopt policies and practices that promote a nonpunitive culture that values open discussion and feedback on diagnostic performance”. Notably, the report emphasises the ineffectiveness of traditional approaches to evaluating medical error that focus on identifying individuals’ errors. In this article published in Radiology, Larson and colleagues review the recommendations set forth by the recent IOM report, discuss the science and theory that underlie several of those recommendations, and assess how well they fit with the current dominant approach to peer review. They also offer an alternative approach to peer review: peer feedback, learning, and improvement (or more succinctly, “peer learning”), which they believe is better aligned with the principles promoted by the IOM.
  3. Content Article
    The Royal College of Nursing has undertaken two surveys of health and care staff to identify their experiences and ongoing issues with the supply of and access to personal protective equipment (PPE) during the COVID-19 pandemic. This report details the findings of the second survey (May 2020).
  4. Event
    Looking at inclusion and diversity within health and social care to look at inspiring the next generation to forge careers in healthtech. Digital Healthcare Show and Health+Care present this webinar look ing at the different perspectives and backgrounds of people who work within healthtech to help shape the future. Further information and registration
  5. Event
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    In the wake of the COVID-19 outbreak, now, more than ever, we are starting to understand the mammoth task that our healthcare professionals are up against while trying to keep the general public safe while within an acute healthcare setting. Convenzis Group Virtual Series will be host the UK’s first Virtual NHS Patient & Staff Safety Conference. Join to discuss some areas of concern highlighted by the recent COVID-19 outbreak and the innovative and forward-thinking technology and services helping to counter these issues and improve both NHS staff and patient safety, key areas of discussion will be; Preventing healthcare-acquired infections. Global leadership for patient safety. Patient Safety Incident Management system. Reducing medication error. Learning from deaths. Inspection round up and review. Register
  6. Event
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    This webinar will be presented by Rob Tomlinson, RGN, Royal Blackburn Hospital Operating Theatres and Pete Smith, Former Nurse at Geelong University Hospital, Australia. Objectives: Noise and distraction is consistently associated with the occurrence of Never Events. Rob Tomlinson has used his experience of being part of a team involved in a never event to address one of the greatest challenges in surgery, reducing noise and distraction. Rob reached out to two nurses in Australia who offer a possible solution to this dilemma. This session will educate the audience about Clinician Led Cultural Change, Below Ten Thousand, how to introduce Ground Up Change (and how not to!), dangers of steep hierarchies and dangers of noise and distraction in healthcare. Further information and registration
  7. News Article
    The coronavirus pandemic is a “magnifier of inequality” that threatens the wellbeing of women, children, and adolescents worldwide, a roundtable of influential female leaders has heard. The United Nations has predicted that 47 million women could lose access to contraception resulting in 7 million additional unintended pregnancies over the next six months1 because of “deadly and disabling” COVID-19, the virtual event was told. There could also be 31 million additional cases of gender based violence in low and middle income countries. Policy makers have a clear duty to protect the most vulnerable and disadvantaged and to tackle the root causes of inequality with targeted policies and resources, the participants concluded. Henrietta Fore, executive director of Unicef, said that, in countries with already weak health systems, COVID-19 was disrupting medical supply chains and straining financial and human resources. Visits to healthcare centres are declining owing to lockdowns, curfews, and transport disruptions, and as communities remain fearful of infection. She cited recent research that indicated there could be an increase in child deaths amounting to an additional 6000 a day over the next six months, and 56 700 more maternal deaths. “This is a statistic we want to avoid. We are concerned about access to services,” she said. Read full story Source: BMJ, 29 May 2020
  8. News Article
    New data has shown the number of coronavirus patients being admitted to hospital and intensive care units across the country has risen as lockdown rules are set to be eased further on Monday. The Public Health England (PHE) data, published on Friday, covers 134 NHS trusts across the country and shows the daily rate of new patients admitted to hospital and critical care with COVID-19 has risen compared to recent weeks, with London experiencing a sharp spike in new admissions in the past week. The south east region also saw an increase. The surveillance data on the spread of COVID-19 throughout England has also revealed an increase in the number of people testing positive at their GP. Read full story Source: Independent, 31 May 2020
  9. News Article
    Pharmacy leaders in the black, Asian and minority ethnic (BAME) communities have expressed concern that assessments of BAME staff’s susceptibility to COVID-19 are not widespread enough in community pharmacy. NHS England wrote to community pharmacies on 29 April 2020 advising employers to “risk assess staff at potentially greater risk” of COVID-19 after “emerging UK and international data” suggested people from BAME backgrounds are “being disproportionately affected”. The Faculty of Occupational Medicine later published a risk reduction framework — backed by NHS England — to assist with the risk assessments on 14 May 2020. This was updated on 28 May 2020 to include guidance from the Health and Safety Executive to “help organisations identify who is at risk of harm”. But speaking to The Pharmaceutical Journal, Elsy Gomez Campos, president of the UK Black Pharmacists’ Association (UKBPA), said she had been told by a small number of community pharmacists that “nothing has been done” in terms of risk assessing BAME staff. “I know of a few people who have been assessed and that is mainly in hospital,” she said. “In terms of community pharmacists — who I’ve had contact with so far — they haven’t even been asked to have the risk assessment done.” However, she stressed that not many from the community pharmacy sector have come forward, but “the people who have come forward have said no, it has not been done”. “People are quite scared to ask as well because it can have repercussions on their employment or their relationships [at work],” she added. Read full story Source: The Pharmaceutical Journal, 29 May 2020
  10. News Article
    Some extremely vulnerable people have been told they have been removed from shielding lists via text message, without the knowledge of their GP. This has caused confusion, with charities demanding clearer guidance for this group as lockdown eases. GPs say they should be notified when their patients are added or removed from the lists. Shielding has now been extended until the end of June and is under constant review, the government says. Around 2.2 million people in the UK are staying at home to protect themselves from the virus because they were told they were at high risk of being seriously ill with COVID-19. But 40 healthcare charities say the lack of a clear plan for their future is causing anxiety and potentially putting their health at risk. Read full story Source: BBC News, 30 May 2020
  11. Content Article
    This checklist from the Health and Safety Executive provides typical elements to score culture, particularly applicable for larger organisations.
  12. Content Article
    Resilience matters now more than ever in healthcare, with the COVID-19 pandemic putting healthcare providers and systems under unprecedented strain. In popular culture and everyday conversation, resilience is often framed as an individual character trait where some people are better able to cope with and bounce back from adversity than others. Research in the management literature highlights that resilience is more complicated than that – it’s not just something you have, it’s something you do. Drawing on research on managing unexpected events, coordinating under challenging conditions, and learning in teams, Barton et al. distill some counter-intuitive findings about resilience into actionable lessons for healthcare leaders.
  13. Content Article
    Watch as Dr Donna Prosser is joined by a panel of experts to discuss how the COVID-19 pandemic is affecting mental health across the globe and share some tips for effectively managing these challenges.
  14. Content Article
    For a child, coming in to hospital can be pretty scary at the best of times, but it's especially daunting at the moment with all the doctors and nurses wearing their special personal protective equipment (PPE) for coronavirus. Edinburgh Children's Hospital Charity has created a video that explains, with help of some big and small superheroes, why various outfits – such as an astronaut's helmet or a firefighter's uniform – protect workers from different types of hazards. The idea is to help children in hospital feel more at ease while staff wearing PPE are caring for them.
  15. Article Comment
    Thanks very much for your feedback. We’re a small charity and we're using our website, social media and other channels to try and get the word about Oscar out. We would also love for those who use Oscar to spread the word more widely. We’ll be promoting with patient networks and would like to syndicate it onto other websites too. We welcome ideas, for Oscar’s development and promotion.
  16. Content Article
    Dr Susan Whalley-Lloyd, Senior Lecturer in Human Factors/Ergonomics at Staffordshire University, discusses how the learning and research opportunities evolving from the coronavirus pandemic will add to our human factors knowledge base and gives us a unique opportunity to achieve new research in human factors and patient safety.
  17. Content Article
    Most Americans are eager to see the country re-open. In this article Nicole Saphier and Marty Makary discuss why we need to be smart about how we do it and why we need accurate statistics.
  18. Content Article
    Dr Susan Whalley-Lloyd, Senior Lecturer in Human Factors/Ergonomics at Staffordshire University, explains in this short video presentation why a human factors course is important for patient safety and what the course at Staffordshire University covers.  
  19. News Article
    NHS staff at a hospital that has stopped taking new patients amid a COVID-19 spike have lodged a series of concerns, including that they are not routinely being informed of when colleagues test positive for the virus. The concerns were laid out in a letter from union representatives to management at Weston general hospital in Somerset, which is now testing all staff while carrying out a deep clean. Another concern raised by Unison was that priority for testing was not being given to BAME staff. University Hospitals Bristol and Weston NHS foundation trust said on Wednesday that as many as 40% of staff from a cohort tested after contact with infected patients were found to be positive. The trust’s chief executive, Robert Woolley, told the BBC the figure was from a sample testing last week and authorities were now attempting to understand the scale of the infection. More than 60 patients were found to be infected last weekend. Read full story Source: The Guardian, 28 May 2020
  20. News Article
    Dental practices in England have been told they can reopen from Monday 8 June, if they put in place appropriate safety measures. All routine dental care in England has been suspended since 25 March. The British Dental Association (BDA) has welcomed the announcement but says key questions remain. Currently, any patient with an emergency dental problem is supposed to be referred to an Urgent Dental Care (UDC) hub for treatment. In a letter to all practices, NHS England's chief dental officer, Sara Hurley, said: "Today, we are asking that all dental practices commence opening from Monday, 8 June for all face-to-face care, where practices assess that they have the necessary IPC and PPE requirements in place." The BDA said that while dentists would be relieved by the announcement, the ability of practices to reopen would depend on the availability of personal protective equipment (PPE). "It is right to allow practices to decide themselves when they are ready to open. Dentists will be keen to start providing care as soon as is safely possible, but we will need everyone to be patient as practices get up and running," said BDA chairman Mick Armstrong. Read full story Source: BBC News, 28 May 2020
  21. News Article
    A hospital trust under the spotlight over avoidable baby deaths provided inadequate antenatal care, with inexperienced junior midwives working alone and doctors not always available to assess high risk women, the Care Quality Commission (CQC) has found. The latest CQC report on maternity services at East Kent Hospitals University Foundation Trust follows a report last month by the NHS Healthcare Services Investigation Branch on 24 maternity care investigations at the trust. Read full story (paywalled) Source: BMJ, 28 May 2020
  22. Content Article
     In this commentary published in the Journal of Patient Safety and Risk Management, Gurses et al. describe how human factors and ergonomics (HFE) can contribute to the COVID-19 pandemic response. Specifically, the authors provide an example of how HFE methodologies informed workflow redesigns implemented as part of COVID-19 pandemic preparations in an academic paediatric ambulatory clinic. They identify key mechanisms and areas where HFE can contribute to and improve the effectiveness of a pandemic response: Just-in-time (JIT) training development, adapting workflows and processes, restructuring teams and tasks, developing effective mechanisms and tools for communication, engaging patient and families to follow the recommended practices (e.g., social distancing, revised hospital visitation policies), identifying and mitigating barriers to implementation of plans, and learning from failures and successes to improve both the current and future pandemic responses.
  23. News Article
    The first hospital dedicated to helping coronavirus patients recover from the long-term effects of the illness has received its first patients. Surrey's NHS Seacole Centre opened this month at Headley Court, a former rehab centre for injured soldiers. COVID-19 patients can be left with tracheostomy wounds from having a tube inserted in the windpipe or need heart, lung or muscle therapy, the NHS said. Others who have survived the virus may need psychological or social care. NHS chief executive Sir Simon Stevens said: "While our country is now emerging from the initial peak of coronavirus, we're now seeing a substantial new need for rehab and aftercare." He said while patients had survived life-threatening complications, many would see a longer-lasting impact on their health. Read full story Source: BBC News, 29 May 2020
  24. Content Article
    Leaders, at all levels, need to understand the range of health and safety risks in their part of the organisation and to give proportionate attention to each of them. This applies to the level of detail and effort put into assessing the risks, implementing controls, supervising and monitoring. The Health and Safety Executive (HSE) gives examples of effective and ineffective health and safety management to check if you are doing what you need to do on leadership.
  25. Content Article
    In April 2009 a 'considerative checklist' was developed to ensure that all important aspects of care on a team's routine and post-take general internal medicine ward rounds had been addressed and in order to answer the question: How long should a ward round take, when conducted to high standards of quality and safety at the point of care? The checklist has been used on 120 ward rounds: 90 routine ward rounds and 30 post-take ward rounds. Overall, the average time per patient was 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds). The considerative checklist has encouraged and enabled documented evidence of high quality and safe medical care, and anecdotally improved team working, communication with patients, and team and patient satisfaction.
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