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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Health & Safety Laboratory (HSL) Safety Climate Tool (SCT) measures the perceptions of the workforce on health and safety issues, offering a unique insight into the safety culture within an organisation. It can be applied across industries of all sizes, from SMEs to large complex organisations. Multi-site companies can also use it to look at the strengths and weaknesses of different sites or business units. The HSL SCT is delivered on a CD-ROM, which you install onto a suitable computer to allow you to produce a customised questionnaire that is then run across your organisation. Once the questionnaire survey has been run, the tool produces a series of automated charts that allow detailed analysis of the findings. (HSL is an agency of the Health and Safety Executive.)
  2. Content Article
    Cancer diagnostics and surgery have been disrupted by the response of healthcare services to the COVID-19 pandemic. Progression of cancers during delay will impact on patient long-term survival. Sud et al., in a paper published in Annals of Oncology, found: Lockdown and re-deployment due to the COVID-19 pandemic is causing significant disruption to cancer diagnosis and management. 3-month delay to surgery across all Stage 1-3 cancers is estimated to cause >4,700 attributable deaths per year in England. The impact on life years lost of 3-6 month to surgery for Stage 1-3 disease varies widely between tumour types. Strategic prioritisation of patients for diagnostics and surgery has potential to mitigate deaths attributable to delays. The resource-adjusted benefit in avoiding delay in cancer management compares favourably to admission for COVID-19 infection.
  3. Content Article
    As the death toll from COVID-19 rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (i.e., missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care.  The COVID-19 pandemic is likely to increase the risk of such errors. Based on emerging literature and collaborative discussions across the globe, Gandhi and Singh propose a new typology of diagnostic errors of concern in the COVID-19 era. These errors span the entire continuum of care and have both systems-based and cognitive origins. While some errors arise from previously described clinical reasoning fallacies, others are unique to the pandemic. We provide a user-friendly nomenclature while describing eight types of diagnostic errors and highlight mitigation strategies to reduce potential preventable harm caused by those errors.
  4. News Article
    We’re living in an unprecedented time and facing new challenges. We’re asking questions we’ve never had to ask before – questions that differ according to our unique circumstances, concerns and needs. With an increasingly complex health and social care system, Patient Safety Learning wants to continue working towards a future that is safe for both patients and staff. It’s for this reason that we’ve launched Oscar, the friendly health chatbot. Available on the hub, Oscar answers the public’s question about their safety – or that of their family members and friends – during the coronavirus pandemic. Oscar is not a diagnostic tool. We at Patient Safety Learning are not medical experts ourselves, but we want to connect patients to the best guidance currently in the public domain. This is what Oscar seeks to do, in pointing visitors to helpful and trustworthy answers, relevant to their specific situations. Whether you’re a well adult seeking general information about how to stay safe from coronavirus, a concerned woman about to give birth and wanting to know your options, or a carer looking for advice, Oscar is here to help you find the answers you need. In time, as we see how the public uses Oscar – and especially as we hear your feedback – we plan to build on the range of information Oscar currently offers. Like everything else on the hub, Oscar is free to use. Please do send us any feedback, including information you’d like Oscar to provide, by emailing feedback@pslhub.org
  5. News Article
    Deaths resulting from COVID-19 infection account for only half of the number of excess deaths taking place in private homes, expert analysis of latest data suggests. Figures from the Office for National Statistics from the seven weeks to 15 May show that more than 40 000 COVID-19 deaths have now taken place in hospitals, care homes, and private homes in England and Wales. The figures also show 14 418 excess non-covid deaths. Although COVID-19 was mentioned on death certificates 13 500 times in care homes and private homes over the past seven weeks, some 23 500 more non-covid deaths have taken place in the community than would be expected. Discussing the data, David Spiegelhalter, chair of the Winton Centre for Risk and Evidence Communication at the University of Cambridge, said that “as soon as the pandemic started we saw a huge immediate spike in non-covid deaths in [private] homes that occurred close to the time hospitals were minimising the service they were providing." “Over the seven weeks up to 15 May, as the NHS focused on covid, around 8800 fewer non-covid deaths than normal occurred in hospitals.” He added that these had not been “exported” to care homes, since fairly few care home residents normally died in hospitals. Instead, he said, it seemed that these deaths had contributed to the huge rise in extra deaths in private homes during this period. Read full story Source: BMJ, 27 May 2020
  6. News Article
    Problems with dispensing drugs during the COVID-19 crisis may be contributing to an “apparent increase” in deaths of patients receiving treatment for opiate addiction, the Care Quality Commission (CQC) has said. The regulator has said the increase in deaths “may be a result of some services stopping all daily dispensing of opiates” and has taken enforcement action against a “large national provider of substance misuse services” which ”stopped all daily dispensing”. The provider has not been named by the CQC as it is “entitled to an appeal period,” but the regulator told HSJ the provider had not recorded their risk assessments for their clients in relation to changes in drug dispensing. The CQC said the provider had now “assured us” individualised risk assessments were in place. The CQC is now reviewing all deaths of people which have been reported by substance misuse services since 1 March due to concerns about the apparent increase and “that some of these deaths may be related to changes in prescribing practices in response to COVID-19”. Read full story Source: HSJ, 27 May 2020
  7. News Article
    Amid warnings that BAME nursing staff may be disproportionately affected by the COVID-19 pandemic, a Royal College of Nursing (RCN) survey reveals that they are more likely to struggle to secure adequate personal protective equipment (PPE) while at work. The latest RCN member-wide survey shows that for nursing staff working in high-risk environments (including intensive and critical care units), only 43% of respondents from a BAME background said they had enough eye and face protection equipment. This is in stark contrast to 66% of white British nursing staff. There were also disparities in access to fluid-repellent gowns and in cases of nursing staff being asked to re-use single-use PPE items. The survey found similar gaps for those working in non-high-risk environments. Meanwhile, staff reported differences in PPE training, with 40% of BAME respondents saying they had not had training compared with just 31% of white British respondents. Nearly a quarter of BAME nursing staff said they had no confidence that their employer is doing enough to protect them from COVID-19, compared with only 11% of white British respondents. Dame Donna Kinnair, RCN Chief Executive & General Secretary, said: “It is simply unacceptable that we are in a situation where BAME nursing staff are less protected than other nursing staff. Read full story Source: Royal College of Nursing, 27 May 2020
  8. News Article
    A team of 25,000 contact tracers are making their first phone calls to track down people who will be told to self-isolate under a new scheme in England. Tracers will text, email or call people who test positive with coronavirus and ask who they have had contact with. Any of those contacts deemed at risk of infection will be told to isolate for 14 days, even if they are not sick. A test and trace system is also launching in Scotland, where an easing of the lockdown is expected later. The aim of England's NHS Test and Trace system is to lift national lockdown restrictions and move towards more localised, targeted measures. The team will start by contacting the 2,013 people who tested positive for the virus on Wednesday. Read full story Source: BBC News, 28 May 2020
  9. Content Article
    On 24 July 2017, the long-running, deeply tragic and emotionally fraught case of Charlie Gard reached its sad conclusion. Following further medical assessment of the infant, Charlie’s parents and doctors finally reached agreement that continuing medical treatment was not in Charlie’s best interests. Life support was subsequently withdrawn and Charlie died on 28 July 2017. This paper from Dominic Wilkinson and Julian Savulescu summarises the case and looks at the key factual and ethical questions arising from the Charlie Gard case, and parents’ role in decision-making for children.
  10. Event
    The first HSJ National Diabetes Forum will bring together the entire diabetes community – including senior national and regional figures, clinicians, managers and patient advocates – to share practical solutions to achieving national priorities, including: type 2 prevention, improving access to diabetes professionals, enhancing supported self management, exploring further the opportunities for remission and increasing use of digital to improve care. The new HSJ National Diabetes Forum is part of the HSJ Clinical Policy Series. The series reflects current national priorities from the long-term plan and will support attendees to take the national policy and translate it into practical actions to improve outcomes in their area. Further information and registration
  11. News Article
    An emergency unit at a Norwich hospital has reduced ward admissions and is helping shield urgent non-COVID-19 patients. The older people’s emergency department (Oped) – a special unit at the Norfolk and Norwich university hospital – is providing emergency care for patients over 80. Launched in 2017, the unit, just down the corridor from A&E, has six beds, two in side rooms and no waiting room. Normally, it admits patients identified as frail and usually with multiple conditions that need a lot of care (such as cognitive impairment, incontinence or reduced mobility). They are brought straight in by ambulance or trolley from other parts of the hospital and seen by a consultant geriatrician within two hours. A team of nurses with experience in both emergency care and care of the elderly, pharmacists and physiotherapists are on hand to support patients much more quickly than A&E to get patients out of hospital and back home within the same day wherever possible. For patients who need to stay longer after treatment there is an adjacent ambulatory ward. This unique model is showing results. The proportion of the specialist department’s patients admitted to the hospital is 50% compared with 68% for the same age group of emergency patients coming to the hospital five years ago, when they were treated at the normal A&E. When Oped patients are admitted, their average length of stay is 1.2 days less. “It’s just what we want for old people,” says Dr Sarah Bailey, the department’s lead consultant geriatrician. “We get the experts in straight away because we recognised that’s the best thing for [them]”. During the pandemic, the unit is helping to keep those who do not have coronavirus symptoms, such as those with injuries from falls and some stroke patients, away from the main A&E ward, providing a degree of shielding not normally possible. But for most NHS trusts, providing a separate unit like Oped is not feasible. “Hospitals are working to separate emergency patients with respiratory problems from those with other conditions,” says Dr Jay Banerjee, who leads the Royal College of Emergency Medicine’s work on emergency care for the elderly. “But most just do not have the capacity to also try to separate elderly patients with other conditions from younger patients.” Read full story Source: The Guardian, 27 May 2020
  12. News Article
    Selected NHS coronavirus patients will soon be able to access an experimental treatment to speed up their recovery, with the health secretary Matt Hancock suggesting it is probably “the biggest step forward’’ in medication since the beginning of the COVID-19 crisis. The anti-viral drug remdesivir will be made available to patients meeting certain clinical criteria to support their recovery in hospital. The drug is currently undergoing clinical trials around the world, including in the UK, and peer-reviewed data showed it can shorten the time to recovery by about four days. Treatment will initially be prioritised for patients who have the greatest likelihood of deriving the most benefit, according to the Department of Health and Social Care (DHSC). Satisfied the drug can help boost recovery, the government’s Medicines and Healthcare products Regulatory Agency (MHRA) approved the use of remdesivir through its early access to medicines scheme. The experimental anti-viral drug was granted emergency authorisation to treat Covid-19 in the US by the Food and Drug Administration earlier this month. Read full story Source: The Independent, 26 May 2020
  13. News Article
    Facial recognition has been added as a way of logging in to an NHS app that lets people order prescriptions, book appointments and find healthcare data. Initially, it will allow faster access to the services on the app, which is separate from the contact-tracing one, but its developers say it could also be used for COVID-19 "immunity passports". The NHS facial-recognition system, built by iProov and available for both Android devices and iOS, requires users to submit a photo of themselves from an official document such as their passport or driving license. They then scan their face using their phone and, following a short sequence of flashing colours, their identification will be verified and they will have access to all the services on the NHS app. Immunity passports need to link a person's identity to their coronavirus test results, so would require a robust way of allowing people to verify themselves. Those deemed clear of the virus could then prove their status via a code generated by an app. However, the idea is controversial, not least because there is no hard scientific evidence that having had the coronavirus provides people with long-lasting immunity. The World Health Organization has warned countries against implementing such passports, saying: "There is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection." Dr Tom Fisher, a senior researcher at Privacy International, said the implementation of such measures needed to be "necessary, proportionate and based on the epidemiological evidence". "For the moment, immunity passports do not meet this test," he said. "We must be concerned about the broad societal impact of such immunity passports. They are essentially about limiting the rights of those who are not deemed to be immune. This is a route to exclusion and discrimination." Read full story Source: BBC News, 27 May 2020
  14. Content Article
    The Royal College of Midwives has put together an infographic of some of the common stresses that mothers and those working in maternity services may be experiencing and some strategies to help you cope.
  15. News Article
    Weston General Hospital has stopped admitting new patients – including to the accident and emergency department – following a spike in coronavirus cases. The hospital announced yesterday it was taking this “precautionary measure” due to the “high number of coronavirus patients” on site. MP for Weston-super-Mare John Penrose tweeted that he had spoken to local health chiefs and a deep clean is being carried out at the hospital “following a spike in infections”. He added that a temporary A&E has been set up outside the hospital, while inpatients will be re-directed to hospitals in Taunton or Bristol. Out of hours GP practices, pharmacies and walk-in services at the minor treatment unit in Clevedon and Yate have also been given as alternative options for patients seeking medical treatment. Read full story Source: HSJ, 25 May 2020
  16. News Article
    NHS England has said disabled and vulnerable patients must not be denied personalised care during the coronavirus pandemic and repeated its warning that blanket do not resuscitate orders should not be happening. In a joint statement with disabled rights campaigner and member of the House of Lords, Baroness Jane Campbell, NHS England said the COVID-19 virus and its impact on the NHS did not change the position for vulnerable patients that decisions must be made on an individualised basis. It said: “This means people making active and informed judgements about their own care and treatment, at all stages of their life, and recognises people’s autonomy, as well as their preferences, aspirations, needs and abilities. This also means ensuring reasonable adjustments are supported where necessary and reinforces that the blanket application of do not attempt resuscitation orders is totally unacceptable and must not happen.” Read full story Source: The Independent, 26 May 2020
  17. News Article
    A dozen charities and voluntary organisations have now called on the Care Quality Commission (CQC) to re-start routine inspections of care homes and mental health units amid concerns about care of patients during the coronavirus pandemic. The watchdog suspended its routine inspections of care providers on 16 March, but said it would inspect providers in “a very small number of cases” where it had concerns for patients such as allegations of abuse. The CQC’s chief executive said the watchdog’s decision was designed in part to limit the spread of the disease but he added that since inspections were curtailed inspectors had maintained contact with providers and helped to source protective equipment for staff. The Relatives and Residents Association, a national charity for older people in care and their relatives, has written to the CQC’s chief executive Ian Trenholm asking him to “urgently reconsider” the decision to stop inspections. Edel Harris, chief executive of Mencap has also highlighted concerns for hundreds of children with learning disabilities who she said were detained in “modern-day asylums” adding: “Some families are rightly terrified about what might be happening to their loved ones behind closed doors. With family contact cut and CQC inspections reduced during lockdown, there is huge concern about who is making sure that some of the most vulnerable people in society are being kept safe and well during this national crisis.” Read full story Source: The Independent, 26 May 2020
  18. News Article
    The World Health Organization has said it will temporarily drop hydroxychloroquine — the malaria drug Donald Trump said he is taking as a precaution — from its global study into experimental coronavirus treatments after safety concerns. The WHO’s director-general Tedros Adhanom Ghebreyesus said in light of a paper published last week in the Lancet that showed people taking hydroxychloroquine were at higher risk of death and heart problems than those who were not, it would pause the hydroxychloroquine arm of its solidarity global clinical trial. “The executive group has implemented a temporary pause of the hydroxychloroquine arm within the solidarity trial while the safety data is reviewed by the data safety monitoring board,” Tedros said on Monday. “The other arms of the trial are continuing,” Read full story Source: The Guardian, 25 May 2020
  19. Content Article
    Feldman et al. set out to document how NHS trusts in the UK record and share disclosures of conflict of interest by their employees. They found that, overall, recording of employees’ conflicts of interest by NHS trusts is poor. None of the NHS Trusts in England met all transparency criteria.
  20. Content Article
    Alexander James Davidson was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition
  21. Content Article
    A medical student describes his experiences of working in the ICU of his local hospital during coronavirus in this Independent blog. "I was one of the first medical students at my university to be recruited to help out in local hospitals as fears grew about the NHS being overwhelmed by COVID-19."
  22. Content Article
    Trisha Greenhalgh and colleagues argue that it is time to apply the precautionary principle. The precautionary principle is, according to Wikipedia, “a strategy for approaching issues of potential harm when extensive scientific knowledge on the matter is lacking.” The evidence base on the efficacy and acceptability of the different types of face mask in preventing respiratory infections during epidemics is sparse and contested. But COVID-19 is a serious illness that currently has no known treatment or vaccine and is spreading in an immune naive population. Deaths are rising steeply, and health systems are under strain. This raises an ethical question: should policy makers apply the precautionary principle now and encourage people to wear face masks on the grounds that we have little to lose and potentially something to gain from this measure? Greenhalgh and colleagues believe we should. However, there are criticisms of this view. Read the original analysis published in the BMJ and Tricia Greenhalgh's follow up paper in the Journal of Evaluation in Clinical Practice where she rebutts the criticisms received.
  23. Community Post
    Thanks for sharing on the hub Akhil. Great to get these insights and to hear how other countries are tackling the pandemic. We'd love to hear what other countries are doing to meet the current challenges and the solutions they are putting in place.
  24. Content Article
    Data published in the New England Journal of Medicine demonstrates that use of CareFusion’s patient preoperative skin preparation ChloraPrep® (2% chlorhexidine gluconate and 70% isopropyl alcohol) reduced total surgical site infections (SSIs) by 41%, from 16.1% to 9.5%, compared to use of povidone-iodine solution, the most commonly used preoperative skin preparation. In this prospective, randomised and well-controlled outcomes trial designed to compare the efficacy of skin antiseptics in reducing the risk of SSIs, ChloraPrep proved superior in clean-contaminated abdominal, urologic, gynecologic and thoracic surgery.  “For nearly a decade, healthcare professionals have relied on the proven efficacy of ChloraPrep,” said Stephen R. Lewis, MD, chief medical officer of CareFusion. “This study is an example of our ongoing commitment to providing clinicians with evidence-based data that clinically differentiates our products in order to help improve patient care and lower costs.”
  25. Content Article
    As the current coronavirus (COVID-19) continues to present significant challenges for healthcare providers both in the independent sector and the NHS, healthcare professionals who are involved in receiving patients confirmed positive for COVID-19 in the perioperative setting require the best evidence-based guidance on infection prevention control. The following published guidance seeks to ensure a consistent and resilient UK approach, as differences in operational details and organisational responsibilities may apply across the four UK countries. 
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