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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Community Post
    Hi Sereima. Welcome to the hub ?. You may be interested in a community thread we had on RCA last year which has some useful resources and links: Since then we have also added some other resources to the hub which might help you: NHS Improvement:Rootcauseanalysis - using five whys NHS Improvement: Quality, service improvement and redesign (QSIR)tools NEBOSH HSE introduction to incident investigation ROSPA accident investigation training And you should take a read of Martin Langham's blog series and presentation slides from Helen Higham. Hope that helps and we'd love to hear others' suggestions. Please add.
  2. News Article
    The risk of dying from coronavirus is more than twice as great in the most deprived areas of England – with the disparity largest for women, analysis shows. A study by the Health Foundation of deaths from COVID-19 showed women in the most deprived parts of the country had a risk of dying that was 133% higher than those in the least deprived neighbourhoods. Between men the difference in risk was 114% higher in worse-off areas, suggesting that while deprivation is a key factor in risk of death from coronavirus for both sexes, its effect is worse for women. Experts say the evidence shows the impact of COVID-19 is falling disproportionately on the poorest in society. Mai Stafford, principal data analyst at the Health Foundation, told The Independent: “This pandemic could and should be a watershed moment in creating the social and political will to build a society that values everyone’s health now and in the long term. Without significant action, there is a real risk that those facing the most disadvantage will eventually pay the highest price.” Read full story Source: The Independent, 21 May 2020
  3. News Article
    National leaders have said healthcare workers must do better on social distancing amid growing evidence that staff-to-staff transmission is the significant factor in the spread of coronavirus throughout hospitals. NHS England national clinical director for trauma Dr Chris Moran, said: “I’ve witnessed and I’m sure you’ve all witnessed that actually healthcare workers are not necessarily been the best at managing social distancing. We know when directly managing patients that it [social distancing] is impossible, that’s what PPE is for to protect both sides of the equation. But I think in the staff-only areas we could do quite a lot better in some of the places that I’ve visited.” National director for acute care Keith Willett added: “The evidence we’ve seen coming through suggests the infection risks from staff to patients or patients to staff seems very low but the risks to staff of infection, COVID-19 infection, within hospitals is much, much, much higher between staff and staff, and patients and patients.” The warning comes after NHS England’s patient safety director Dr Aidan Fowler said he was concerned about the rates of "nosocomial spread within our hospitals”. Following national guidance designed to facilitate an increase in elective operations and other routine work, NHS trusts have been asked to set up “covid free” green zones and blue zones with a higher COVID-19 risk. Read full story Source: HSJ, 21 May 2020
  4. News Article
    People will be asked to self-isolate for two weeks even if they are asymptomatic after coming into ‘high-risk’ contact with a person who has tested positive for COVID-19 – a testing chief has told NHS executives. This marks a change from the official guidance given to users of the government’s contact tracing app – on NHS’ COVID-19 website – which states: “If you do not have symptoms, you do not need to self-isolate at this time.” John Newton, a leader of the UK’s testing programme, would be “directed towards those people at high risk” instead of the wider public. He added the government faces a “huge communications exercise” next week ahead of the launch of the test and trace programme. Giving an update on the test and trace programme – which is due to launch on 1 June – Professor Newton said: “People who are deemed high risk contact of confirmed [COVID-19] cases will be told to self-isolate for 14 days, even if they have no symptoms at the time. Professor Newton said: “The point is there will still be a requirement to contain the virus, but the impact in terms of containment will be directed towards those people at high risk so the rest of the population can enjoy more normal life." He said the programme’s success would depend on the public’s response in terms of: Presenting themselves for a test if they have symptoms; Providing the information needed to identify high risk contacts; and Those people identified as high risk contacts complying with advice to self-isolate. Read full story Source: HSJ, 21 May 2020
  5. Content Article
    COVID-19 brings an enormous set of challenges to hospitals around the world. One challenge in particular, the current mental state of healthcare workers, is now taking centre stage as clinicians face delivering difficult news to patients and their families about what is happening, what to expect, and how to prepare. ECRI and RLDatix came together to deliver a special webcast led by Dr Tim McDonald, an expert on Communication and Optimal Resolution (CANDOR). A recording of the webinar can be viewed below.
  6. Content Article
    An ECRI position paper from Jeffrey T. Oristaglio and Jonathan R. Treadwell looking at the role of diagnostic testing in combating COVID-19.
  7. Content Article
    Our NHS staff are doing fantastic work to tackle the COVID-19 pandemic and keep essential services going – their hard work and dedication during this difficult time is remarkable. As the NHS Chief Executive Sir Simon Stevens made clear in his letter of 29 April 2020 to NHS chief executives, it is important to remind everyone of the duty – and right – of those who work in the NHS to speak up about anything which gets in the way of patient care and worker wellbeing. Hear what Prerana Issar, the first NHS Chief People Officer, has to say in her blog. See also our hub resources on Whistleblowing and Speak Up Guardians.
  8. Content Article
    How will the coronavirus pandemic affect the nation’s mental health? Covid-19 and the nation’s mental health: Forecasting needs and risks in the UK is the first assessment from the Centre for Mental Health of the likely impacts of COVID-19 on mental health in Britain. It uses evidence from previous epidemics internationally and from the aftermath of the 2008 banking crisis to estimate what effect COVID-19 will have on mental health at population level in the UK.
  9. Event
    How ergonomics is influencing the design and use of wearable technology to help augment human capability and performance. This free seminar, delivered by webinar, will consist of two presentations and a curated Q&A session by the chair, Dr Chris Ramsden, CIEHF’s President Elect and co-lead of the Healthcare Sector Group, Fellow of the Royal Society of Medicine, and current President of the Chartered Society of Designers. Who should attend? Anyone focused on improving human-centred processes by minimising musculoskeletal disorders, finding new ways to improve work safety, and designing more ergonomic products, tools or processes. Anyone seeking to understand how to integrate human factors engineering throughout the design process in order to design a truly adaptable and usable product, resulting in an effortless and enjoyable experience for the user. Further information
  10. Content Article
    Draft resolution proposed by Albania, Australia, Bangladesh, Belarus, Bhutan, Botswana, Brazil, Canada, Chile, Colombia, El Salvador, Guatemala, Iceland, India, Indonesia, Japan, Mexico, Monaco, Montenegro, Mozambique, New Zealand, North Macedonia, Norway, Paraguay, Peru, Republic of Korea, Republic of Moldova, Russian Federation, San Marino, Sierra Leone, South Africa, the European Union and its Member States, Turkey, Ukraine, United Kingdom of Great Britain and Northern Ireland and Zambia following the 73rd World Health Assembly.
  11. News Article
    A hospital A&E department has been rated "inadequate" after inspectors found patients at "high risk of avoidable harm". The Care Quality Commission (CQC) reported a "range of regulation breaches" and a shortage of nurses at Stepping Hill hospital's A&E unit. It also criticised maternity and children's services. Stockport NHS Foundation Trust's chief executive said the trust had taken "immediate steps" to improve. The CQC inspected Stepping Hill Hospital in January and February and found A&E performance "had deteriorated significantly" since its last inspection in 2018. Inspectors found shortcomings "relating to patient-centred care, dignity and respect, safe care and treatment, environment and equipment, good governance, and staffing". Their report said the service "could not assure itself that staff were competent for their roles" and patient outcomes "were not always positive or met expectations in line with national standards". Read full story Source: BBC News, 19 May 2020
  12. Content Article
    The Care Quality Commission (CQC) has published the first of what will be a regular series of insight documents intended to highlight COVID-19 related pressures on the sectors that CQC regulates.   This document draws on information gathered through direct feedback from staff and people receiving care, regular data collection from services who provide care for people in their own homes, and insight from providers and partners.   The information collected from these sources is being used to understand the wider impact of COVID-19, to share regular updates with local, regional, and national system partners and the Department of Health and Social Care, and to highlight any emerging trends and issues.
  13. Content Article
    The Scottish Patient Safety Programme (SPSP) is part of Healthcare Improvement Scotland's Improvement Hub supporting improvement across health and social care. The aim of theSPSP for Mental Health is People are and feel safe.
  14. News Article
    Dozens of intensive care units are still running well over their normal capacity – in some cases more than double – weeks after the peak of demand, figures seen by HSJ reveal. It contrasts with the picture painted at some government coronavirus press conferences that there is huge “spare capacity” in critical care and has been throughout the outbreak, with Downing Street charts putting England-wide occupancy at around 20% currently. The government’s assertions include the additional “surge” capacity which was hurriedly established at the start of the outbreak. But intensive care staff have been frustrated by this being labelled spare capacity, when the number of patients being treated is still well above normal levels. In addition, the ongoing reliance on keeping surge beds open – with ICUs still spilling over other spaces and calling on staff and equipment from other services – will limit hospitals’ ability to resume normal care, such as planned surgery. Steve Mathieu, a consultant in intensive care medicine in the south of England, said: “The majority of ICUs will currently be operating at over 100 per cent capacity and typically somewhere around 130-150 per cent, although there is significant regional variation". “There are uncertainties whether this will now represent the ‘new normal’ for the foreseeable future and there is a national need to plan for further potential surges in activity requiring more critical care demand." Read full story Source: HSJ, 21 May 2020
  15. Content Article
    Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. In this paper published in the BMJ, Gerry et al. carried out a systematic review and critical appraisal of early warning scores for adult hospital patients. The results found that many early warning scores in clinical use had methodological weaknesses.The study's authors concluded that the early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care.  “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.”
  16. News Article
    Early warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
  17. News Article
    Time is running out to finalise a track and trace strategy that would avoid a potential second surge in coronavirus cases, NHS leaders have said. The NHS Confederation warned of "severe" consequences to staff and patients if the right system was not established quickly and that lockdown measures should not be eased until a clear plan was in place. Contact tracing identifies those who may have come into contact with an infected person, either through an app or by phone and email, so they can avoid potentially passing the disease on. It follows the Prime Minister's pledge to introduce a "world-beating" contact tracing system in England from June. Niall Dickson, chief executive of the confederation, which represents health and care leaders, welcomed Boris Johnson's pledge made at Prime Minister's Questions on Wednesday. But in a letter to Health Secretary Matt Hancock, Mr Dickson said without a clear strategy the UK was at greater risk of a second peak of the virus. He said a strategy should have been in place sooner and if the right system was not instigated rapidly the ramifications for the NHS "could be severe". Speaking on the Today programme, Mr Dickson said: "We are absolutely clear that contact tracing is the right thing to do, it is absolutely critical, it has got to be in place to prevent any notion of a second surge if the lockdown is being further released." Read full story Source: 21 May 2020
  18. News Article
    GPs have been warned of a double risk from flu and COVID-19 this winter which could hit the NHS just months after its recovery from the coronavirus surge. NHS England has told practices to stock up on flu vaccines while discussions are ongoing as to whether to widen the eligibility for flu jabs to try and protect as many people as possible from September onwards. A second wave of coronavirus during winter, when the NHS is typically under strain from flu could overwhelm services with those most at risk from flu similarly vulnerable to coronavirus. In a letter from NHS chiefs, including chief medical officer Chris Whitty, GPs were told: “Flu vaccination is one of the most effective interventions we have to reduce pressure on the health and social care system this winter. We are currently seeing the impact of COVID-19 on the NHS and social care, and this coming winter we may be faced with co-circulation of COVID-19 and flu. “Those most at risk from flu are also most vulnerable to COVID-19. We must do all we can to help protect them this winter.” Read full story Source: The Independent, 20 May 2020
  19. Content Article
    The 'My Mesothelioma Care Passport' is a pack designed to help patients keep up-to-date with the planned care that they have discussed and agreed with healthcare professionals.
  20. Content Article
    Based on the Health & Safety Executive Guidance (HSE (2013) INDG451 ‘Heat Stress in the workplace’), Dr Susan Whalley-Lloyd has produced a document and flowchart addressing what happens to us when we experience extreme heat. This can be the result of extreme outside air temperature due to the weather or heat build-up in a work area due to equipment generating heat, or restricted workspace, or large areas of glass within a building, or air conditioning problems or windows that won’t open, or a combination of conditions eg high energy tasks whilst wearing PPE and few rest breaks for fluid intake.
  21. Content Article
    No one can say with certainty what the consequences of this pandemic will be in 6 months, let alone 6 years or 60. Some “new normal” may emerge, in which novel systems and assumptions will replace many others long taken for granted. But at this early stage, it is more honest to frame the new, post–COVID-19 normal not as predictions, but as a series of choices. In this article in JAMA, Donald Berwick proposes six properties of care for durable change: tempo, standards, working conditions, proximity, preparedness, and equity.
  22. Content Article
    CORESS Programme Director Frank Smith's talk at the Royal College of Surgeons of Edinburgh.
  23. News Article
    The NHS must ensure cancer-surgery delays do not cost more lives than the number of COVID-19 patients saved, the Institute of Cancer Research says. In some cancers, a three-month delay could make the difference between a tumour being curable or not, Prof Clare Turnbull said. And her modelling suggested delaying surgery risked thousands of additional deaths. NHS England is already urging people to seek help for worrying symptoms, but by the end of April, cancer referrals had dropped by an estimated 70%. Cancer doctors have told BBC News of having to make difficult decisions to postpone some patients' care during the coronavirus crisis. As normal service resumed, the NHS should prioritise "certain cancer types in particular", Prof Turnbull said. Lung and colorectal cancers, for example, were particularly fast moving. But for others, such as prostate and certain breast cancers, treatment could more safely be delayed. Read full story Source: BBC News, 20 May 2020
  24. News Article
    The coroner investigating the botched birth of a baby boy who died from hypoxia has strongly criticised the Healthcare Service Investigation Branch (HSIB) over its report on his death. Karen Henderson, who conducted the inquest into the death of baby Theo Young in May 2018 at East Surrey Hospital said that the HSIB had asked Surrey and Sussex Healthcare NHS Trust not to undertake its own investigation, “effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.” Read full story (paywalled) Source: BMJ, 19 May 2020
  25. News Article
    European countries should brace themselves for a deadly second wave of coronavirus infections because the pandemic is not over, the World Health Organization’s top official in Europe has said. In an exclusive interview with The Telegraph, Dr Hans Kluge, director for the WHO European region, delivered a stark warning to countries beginning to ease their lockdown restrictions, saying that now is the "time for preparation, not celebration". Dr Kluge stressed that, as the number of cases of COVID-19 in countries such as the UK, France and Italy was beginning to fall, it did not mean the pandemic was coming to an end. The epicentre of the European outbreak is now in the east, with the number of cases rising in Russia, Ukraine, Belarus and Kazakhstan, he warned. Read full story (paywalled) Source: The Telegraph, 20 May 2020
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