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Patient Safety Learning

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  1. News Article
    More than 460 people with a learning disability have died from coronavirus in just eight weeks since the start of the outbreak in England. New data shows between the 16 March and 10 May 1,029 people with a learning disability died in England, with 45 per cent, 467, linked to coronavirus.Overall the number of deaths during the eight weeks is 550 more than would be expected when compared to the same period last year. The charity Mencap warned people with a learning disability were “being forgotten in this crisis” and called for action to tackle what it said could be “potentially discriminatory practice.” It highlighted the percentage of Covid-19 related deaths among learning disabled people was higher than those in care homes, where the proportion of Covid-19 deaths was 31 per cent for the same period. The data has been published after an outcry over the lack of transparency about the impact of Covid-19 on mental health patients and people with a learning disability or autism. Read full story Source: The Independent, 19 May 2020
  2. Content Article
    The first two steps in making any process more reliable are to standardize or simplify the process thus turning a desired action into a default action. Standardisation reduces reliance on short-term memory and allows those unfamiliar with new location to follow an already experienced standard process or design thus leading to safe and efficient work practices. This study from Price and Lu reports on research into healthcare facility design and identifies the drivers, barriers, priorities and potential areas that can inform the design process and the adoption of standardisation aimed at significantly improving patient care and safety as well as enhancing staff productivity. Interviews were held with architects, project managers, healthcare planners and contractors to elicit their views. An interview protocol was developed based on initial literature findings. This paper highlights the need to think more deeply about why space standardisation is needed and which benefits need to be captured from space standardisation. Meanwhile, hospitals and Trusts provide very different situations and contexts, such as the model of care, the patient s journey, medical technologies and demographics. Innovative solutions to the space standardization must be in response to the context being considered, but there are some generic principles and concepts that apply to most situations.
  3. Content Article
    An increasing number of studies show that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety and reliability may be compromised. This article from Rozich et al. discusses how standardisation may help to increase uniformity of practice, increase safety, and possibly reduce costs. Also described is an effort made by Luther Midlefort, Mayo Health System, to reduce variation by creating a system-wide protocol for insulin use. After six weeks, Luther Midelfort achieved a great reduction in the number of hypoglycaemic events as a result of standardised practices.
  4. Content Article
    Despite its success in other industries, process standardisation in healthcare has been slow to gain traction or to demonstrate a positive impact on the safety of care. The High 5s project is a global patient safety initiative of the World Health Organization (WHO) to facilitate the development, implementation and evaluation of Standard Operating Protocols (SOPs) within a global learning community to achieve measurable, significant and sustainable reductions in challenging patient safety problems. The project seeks to answer two questions: (i) Is it feasible to implement standardized health care processes in individual hospitals, among multiple hospitals within individual countries and across country boundaries? (ii) If so, what is the impact of standardization on the safety problems that the project is targeting? Three SOPs—correct surgery, medication reconciliation, concentrated injectable medicines—have been developed and are being implemented and evaluated in multiple hospitals in seven participating countries. Nearly 5 years into the implementation, it is clear that this is just the beginning of what can be seen as an exercise in behaviour management, asking whether healthcare workers can adapt their behaviours and environments to standardise care processes in widely varying hospital settings.
  5. Event
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    Patient Safety 2020 is a world class online event where renowned international speakers, specialists will take concurrent sessions of patient safety and healthcare. The webinar has been carefully designed so as to acknowledge the various recent researches going on in the field of patient safety and healthcare. This webinar will deal with various tracks from the different fields of patient safety and healthcare and provides you with a unique opportunity to meet up with peers from both industry and academia. A vast array of topics will be discusses in the webinar which includes patient safety, healthcare, occupational health & safety, nursing education, clinical Trials, nursing care & practice, errors in patient safety and public health. Further information and registration
  6. Event
    This seminar will introduce recent research on the professional duty of candour and reflect on the relationship between candour and patient safety. In particular, it will focus on factors which can encourage or discourage candour in the workplace and how these are reflected in the surgical setting. Registration
  7. Event
    Surgeons are affected by adverse events. There is a paucity of data on the impact of adverse events on UK surgeons, on the factors that affect the degree and nature of this impact, and on the interventions that might ameliorate this impact either before or after an adverse event. This presentation will include early results of a UK survey and details of an RCT to evaluate the effectiveness of resilience training for surgical trainees. Registrations
  8. Event
    Patient safety is not a single absolute. This ICONS webinar will explore how safety can be regarded as a patient centred, relative concept whose understanding is essential for robust informed consent processes. It will also focus on how surgeons share decisions with patients, and how patients in turn share their decision with others outwith the clinic. Registration
  9. Content Article
    The World Health Organization Global Patient Safety Challenge, Medication Without Harm, aims to reduce serious, avoidable medication-related harm by 50% in 5 years, globally. Three areas have been identified for early priority action. This technical report addresses Medication Safety in Transitions of Care; why it is a priority, what has been done to address it to date and what needs to be done. 
  10. Content Article
    Mental Health UK has provided information and tips for managing your mental health during the coronavirus pandemic. Whether you're social distancing or self-isolating you may be feeling anxious or stressed during this time, and that's completely normal. There are simple steps you can take to look after your mental health and wellbeing. 
  11. Content Article
    From the early stages of the COVID-19 pandemic in the UK, Patient Safety Learning has been working with others in healthcare – from patients and staff to healthcare leaders and politicians – to identify the impact the pandemic is having on non COVID-19 treatment and care, and on patient safety. Recently, Patient Safety Learning hosted a webinar, in partnership with HealthPlusCare, titled ‘Patient safety: Time for questions? Non Covid-19 care and treatment’. The webinar took place on Wednesday 6 May, with a panel consisting of: Professor Maureen Baker CBE, Chair of the Professional Records Standards Body and past Chair of the Royal College of GPs Professor Mike Bewick, Chair of CECOPS and past Deputy Medical Director to Sir Bruce Keogh at NHS England Dr Jane Carthey, Human Factors and Patient Safety Specialist Mike Fairbourn, Chair of ABHI Patient Safety Working Group and BD Country General Manager Dean Russell MP, MP for Watford and member of the Health and Social Care Select Committee Claire Cox, Patient Safety Learning’s Associate Director of Patient Safety and Critical Care Outreach Nurse Helen Hughes, Patient Safety Learning’s Chief Executive We are delighted with the success of the webinar, with 542 participants. Those who attended represented stakeholders from across the health and care system, and were well-engaged, making good use of the chat, Q&A and polls.
  12. Content Article
    On 4 May 2020, a 13-strong committee convened by former UK government Chief Scientific Adviser Sir David King discussed some aspects of the science behind the UK strategy in a two and a half hour meeting. Leading experts in public health, epidemiology, primary care, virology, mathematical modelling, and social and health policy, raised ideas and issues for consideration which are shared in this report. The report does not aim to critique such work. Rather, it recognises that such solutions will take time and will still require an appropriate public health infrastructure to maximise their benefit. This is the focus of this first report and the meeting aimed to offer some constructive ideas to the governments of the UK and the devolved nations about how best to tackle this crisis, to save lives, suppress the coronavirus and get the economy moving again.
  13. Content Article
    Module 13 of the Canadian Patient Safety Institute (CPSI) patient safety education programme.
  14. News Article
    People carrying Emerade 500 microgram adrenaline auto-injector pens should return them and get hold of a prescription for a different brand. A fault has been detected in the pens, meaning the dose of adrenaline may not be delivered when needed for people with severe allergies. The official advice comes from the Medicines and Healthcare products Regulatory Agency (MHRA). Alternative brands - EpiPen and Jext - are available up to 300 micrograms. "Action has been taken to protect patients, following detection of a fault in one component of the Emerade adrenaline auto-injector pens," an MHRA spokesperson said. "Patients should return all Emerade 500 microgram pens to their local pharmacy once they have a new prescription and have been supplied with pens of an alternative brand." If an Emerade pen does need to be used before a patient can get hold an alternative pen, the advice is that it should be pressed very firmly against the thigh. If this does not work, the patient should immediately use their second pen. Read full story Source: BBC News, 19 May 2020
  15. Content Article
    The charity Rethink Mental Illness have set up an online hub to provide practical support and information that is useful for people living with, or supporting people with mental illness during the coronavirus pandemic.
  16. Content Article
    Pharmaswiss Česka republika s.r.o. (an affiliate of Bausch & Lomb UK Limited) is recalling all unexpired batches of Emerade 500 microgram auto-injectors (also referred to as pens) from patients due to an error in one component of the auto-injector believed to cause some pens to fail to activate and deliver adrenaline.
  17. News Article
    Delirium and confusion may be common among some seriously-ill hospital patients with COVID-19, a study in The Lancet suggests. Long stays in intensive care and being ventilated are thought to increase the risk, the researchers say. Doctors should look out for depression, anxiety and post-traumatic stress disorder (PTSD) after recovery, although most patients, particularly those with mild symptoms, will not be affected by mental health problems. The evidence is based on studies of patients with severe acute respiratory syndrome (Sars) and Middle-East respiratory syndrome (Mers), as well early data on COVID-19 patients. Read full story Source: BBC News, 19 May 2020
  18. News Article
    Suspected cancer patients are being refused hospital appointments despite being referred by GPs, it has emerged. Family doctors working for one NHS trust in north east London claimed that hundreds of referrals had been rejected in recent weeks. Many were for ultrasounds and chest X-rays and were sent via the two-week wait system, in which suspected cancer patients referred by GPs are seen within a fortnight. A rejection letter sent from Whipps Cross hospital seen by Pulse magazine, said the referral had been “due to the Covid-19 pandemic”. It added: “Following triage by a consultant radiologist, your imaging request has been assessed as non-urgent and cancelled.” Read full story Source: The Telegraph (18 May 202)
  19. News Article
    Global efforts to vaccinate children against fatal diseases such as measles and polio could be set back a decade due to the disruption caused by the coronavirus pandemic, Unicef has warned. Immunisation campaigns and routine vaccine services have been suspended across the world to limit the transmission of COVID-19, leaving countries with weak health systems susceptible to a resurgence in preventable illnesses once lockdown restrictions are lifted and societies reopen. More than 25 vulnerable countries have placed their immunisation programmes for measles on hold, while the delivery of Ebola vaccinations across central Africa, in countries such as the Democratic Republic of the Congo (DRC) and Central African Republic (CAR), has similarly been suspended or curtailed. “Our immediate concern is with disruption to currently available vaccines,” Dr Robin Nandy, global chief of immunisation at Unicef, told The Independent. “We expect to go back maybe five to 10 years. The longer the disruptions continue, the more concerned we are as it builds the number of susceptible kids in populations. “What we’re trying to avoid is countries recovering from the current Covid pandemic then being hit by another outbreak of a vaccine-preventable disease.” Read full story Source: The Independent, 18 May 2020
  20. Content Article
    If a nasogastric tube (NGT) has been misplaced into the respiratory tract and this is not detected before fluids, feed or medication are given, death or severe harm can be caused. The consequences are even more likely to be fatal for patients who are already critically ill. Most nasogastric ‘Never Events’ of feeding into the respiratory tract through a misplaced tube continue to arise from misinterpretation of x-rays by staff who had not been given training in the ‘four criteria’ technique and were unaware that relying on the position of the tube tip alone on a radiograph can be a fatal error. BAPEN has produced this easy reference guide.
  21. News Article
    Tens of thousands of cases of COCID-19 may have been missed because of delays in warning the public that loss of taste and smell is a key symptom that should lead to self-isolation or testing, experts say. The four chief medical officers of the UK have finally made official what many scientists had been saying for weeks: that anosmia, or loss of smell, should be added to the other two main warning symptoms, a continuous cough and high temperature. Those who experience any of the three symptoms should isolate for seven days and their families for 14 days. Prof Tim Spector from King’s College London and his team said data from 1.5 million people who downloaded their symptom-reporting app suggested 50,000 to 70,000 people in the UK had been missed. As early as 1 April, they warned that people with anosmia should self-isolate. They were joined by ear, nose and throat surgeons, who said loss of taste and smell could be one of the few markers for people who were otherwise asymptomatic and potentially able to infect other people without realising they were a risk. Their professional body, ENT-UK, said they had been calling for eight weeks for anosmia to be listed as a marker for asymptomatic carriers. It issued a joint statement with the British Rhinology Society (BRS) on 20 March, it said. “We estimate that many hundreds of thousands of patients in the UK have developed anosmia as a result of COVID-19,” said Prof Claire Hopkins, the BRS president. Read full story Source: Guardian, 18 May 2020
  22. Content Article
    Anxiety UK have produced a number of videos to help you cope with anxiety.
  23. Content Article
    Having good mental health helps us relax more, achieve more and enjoy our lives more. The Every Mind Matters website has expert advice and practical tips to help you look after your mental health and wellbeing.
  24. Content Article
    The British public have been offered alternating periods of lockdown and relaxation of restrictions as part of the COVID-19 lockdown exit strategy. Extended periods of lockdown will increase economic and social damage, and each relaxation will almost certainly trigger a further epidemic wave of deaths. These cycles will kill tens of thousands, perhaps hundreds of thousands, of people before a vaccine becomes available, with the most disadvantaged groups experiencing the greatest suffering. There is an alternative strategy: universal repeated testing. The authors of this article published in The Lancet recommend evaluation of weekly severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigen testing of the whole population in an entire city as a demonstration site (preferably several towns and cities, if possible), with strict household quarantine after a positive test. Quarantine would end when all residents of the household test negative at the same time; everyone else in the city can resume normal life, if they choose to.
  25. Event
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    Staffordshire University's postgraduate virtual open event is the perfect opportunity to find out everything you need to know about studying with us, what it’s like to be a postgraduate student and to discover how we put your learning at the heart of everything we do. You’ll have the chance to: Chat online to our brilliant and friendly academics to discuss the course you’re interested in. Get one-to-one advice and guidance from our expert student support, finance, careers and personal development teams. Chat online to some of our current postgraduate students to discover more about student life and why Staffordshire University is the place to be for postgraduate study. Find out more about the application process for postgraduate courses. Learn more about our on-campus facilities including our library, nursery and careers studio. Explore our state-of-the-art facilities with our virtual tours. Further information
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