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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Clinical Risk Management and Patient Safety Centre (GRC) is a clinical governance structure instituted in 2003 by the Italian Tuscan regional council. GRC builds on the expertise and vision of the former Ergonomics and Human Factors Research Centre in Healthcare (CRE), founded in 2000 as a joint endeavor of the Florence Heathcare Trust, the University of Florence and Siena. The GRC now enrolls professionals of different disciplines (public health, clinical risk management, industrial design, human factors, organisation studies, communication science, law, psicology, international relations). It promotes the safety culture through the active and cross disciplinary learning from adverse events and errors. The GRC aims to construct a shared vision for safety through the sharing of experiences and the development of collaborative projects for patient safety.
  2. Content Article
    A blog in the Guardian from an anonymous care worker about the unfair treatment of care home workers, the lack of personal protective equipment available, the fear of speaking up, and the stress and anxiety the pandemic is causing.
  3. Content Article
    In September 2016, WHO Patient Safety and Quality Improvement unit organised the first Global Consultation 'Setting Priorities for Global Patient Safety' in collaboration with the Centre for Clinical Risk Management and Patient Safety, Florence, Italy, a newly designated WHO Collaborating Centre in Human Factors and Communication for the Delivery of Safe and Quality care. The aim of the consultation was to cultivate a global expert think tank to deliberate and identify key challenges, new directions and hot topics in an effort to prioritise future actions for global patient safety over the next 5-10 years. 
  4. Content Article
    New Brunswick is the first province in Canada to begin relaxing the restrictions it put in place to control the spread of the novel coronavirus. On 24 April, Premier Blaine Higgs was joined by other political parties in announcing the immediate reduction of safety restrictions. It was an act of cross-party support in response to the COVID-19 pandemic which has seen Higgs invite the fellow party leaders to form an all-party cabinet committee. The decision to relax the restrictions came as New Brunswick experienced a sixth straight day of no new cases. Read their four-step plan.
  5. Content Article
    Going through critical illness and recovery is difficult for both patients and their relatives and will be unlike anything we've experienced before. Not knowing what's normal and what might lie ahead in the journey makes coping with things that much harder, which is why honest, accurate, patient-centered information is fundamental to the work of ICUsteps. Only people who've been through it really know what matters to patients and relatives in the position we were in. This understanding is what drives ICUSteps to produce a range of information resources that can help patients and relatives make sense of what has happened and cope with the road ahead.
  6. Content Article
    Simon Whitely in this video responds to some of the comments received on his last video, where he talk about a high-level HCS Model of the Healthcare System and how interactions with the general public are key for patient safety. He also talks about the challenges between managing safety and the potential impacts upon the overall economy.
  7. Content Article
    Kerala is a state in India. The Government of Kerala set up an Expert Committee on Strategy to look at easing lockdown restrictions and has produced the attached report.
  8. Content Article
    This report represents the collective work of the National Patient Safety Consortium to identify, for the first time, a list of 15 never events for hospital care in Canada. Never events are patient safety incidents that result in serious patient harm or death and that are preventable using organisational checks and balances. Never events are not intended to reflect judgment, blame or provide a guarantee; rather, they represent a call-to-action to prevent their occurrence. But a list of never events won’t solve anything on its own. For it to have meaning, we need to take deliberate steps to identify when they occur, and harness the knowledge in hospitals across the country to prevent never events from happening. The Canadian Patient Safety Institute (CPSI) encourages a culture of continuous quality improvement — where mistakes are openly reported, disclosure occurs routinely and open discussion and problem solving are encouraged — with patients and families as full and active participants.  
  9. Content Article
    For patients who require multiple medications or who are transitioning between treatments, safety can become a concern. You or your loved one may be at risk of fragmented care, adverse drug reactions, and medication errors. To be an active partner in your health, you need the right information to use your medications safely. The Canadian Patient Safety Institute (CPSI) has teamed up with the Institute for Safe Medication Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create a list of top questions to help patients and their caregivers have a conversation about medications with their healthcare provider.
  10. News Article
    Revised legislation allowing pharmacists to supply some controlled drugs without prescription must be enacted “without delay” to protect patients and to support clinicians, experts have said. Last week (28 April) the UK home secretary, Priti Patel, laid legislation before parliament that allows for a relaxation of the regulations for prescribing controlled drugs, to ensure access is not delayed during the COVID-19 pandemic. The relaxation would allow pharmacists, in a pandemic situation, to supply some drugs that were previously only supplied to a patient by doctors on prescription. It would also allow pharmacists, in cases of shortages, to alter dosages or substitute drugs without having to go back to the prescribing doctor to seek a new prescription. But the changes can be triggered only with the express permission of the home secretary, who has so far not given this despite the legislation being tabled to be used in situations of crisis. Ian Hamilton, an academic at the University of York with an interest in addiction and mental health, who coordinated the letter, told The BMJ that although it was positive that the home secretary laid the legislation before parliament, it needed to be activated now. He said, “Each day there’s a delay our concern is that the potential for suffering just goes on.” “The problem with this is that if somebody is in a lot of pain and they’re really severely short of breath, that in itself is problematic because it can trigger a cardiac arrest. A worst case scenario is that someone could actually die because of a two or three hour delay in getting morphine. So this is something that I think is essential for healthcare workers to have.” Read full story Source: The BMJ, 7 March 2020
  11. Content Article
    Charts comparing COVID-19 deaths across countries are appearing daily in our newsfeeds. Done well, these international comparisons can help us to understand how different national strategies and policies have affected the spread and severity of COVID-19 outbreaks. But sometimes what is presented in these neat charts is not quite as straightforward as it seems, and can draw misleading conclusions. Excess deaths is a better measure than COVID-19 deaths of the pandemic’s total mortality. It measures the additional deaths in a given time period compared to the number usually expected, and does not depend on how COVID-19 deaths are recorded. This report, written by Holly Krelle, Claudia Barclay and Charles Tallack, summarises some of the ways of comparing countries to help use make sense of data on deaths.
  12. News Article
    Intensive care units (ICU) will be advised how to improve their staffing-to-patient ratios shortly as the number of patients admitted to hospital with COVID-19 falls across the country. In expectation that the pandemic would put intense pressures on ICUs, staff ratios were relaxed. NHS England told trusts to base their staffing models on one critical care nurse for every six ICU patients, supported by two non-specialist nurses, and one senior ICU clinician for every 30 patients, supported by two middle-grade doctors. Before the pandemic, guidance from the Faculty of Intensive Care Medicine recommended a ratio of one non-specialist nurse per patient. For senior clinicians the ratio was 1:10 New guidance, expected as early as next week, will encourage trusts to reduce the number of patients per ICU specialist nurses and senior clinicians on a localised basis as part of “transitional arrangements” aimed at moving staffing models back towards normal standards of care, HSJ has been told. The new guidance, drawn up by NHS England, the Faculty of Intensive Care Medicine and the British Association of Critical Care Nurses, will give trusts recommended staffing ratios based on the occupancy rates of their ICUs. It will tell trusts the existing ratios should be applied if their ICUs are running at four times their normal capacity. For ICUs running at double capacity, this ratio would be reduced to 1:2 for ICU nurses, and 1:15 for senior clinicians. Read full story Source: HSJ, 8 May 2020
  13. Content Article
    "Some weeks ago my main worries were around my GCSEs. Now I hear every day about deaths from COVID-19." Teenager Zoya Aziz's parents are both doctors. In this blog in the Guardian, she gives a frank account of her life at the moment and her fears.
  14. News Article
    Deaths in mental health hospitals have doubled compared to last year after 54 deaths linked to coronavirus in just three months, it has emerged. The care watchdog, the Care Quality Commission (CQC), has issued a warning to mental health hospitals that they must take action to protect vulnerable patients. New data published by the regulator showed there was a total of 106 deaths of people in mental health hospitals between 1 March and 1 May compared to 51 in the same period in 2019. In total 54 of these deaths are from confirmed or suspected coronavirus infections. The CQC has now written to all mental health hospital providers highlighting its fears over the spread of the virus within secure hospitals and units. Read full story Source: The Independent, 8 May 2020
  15. Content Article
    The COVID-19 pandemic has affected some sections of the population more than others, and there are growing concerns that the UK’s minority ethnic groups are being disproportionately affected. Following evidence that minority groups are over-represented in hospitalisations and deaths from the virus, Public Health England has launched an inquiry into the issue. In the short term, ethnic inequalities are likely to manifest from the COVID-19 crisis in two main ways: through exposure to infection and health risks, including mortality; through exposure to loss of income. This report brings together evidence on the unequal health and economic impacts of COVID-19 on people in minority ethnic groups in the UK, presenting information on risk factors for each of the largest minority ethnic groups in England and Wales: white other, Indian, Pakistani, Bangladeshi, black African and black Caribbean. The analysis focuses on a limited but crucial set of risk factors in terms of both infection risk and economic vulnerability in the short term.
  16. Event
    Join International Society for Quality in Healthcare (ISQua) on 11 May 2020 at 03:30 UTC+1 to hear from Patient Safety Learning's Helen Hughes, Patient Advocate Kathy Kovacs Burns, Rob Galloway ED Consultant at the NHS and Rachael Grimaldi the creator of Cardmedic. This webinar will focus on finding solutions to the difficulties that arise in communication between healthcare staff and patients, particularly during events like COVID-19 where the use of face masks and shields create a barrier in communication. We will also hear from the perspective of the patient - what are the unintended consequences of failures in communication? We will hear from Patient Safety Learning's Helen Hughes, Patient Advocate Kathy Kovacs Burns, Rob Galloway ED Consultant at the NHS and Rachael Grimaldi the creator of Cardmedic, an innovative tool to aid in the communication between patients and their carers during the pandemic. Further information and registration
  17. Content Article
    The Medical Device Safety Officer role was created on 20 March 2014 following the publication of an NHS England Patient Safety Alert that aimed to help healthcare providers increase the quality and frequency of incident reporting for medication errors and medical devices problems. The alert called on large healthcare provider organisations across both public and independent  sectors, along with healthcare commissioners, to identify named responsible persons in both medication and medical device safety roles. A new National Network was set up to support Medical Device Safety Officers through improved communication and feedback on reported safety issues, monthly webinars, online forums, conferences and workshops. An editorial board was established to provide expert and strategic clinical support for the Medical Device Safety Officers and the National Network. This handbook provides practical information and resources to support those who have been designated the Medical Device Safety Officer in their organisation. It is particularly relevant to people new in post or as a quick reference for established staff.
  18. Content Article
    Around £240m of taxpayers’ money has been spent on government inquiries since 2005, but evidence that recommendations from these high profile investigations have been adopted is lacking, the UK public spending watchdog has concluded. The report by the National Audit Office into government funded inquiries, including those on NHS matters, describes uncertainty and variation in the relative costs of inquiries, the effects they had, and how they were carried out.1 In all, the watchdog found that the government spent at least £239m on the 26 inquiries that have concluded since 2005 and that they lasted on average 40 months
  19. Event
    More than 2,000 people with autism or a learning disability are currently living in care settings that do not meet their needs. This free online event from The King's Fund will look at the challenges of moving these individuals into homes in the community and how to overcome them. It will look at the lessons learned from examples where the NHS, local government, the housing sector and care providers have worked together and the challenges they faced. Registration
  20. News Article
    Deaths of those with learning disabilities and autism fromCOVID-19 are to be analysed by Public Health England (PHE), HSJ can reveal. Several senior sources have confirmed PHE has put together a group, which includes independent experts, to analyse mortality data. They had previously not been included in the government’s inquiry into the over-representation of some groups among covid fatalities. The news comes amid mounting concerns from major charities over the of lack transparency in data collected centrally on the deaths of people from these these groups during the pandemic. In a letter yesterday , seen by HSJ, Labour’s shadow secretary for social care Liz Kendall, urged Department of Health and Social Care minister Helen Whately to publish data on deaths reported to the Learning Disabilities Mortality Review Programme (LeDer). Earlier this week NHS England and NHS Improvement told HSJ the weekly data it is receiving from the national learning disability morality review programme (LeDer) on suspected and confirmed deaths of those with learning disabilities and autism from COVID-19 would not be published until next year. In her letter Ms Liz Kendall said the Government should “immediately” release the deaths notifications being provided by LeDer along with a “retrospective” analysis from the beginning of the pandemic. Read full story Source: HSJ, 7 May 2020
  21. News Article
    The Office for National Statistics (ONS) has published its first figures analysis Covid-19 related deaths by ethnic group in England and Wales between March 2 and April 10. The results showed that the risk of death involving the coronavirus among Black, Asian, and minority ethnic (BAME) groups is “significantly higher” than that of those of white ethnicity. Researchers found that when taking age into account, in comparison to white men and women, black men are 4.2 times more likely to die from a Covid-19-related death and black women are 4.3 times more likely. People with Bangladeshi, Pakistani, Indian and mixed ethnicities have a raised risk of death, too. Read full story (paywalled) Source: The Telegraph, 7 May 2020
  22. News Article
    The shipment of 400,000 gowns from Turkey which was part of a delayed consignment of personal protective equipment (PPE) has been impounded in a warehouse after falling short of UK standards. The personal protective equipment (PPE) was flown into the UK by the RAF last month, arriving three days late, but has been held in a government warehouse near Heathrow since, the Daily Telegraph said. During mid-April, when coronavirus deaths in the UK were at their highest, the NHS required 150,000 gowns each day. Cabinet minister Brandon Lewis said the gowns were “not be of the quality that we feel is good enough for our frontline staff”. Speaking on Sky News, Mr Lewis said: “Well when we’re securing PPE from around the world you do it based on a set of standards that you’re looking to acquire to, but obviously once it’s here we check that it is good enough for what we want to use and in this instance some of this PPE turned out not to be good enough.” “I think it is right that if we have got particular standards for what we want our frontline staff to be able to have access to we make sure we stick to that. If something isn’t right, if we’re not even sure about it then I think it is better to be safe and not use that product and stick with products we are confident are the right products and the right standards.” Read full story Source: ITV News, 7 May 2020
  23. News Article
    Trials have begun in the UK to test the effectiveness of blood plasma transfusions in treating patients suffering from COVID-19. NHS Blood and Transplant (NHSBT) have started delivering the first units of convalescent plasma, which contains the antibodies of people who have recovered from coronavirus, to hospitals in England. In total, 14 units have been supplied to Guy’s and St Thomas’ NHS Foundation Trust, Imperial College Healthcare NHS Trust and University Hospitals Birmingham NHS Foundation Trust. The first transfusions have been administered, NHSBT confirmed on Wednesday, though the efficacy of the treatment will not be known until the trial ends. Seven hospitals are currently taking part in the trials, which will assess a patient’s speed of recovery and chances of survival, with more expected to join in the coming months as the number of people eligible to donate blood plasma increases. As of Tuesday, more than 6,500 people had signed up while around 400 donations had been made. Gail Miflin, Chief Medical Officer for NHS Blood and Transplant, said: “We’re delighted the first patients are receiving convalescent plasma transfusions thanks to the generosity of our donors." Read full story Source: The Independent, 7 May 2020
  24. News Article
    Concerns for the wellbeing of babies born in lockdown are being raised, as parents struggle to access regular support services. England's children's commissioner is highlighting pressures facing mothers caring for babies without the usual family and state support networks. Playgroups are closed and health visitor "visits" are being carried out remotely in most cases. The NHS said adaptations had been made to keep new mothers and babies safe. The briefing paper from Anne Longfield's office says an estimated 76,000 babies will have been born in England under lockdown so far. But births are not being registered, because of temporary rules tied to the virus pandemic, so even basic information about new babies is not being gathered. At the same time, support services provided by health visitors and GPs are not readily accessible, with many taking place via phone and video calls or not at all. There are concerns many babies may have missed their developmental health checks, due in the first few weeks of life to pick up urgent developmental needs. "In some areas, the six-week GP baby check hasn't been available or parents haven't wanted to attend it due to a potential risk of infection," she said. Read full story Source: BBC News, 7 May 2020
  25. News Article
    More than three quarters of GPs fear delays to care because of COVID-19 will harm patients, with one in three reporting that urgent referrals have been rejected during the pandemic, a GPonline poll shows. The poll of 415 GPs found that 77% were concerned that delays to operations and treatments for non-COVID-19 issues would result in patients coming to harm. Meanwhile, 30% of GPs said they have had an urgent referral rejected during the pandemic. Rejected referrals included two-week-wait referrals for suspected cancer as well as urgent referrals for investigations such as ECGs, echocardiograms and CT scans. GPs also highlighted concerns over delays to treatment for cancer, with respondents warning that breast cancer surgeries had been postponed or chemotherapy delayed. Read full story Source: GP Online, 5 May 2020
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