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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    As a medical examiner at St George's Hospital, in south London, Dr Nigel Kennea's job is to advise clinical teams on completing death certificates, then support relatives through their grief. But like so much during this pandemic, none of that is straightforward. "The most harrowing thing is knowing that many said goodbye to their loved ones in an ambulance," he says. Despite staff "going above and beyond" to support patients in desperate times, using mobile phones and iPads to connect seriously ill patients and their families, contact is just not always possible. Even after a patient's death, social distancing has meant grieving relatives are left in limbo. "Normally, registering a death is done face-to-face with relatives," Dr Kennea says. "They come in, talk through the admin and how to plan for after death. Now, it's all done on the phone." Dr Kennea's job is to take an overview of all deaths at the hospital. It's a relatively new role in the UK, introduced last year, which is independent of trusts. Dr Kennea discusses each death at the hospital with the doctors and nurses involved in that patient's care, making sure death certificates are completed correctly and consistently. But with COVID-19 deaths so closely scrutinised, there is added pressure and "some are complicated", he says. There are also challenges with communicating with patients. When Dr Kennea goes into COVID-19 areas, he has to wear full PPE which has its limits when communicating with patients. "It's hard to share a smile behind a mask and goggles," he says. Read full story Source: 1 May 2020
  2. News Article
    The health service will face a “tsunami” of coronavirus survivors discharged from hospitals needing long-term physical and mental support that the NHS will struggle to provide, The Independent has been told. Coronavirus can leave patients with lasting physical damage and scarring to their lungs, meaning many could struggle to breathe and move around as well as they did before – in some cases permanently. Patients admitted to intensive care can also suffer physical effects of being paralysed weeks and almost half who are ventilated with a tube in their windpipe will experience a form of delirium that can include terrifying hallucinations and leave survivors with lasting mental problems including post-traumatic stress. Experts have warned a long-term lack of funding of NHS rehabilitation services and post-discharge care for ITU patients means the health service will struggle to help the thousands of patients who beat the virus but face a long road to recovery. Read full story Source: 3 May 2020
  3. News Article
    Healthcare workers providing support outside of the NHS are finding it harder to access coronavirus tests than their colleagues inside the service, a survey of nurses has suggested. A poll of 22,000 health and care workers conducted by the Royal College of Nursing found 44% of respondents did not know how to access testing – while 76% said they had not been offered a test. The problem was also particularly pronounced among the temporary workers, with four in five not offered testing compared to three-quarters of full time workers. Meanwhile the survey found 79% of those working outside of the NHS had not been offered a test, compared with 75% in the health service. Dame Donna Kinnair, chief executive and general secretary of the RCN, said: “It is concerning to see that some nursing staff, particularly those outside the NHS, are still having issues accessing COVID-19 testing. Read full story Source: The Independent, 4 May 2020
  4. Content Article
    Roger Kline, Research Fellow at Middlesex University, highlights the three principles NHS organisations should take forward immediately to avoid unecessary staff deaths.
  5. Content Article
    With the ongoing Covid-19 crisis changing the way we live our lives and having a huge impact on the NHS, David Oliver speaks to the Nuffield Trust about what motivates him as a clinician at such a time, what the health service and the wider country need to learn from the past few months, and how pleased he is to be doing the job that he trained for.
  6. Content Article
    Benning et al. conducted an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and identified the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Four hospitals (one in each country in the UK) participated in the first phase of the SPI (SPI1). The SPI1 was a multi-component organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. The authors found that the introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.
  7. Content Article
    An analysis from Dr Rodney P. Jones, Lecturer in Healthcare Management.
  8. Content Article
    This month sees the call from the Nursing Midwifery Council in the UK to ex nurses and students to join the emergency register in response to COVID-19. In this Episode of the 'This Is Nursing' podcast series, Gavin Portier reflects on his return to critical care and what he learnt about going from a corporate nursing role back into the direct care setting.r
  9. News Article
    The Chief Scientific Adviser reportedly warned the government in January that the care homes sector in the UK was particularly vulnerable to COVID-19 – and that has unfortunately proved to be the case. With care home deaths now being reported daily, what do the numbers tell us about this group? Have care home residents been disproportionately affected? And is there a chance the crisis could belatedly mark the start of better times for a sector in danger of collapse? Read full story Source: Nuffield Trust, 1 May 2020
  10. Event
    until
    Dr Clare Gerada, GP and Medical Director of the NHS Practitioner Health Programme will discuss how the current pandemic is likely to impact doctors and other health professionals with guest interviewer Adam Kay (award-winning author and former doctor). They will discuss the emotional and psychological impact of the crisis on the mental health of doctors, how to build resilience, and the extraordinary response of the NHS to the crisis. Register
  11. Community Post
    Frontline healthcare workers in the US are sharing their creative solutions to the PPE shortage and other innovative ideas on Twitter at #MacGuyverCare
  12. Content Article
    Diagnosis involves a complex system with many team members and numerous interdependent steps, all of which can make it challenging to identify and learn from failures in the process. The Patient Safety Authority has collated guidelines, resources and educational tools on diagnostic errors.
  13. Content Article
    The theme of this Issue of Hindsight is ‘Wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about. This Issue coincides with the COVID-19 pandemic. The authors of the articles in this Issue were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
  14. Content Article
    Patient Safety Learning interviews a critical care outreach nurse from America to find out the challenges frontline teams are facing during the coronavirus pandemic.
  15. Content Article
    The purpose of this document is to provide designers and manufacturers of ventilators with overarching advice and guidance on the key themes for consideration and specific Human Factors and Ergonomic (HFE) issues in a period of “crisis management” requiring rapid design and production.
  16. News Article
    Hundreds of ventilators the UK government bought from China to relieve a major shortage are the wrong type and could kill patients, senior doctors have warned in a newly uncovered letter. The medical staff behind the letter say the devices were designed for use in ambulances rather than hospitals, had an "unreliable" oxygen supply and were of "basic" quality. Seen by Sky News' partner organisation NBC, the document also claims the ventilators cannot be cleaned properly, are an unfamiliar design and come with a confusing instruction manual. Cabinet Office minister Michael Gove triumphantly announced the arrival of "300 ventilators from China" to help treat COVID-19 patients on 4 April. But the letter of warning from doctors was issued just nine days later. "We believe that if used, significant patient harm, including death, is likely," it says. Read full story Source: Sky News, 30 April 2020
  17. News Article
    Patients with the most severe eating disorders have received the least support during the COVID-19 pandemic, a leading expert has warned. Dr Agnes Ayton, chair of the Royal College of Psychiatrists eating disorder faculty, told HSJ that although it was an achievement that services had implemented digital consultations so quickly, for the most severe and high-risk patients this would not work as well. She also warned that some specialist eating disorder units across the country have had to limit admissions and run below full capacity. Her warning comes after a leading charity for eating disorders, Beat, said it has seen a 35% increase in calls to its national helpline since the pandemic began. Read full story Source: HSJ, 1 May 2020
  18. Content Article
    When it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to improved patient outcomes for numerous healthcare conditions. Despite available evidence, practice changes are not implemented consistently and effectively to support organizations and teams to address patient safety challenges. This resource has been designed by the Canadian Patient Safety Institute to support teams across all healthcare sectors in using a Knowledge Translation and Quality Improvement integrated approach to change that will impact patient safety outcomes. This Guide for Patient Safety Improvement is intended to accompany current best available evidence change ideas, and tools and resources for your specific project. It includes ideal practice changes “the what” and strategies “the how” that creates the evidence-based intervention. Adaptations are expected and important considerations for implementation will be provided in this guide.
  19. News Article
    Experts have raised fears that high-risk pregnancies may be missed due to the coronavirus pandemic, leading to a potential rise in stillbirths and neonatal deaths. During a session of Westminster’s Health and Social Care Committee, Gill Walton, the Chief Executive of the Royal College of Midwives, said there was a “fear” among pregnant women presenting themselves to maternity services during the COVID-19 outbreak. Former health secretary Jeremy Hunt, who chairs the committee, said one of the most important elements of maternity safety was to identify higher-risk pregnancies early “so that interventions can be made to prevent stillbirths, complications, or even the death of a baby”. Mr Hunt added the President of the Royal College of Obstetricians, Dr Edward Morris, had told him he is “worried that some higher-risk pregnancies may be being missed” because of fewer face-to-face appointments and missed scans. Asked whether she shared that concern, Ms Walton told MPs: “I do share that concern. Some of that is related to the fear of the pregnant population and presenting to maternity services during the pandemic." "That fear then prevents them sometimes just picking up the phone to call their midwife to say that may be concerned about not feeling well, or that they’ve got reduced foetal movements.” Read full story Source: The Independent, 1 May 2020
  20. News Article
    Death rates from coronavirus in the most deprived parts of England are more than double than in less deprived areas, according to new figures that show London is the worst-hit part of the country. The mortality rate for the most deprived areas for March and early April was 55.1 deaths per 100,000 population – compared with 25.3 deaths per 100,000 in the least deprived areas, according to the Office for National Statistics (ONS). The statistics show London has by far the highest mortality rate, with 85.7 deaths per 100,000 persons. This was found to be “statistically significantly higher” than any other region – almost double the next highest rate. Read full story Source: The Independent, 1 May 2020
  21. News Article
    Hospital leaders have launched a strident attack on the government’s coronavirus testing strategy, as it became clear that the target of 100,000 daily tests by 30 April would be comprehensively missed. NHS Providers, which represents foundation trusts in England, rounded on ministers for “a series of frequent tactical announcements” to expand testing criteria, and dismissed the 100,000 target as a “red herring” that distracted from their failures. Just 33,000 people were tested for COVID-19 in the latest 24-hour period – a record high for a single day – according to official figures. Dominic Raab, the first secretary of state, said that more than 52,000 tests were carried out, but this total is apparently bolstered by 19,000 retests. Test capacity was now more than 73,000 a day, he said – still considerably below the target set by the health secretary, Matt Hancock, at the start of April. Read full story Source: The Guardian, 30 April 2020
  22. Event
    Co-hosted by Patient Safety Learning and Health+Care. This free webinar will cover non COVID-19 care and treatment. The webinar will include a panel of experts around patient safety that both pose and answer questions relating to patient and staff safety. This will include everything from leadership, safety culture, access to safe care, human factors, the challenges to this and innovative solutions including products/services. The panel includes: Professor Maureen Baker CBE, Chair of the Professional Record 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 & BD Country General Manger Claire Cox – Associate Director of Patient Safety Learning and Clinical Care Outreach Sister Helen Hughes, Chief Executive, Patient Safety Learning It will cover patient and staff safety issues including: How to achieve an appropriate balance between coronavirus and ‘ordinary’ health and care demand. Meeting the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak. Meeting extra demand for mental health services as a result of the societal and economic impacts of lockdown. Meeting the needs of rapidly discharged hospital patients with a higher level of complexity. Register
  23. Content Article
    Letter to the Chief executives of all NHS trusts and foundation trusts, CCG Accountable Officers, GP practices and primary care networks, providers of community health services and NHS 111 providers from the NHS Chief Executive, Simon Stevens, and Chief Operating Officer, Amanda Pritchard, on the second phase of NHS response to COVID-19.
  24. Content Article
    COVID-19 has led to hospitals suspending cancer treatment and deterred some from seeking care. Alan Mayberry, 67, was diagnosed with oesophageal cancer in January and was due to have four treatments and then surgery to remove the cancer. Unfortunately due to the coronavirus pandemic Alan's operation in early May has been cancelled because beds in the intensive care unit are in short supply. Read Alan's story (published in The Guardian).
  25. News Article
    Inquests into coronavirus deaths among NHS workers should avoid examining systemic failures in provision of personal protective equipment (PPE), coroners have been told, in a move described by Labour as “very worrying”. The chief coroner for England and Wales, Mark Lucraft QC, has issued guidance that “an inquest would not be a satisfactory means of deciding whether adequate general policies and arrangements were in place for provision of PPE to healthcare workers”. Lucraft said that “if there were reason to suspect that some human failure contributed to the person being infected with the virus”, an inquest may be required. The coroner “may need to consider whether any failures of precautions in a particular workplace caused the deceased to contract the virus and so contributed to death”. But he added: “An inquest is not the right forum for addressing concerns about high-level government or public policy.” Labour warned the advice could limit the scope of investigations into the impact of PPE shortages on frontline staff who have died from COVID-19. “I am very worried that an impression is being given that coroners will never investigate whether a failure to provide PPE led to the death of a key worker,” said Lord Falconer, the shadow attorney general. “This guidance may have an unduly restricting effect on the width of inquests arising out of Covid-19-related deaths.” Read full story Source: The Guardian, 29 April 2020
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