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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    There are 15 Academic Health Science Networks, or AHSNs, across England. Together they form the AHSN Network. Find out how they are transforming lives through healthcare innovation in this short animation.
  2. Community Post
    Useful visual from an intensive care doctor on ventilators:
  3. News Article
    Significant concerns about the NHS’ refusal to share data with councils have emerged in a letter from a leading council chief executive and clinical commissioning group accountable officer. Steven Pleasant, chief executive of Tameside Metropolitan Borough Council and accountable officer of Tameside and Glossop CCG, said the failures are “becoming increasingly exasperating”, in a letter intended for the Ministry of Housing, Communities and Local Government’s shielding sounding board. Steven said he understands NHS Digital has decided the most recent version of the list cannot be shared with councils even though it is being shared with police, fire, voluntary organisations and companies offering logistical support. “I am sure that you will appreciate that this is counterproductive and frustrating given that local authorities are leading and coordinating the response to the most vulnerable in communities,” he wrote. He also raised concerns about how the NHS’ shielded patients team is passing on to councils information about people needing additional support — for instance, if the recipient’s food parcel stock is running low, requiring the council to step in. Welfare concerns and medication information could also need to be passed on. Mr Pleasant said although his council had asked for this information to be provided via email, staff “have been told by the NHS shielding team that they do not have permission to do this and that details can only be provided verbally over the phone”. “We believe this significantly increases the chances of error and presents significant risk… around incorrect information being captured,” he wrote. Read full story Source: HSJ, 21 April 2020
  4. News Article
    Dozens of patients with Covid-19 have been turned away from the NHS Nightingale hospital in London because it has too few nurses to treat them, the Guardian can reveal. The hospital has been unable to admit about 50 people with the disease and needing “life or death” care since its first patient arrived at the site, in the ExCeL exhibition centre, in London’s Docklands, on 7 April. Thirty of these people were rejected because of a lack of staff. The planned transfer of more than 30 patients from established London hospitals to the Nightingale was “cancelled due to staffing issues”, according to NHS documents seen by the Guardian. The revelation raises questions about the role and future of the hospital, which up until Monday had only treated 41 patients, despite being designed to include almost 4,000 beds. One member of staff said: “There are plenty of people working here, including plenty of doctors. But there aren’t enough critical care nurses. They’re already working in other hospitals and being run ragged there. There aren’t spare people [specialist nurses] around to do this. That’s the problem. That leads to patients having to be rejected, because there aren’t enough critical care nurses.” Read full story Source: The Guardian. 21 April 2020
  5. News Article
    An independent investigation into one of the worst maternity safety scandals in NHS history has written to 400 families today as the number of cases under investigation swell to almost 1,200. Despite the coronavirus crisis the review, chaired by midwifery expert Donna Ockenden, is continuing its work investigating poor maternity care at the Shrewsbury and Telford Hospitals Trust where dozens of babies died or suffered brain damage as a result of poor care over several decades. Read full story Source: The Independent, 21 April 2020
  6. News Article
    NHS staff should “feel free” to speak out about problems like protective equipment shortages, Matt Hancock has said, despite many having been warned not to do so. The health and social care secretary told the daily coronavirus briefing on 21 April that it’s “totally normal” for NHS staff to raise concerns about personal protective equipment shortages in their areas and said “transparency is important”. HSJ has heard from multiple senior local NHS leaders that they have been given strong warnings not to communicate externally about the COVID-19 response, with national officials seeking to closely grip information given to the media. There have been several reports of healthcare professionals having been “gagged” by hospitals and NHS bodies, with some reports of threats of disciplinary action if they raise concerns on social media or speak to journalists. Read full story Source: HSJ, 21 April 2020
  7. News Article
    Coronavirus tests given to thousands of NHS staff so they could return to work have been found to be flawed and should no longer be relied on, a leaked document reveals. The memo from Public Health England (PHE), sent earlier this month, warns of "degraded" performance, meaning the results are less reliable than first thought. Almost 100,000 NHS and social care workers and their relatives have now undergone tests in an effort to get as many staff back to the frontline as possible. But the memo, dated April 11, reveals that "discordant results" have been identified in the tests, run by PHE and NHS laboratories, requiring ambiguous samples to be re-checked. Read full story Source: The Telegraph, 22 April 2020
  8. Content Article
    In a crisis, normal processes must often be modified to ensure that the best possible care is provided while ensuring the safety of patients and personnel despite limited resources. ECRI has collated resources that include preparation checklists, patient handling checklists, equipment lists, lists of alternative suppliers, recommendations for patient care equipment such as ventilators, and recommendations for infection control.
  9. Content Article
    How do we protect individuals during lockdown and ensure their health needs are not exacerbated or overshadowed by COVID-19? Simple Stuff Works has created a webinar series to support those providing care for people with postural care needs (anyone who finds it difficult to change position independently and is reliant on others for their positioning / repositioning needs).
  10. News Article
    More than a quarter of patients with COVID-19 on ventilators also need renal support in the form of dialysis, raising concerns that there could be significant supply problems as countries attempt to stock up on the required fluid and plastic consumables. Nephrology consultant Graham Lipkin told The BMJ, “This is an under-recognised challenge. While the original focus has been on whether we have enough ventilators and intensive care beds, it has become apparent that there is a high incidence of acute kidney injury (AKI) requiring some form of renal replacement therapy (RRT) through dialysis. With the volume of people coming into intensive care, there are increasing challenges to capacity across the system.” Lipkin, who is president of the Renal Association, has been working with NHS England to develop new clinical guidelines for the prevention and optimal management of AKI in hospital. The guidance aims to reduce the incidence of AKI and therefore the demand for dialysis. Read full story Source: BMJ, 21 April 2020
  11. News Article
    UK medicines agencies have changed their advice on ibuprofen to say that the drug can be used to treat patients with symptoms of COVID-19, although the evidence that prompted the revision has not been made public. The change follows a review by the Commission on Human Medicines’ expert working group on COVID-19 which, along with previous reviews of evidence, concluded that there is currently insufficient evidence to establish a link between use of ibuprofen, or other non-steroidal anti-inflammatory drugs (NSAIDs), and contracting or worsening of COVID-19. The group’s review has not been published, but prompted the Medicines and Healthcare Products Regulatory Agency (MHRA), NHS England, and the National Institute for Health and Care Excellence (NICE) to update their advice to say that patients can take paracetamol or ibuprofen for symptoms of COVID-19, such as fever and headache. This is a change to NICE’s recommendation on 3 April that paracetamol should be used in preference to NSAIDs for managing fever in patients with suspected COVID-19 until more evidence is available. Read full story Source: BMJ, 17 April 2020
  12. News Article
    More than 16% of people who had tested positive for coronavirus when they died were from black, Asian and minority ethnic (BAME) communities, new data shows. On Monday, NHS England released data showing the ethnic breakdown of people who have died with coronavirus for the first time. The statistics come days after a review was announced to examine what appears to be a disproportionate number of BAME people who have been affected by Covid-19. Last week Downing Street confirmed the NHS and Public Health England will lead the review of evidence, following pressure on ministers to launch an investigation. Discussing the review, Professor Chris Whitty, the chief medical officer for England, said ethnicity is "less clear" than three others factors in determining who is most at risk from coronavirus. Read full story Source: The Independent, 21 April 2020
  13. Content Article
    Hundreds of healthcare organisations around the world are Schwartz Center healthcare members and conduct Schwartz Rounds® to bring doctors, nurses and other caregivers together to discuss the social and emotional side of caring for patients and families. This video explains more.
  14. Content Article
    Calls to integrate human factors and ergonomics (HFE) within healthcare and patient safety have become increasingly frequent in the last few years.This editorial from Waterson and Catchpole decscribes some of the misconceptions and misunderstandings that sometimes surround HFE.
  15. News Article
    NHS supplies of face masks could be put at risk if the government starts advising the public to wear them, hospital bosses have warned. The government's scientific advisers are to meet later to discuss whether the public should be urged to wear masks in a bid to combat coronavirus, but Chris Hopson, chief executive of NHS Providers, warned there should be "clear evidence" to justify their use. He said securing supplies for NHS staff amid huge global demand was "crucial". The World Health Organization (WHO) has said there is no evidence to support the use of face masks by the general population. It says people who are not in health and care facilities should only wear masks if they are sick or caring for those who are ill. But the debate around their use in the UK has been gaining momentum in recent weeks, with proponents arguing they can help reduce the risk of people with the virus passing it on to others. Read full story Source: BBC News, 21 April 2020
  16. Content Article
    Providing high quality healthcare has an emotional impact on staff. Often they experience high levels of psychological distress, face increasing levels of scrutiny, regulation and demand, and have increasingly limited resources. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff deliver compassionate care by providing a safe space where staff could openly share and reflect on the emotional, social and ethical challenges of their work. Rounds are a monthly staff forum (not attended by patients) where three to four employees (panellists) present short accounts of their experiences of delivering patient care. This organisational guide is based upon the findings from an evaluation of Rounds in the UK, undertaken between 2014 and 2016. The evaluation was commissioned by the National Institute for Health Research and led by Professor Jill Maben at King’s College London (now at the University of Surrey). The evaluation aimed to distil the findings and learning for practical application by organisations seeking to implement and/or sustain Rounds in their organisations.
  17. Content Article
    Everybody responds differently to the stresses and strains of modern life. We all need and, to a degree, thrive on pressure: it gives us energy, helps with performance and inspires confidence. But excessive pressure can lead to stress. Stress may become a problem when someone feels they don’t have the resources to cope with the demands placed upon them. Harmful levels of stress can lead to a mental health condition such as anxiety or depression. This booklet from the Devon Partnership NHS Trust aims to give you some very practical information and guidance – and provides spaces for you to make notes so you can make it work for you.
  18. Content Article
    MINDFUL EMPLOYER provides employers with easier access to information and support in relation to supporting staff who experience stress, anxiety, depression and other mental health conditions. Run by Workways, a service of Devon Partnership NHS Trust, MINDFUL EMPLOYER was developed with employers in Exeter and launched in October 2004. This completely voluntary initiative has since attracted interest and commitment from hundreds of small, medium and large employers from all sectors throughout the UK. The initiative provides a wide range of information and signposting to local, regional and national support services.
  19. Content Article
    NHS Employers provide an emotional wellbeing toolkit to help you track your emotional wellbeing and support others. If you're a manager, a team leader or looking for yourself, there are resources here for you. 
  20. News Article
    According to an Allego press release, several of the world’s ventilator manufacturers have formed a Ventilator Training Alliance (VTA) and partnered with Allego to create a mobile app that front-line medical providers can use to access a centralised repository of ventilator training resources. Dräger, GE Healthcare, Getinge, Hamilton Medical, Medtronic, Nihon Kohden, and Philips have joined this humanitarian training coalition. The VTA app – powered by learning and readiness platform provider Allego – connects respiratory therapists, nurses and other medical professionals with ventilator training resources from alliance member companies, including instructional how-to videos, manuals, troubleshooting guides, and other ventilator-operation expertise critical to helping responders treat patients suffering from COVID-19-related respiratory distress. Read full story Source: American Association for Respiratory Care, 16 April 2020
  21. Content Article
    Shabazz et al. explore incidents of bullying and undermining among obstetrics and gynaecology consultants in the UK, to add another dimension to previous research and assist in providing a more holistic understanding of the problem in medicine.
  22. Content Article
    When employees share novel ideas and bring up concerns or problems, organisations innovate and perform better. But managers do not always promote employees’ ideas. In fact, they can even actively disregard employee concerns and act in ways that discourage employees from speaking up at all. While much current research suggests that managers are frequently stuck in their own ways of working and identify so strongly with the status quo that they are fearful of listening to contrary input from below, new research offers an alternative perspective: managers fail to create speak-up cultures not because they are self-focused or egotistical, but because their organisations put them in impossible positions. They face two distinct hurdles: they are not empowered to act on input from below, and they feel compelled to adopt a short-term outlook to work.
  23. Event
    Healthcare workers dedicate their lives to caring for the health and wellness of others. Between the long hours, the tremendous pressure, and patient safety risks – all magnified by the threat of COVID-19 – these essential care providers are under constant assault. Healthcare workers experience astronomical levels of burnout, compassion fatigue, and strain on their psychological safety and wellbeing. If these are not addressed, the worker may suffer in silence, change their role, or leave the profession altogether. Protect them – now and after the global pandemic – to benefit the worker, their patients and the healthcare system. The Canadian Patient Safety Institute (CPSI), a World Health Organization (WHO) Collaborating Center in Patient Safety and Patient Engagement, has over 15 years of experience in safety leadership and implementing programs to enhance safety in every part of the healthcare continuum. This webinar will reveal lessons learned in the development of peer-to-peer support programs, introduce best practices from around the world, and provide a toolkit to develop your own programmes. Registration
  24. Content Article
    Carers UK's website sets out the current government guidance as it relates to carers and offers suggestions for making plans. They've also answered common questions many carers have been asking on their FAQ page and offer some tailored tips on keeping a positive frame of mind in their Wellbeing Action Plan. For recent updates to the benefits system, see their A-Z of changes to benefits, assessments and support – COVID-19. 
  25. News Article
    The NHS should expect a “huge number” of legal challenges relating to decisions made during the coronavirus pandemic, healthcare lawyers have warned. The specialists said legal challenges against clinical commissioning groups and NHS providers would be inevitable, around issues such as breaches of human rights and clinical negligence claims. Francesca Burfield, a barrister specialising in children’s health and social care, told HSJ’s Healthcheck podcast: “I think there is going to be huge number of challenges. If and when we move through this there will not only be a public enquiry, [but] I anticipate judicial reviews, civil actions in relation to negligence claims and breach[es] of human rights….” She said criminal proceedings by the Care Quality Commission or Crown Prosecution Service would also be a possibility, around issues such as deprivation of liberty, neglect, safeguarding, and potential gross negligence manslaughter. Read full story Source: HSJ, 20 April 2020
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