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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Some hospitals are washing single-use protective gowns at 60C so they can be used several times by frontline staff because of the ongoing shortage, according to a senior NHS official. Chris Hopson, the chief executive of NHS Providers, also said hospitals could not rely on government promises that more personal protective equipment (PPE) was on the way – saying there was “relatively low confidence” a shipment of 400,000 gowns would arrive from Turkey on Monday. The head of the membership organisation for NHS trusts in England said some trusts had taken to “hand-to mouth” arrangements, with one discovering that some types of gowns remained fluid-repellent if washed at high temperatures. “There is no doubt that at the moment, we have now got trusts who have definitely got shortages of gowns,” Mr Hopson told BBC Radio 4’s Today programme. “Trust leaders are doing absolutely everything they can to try and address that problem.” Read full story Source: The Independent, 20 April 2020
  2. Content Article
    In 2014, Chris Gibson MBE held the role of Chief Instructor for the UK Ministry of Defence and led on the development and delivery of a training model for 1,200 UK military personnel and NHS volunteers to combat the Ebola virus in West Africa. Through this role, he was responsible for ensuring that each individual deployed was appropriately trained and equipped for the rigor of delivering care in a West African jungle. Read an interview with Chris, first published on LinkedIn.
  3. News Article
    The government’s chief scientific adviser has cautioned against banking on a OVID-19 jab, warning that new vaccines are “long shots”. Oxford University researchers are planning to begin human trials of a vaccine this week and believe that they could have results showing whether it works as early as September. However, Sir Patrick Vallance, the chief scientific adviser, has cautioned that even if a vaccine shows signs of protecting against the virus, ensuring that it is safe could take much longer. “All new vaccines that come into development are long shots. Only some end up being successful,” he said yesterday. “Coronavirus will be no different and presents new challenges for vaccine development. This will take time.” Read full story (paywalled) Source: The Times, 20 April 2020
  4. News Article
    Having access to a ventilator can mean the difference between life and death for patients who are seriously ill with COVID-19, but sometimes even these breathing machines cannot save someone's life. Juanita Nittla is a chief nurse in the intensive care unit (ICU) at London's Royal Free Hospital, and has been working for the NHS as an intensive care specialist nurse for the past 16 years. Switching off ventilators is part of Juanita's job. The work is traumatic and painful, the 42-year-old says. "Sometimes I feel like I am somewhat responsible for someone's death." Medical teams face tough decisions about when to stop treatment for patients who aren't getting better. The decision is made after careful consideration, analysing factors such as the age of the patient, underlying health conditions, their response to the virus and likelihood of recovery. Read full story Source: BBC News, 20 April 2020
  5. News Article
    The UK is gearing up to use the blood of coronavirus survivors to treat hospital patients ill with the disease. NHS Blood and Transplant is asking some people who recovered from COVID-19 to donate blood so they can potentially assess the therapy in trials. The hope is that the antibodies they have built up will help to clear the virus in others. The US has already started a major project to study this, involving more than 1,500 hospitals. A statement from the organisation said: "We envisage that this will be initially used in trials as a possible treatment for Covid-19. If fully approved, the trials will investigate whether convalescent plasma transfusions could improve a Covid-19 patient's speed of recovery and chances of survival." "All clinical trials have to follow a rigorous approval process to protect patients and to ensure robust results are generated. We are working closely with the government and all relevant bodies to move through the approvals process as quickly as possible." Read full story Source: BBC News, 20 April 2020
  6. Content Article
    Alzheimer's Disease International (ADI) is the international federation of Alzheimer associations around the world, in official relations with the World Health Organization. They have put together resources to support and advice for those with dementia and those caring for people with dementia.
  7. Content Article
    Amiri et al. analysed the role of nurse staffing in improving patient safety due to reducing surgical complications in member countries of Organization for Economic Co-operation and Development (OECD). They found that a higher proportion of nurses is associated with higher patient safety resulting from lower surgical complications and adverse clinical outcomes in OECD countries.
  8. Content Article
    As the coronavirus pandemic focuses medical attention on treating affected patients and protecting others from infection, how do we best care for people with non–Covid-related disease? In her article in the New England Journal of Medicine, Lisa Rosenbaum discusses the impact the pandemic is having and how we help those people who are afraid to seek care.
  9. Content Article
    COVID-19 is an illness that can affect your lungs and other parts of the respiratory system. The main symptoms of the disease are fever, cough, and shortness of breath. Most people will have mild symptoms and recover without having to go to the hospital, but the virus can cause severe illness with complications such as pneumonia and even death. People who are at higher risk of these complications include those with heart disease, lung disease, and those who are older than 65. People with high blood pressure also appear to be at higher risk, according to early research from China. More research is needed to understand whether high blood pressure alone increases risk. CardioSmart (Amercian College of Cardiology) have put together resources and updates about how COVID-19 affects patients with heart conditions. 
  10. Content Article
    Recording now available for the ISQUA webinar. Dr David Bates reflects on achievements and challenges in patient safety since the publication of To Err is Human: Building a Safer Health System.
  11. News Article
    Concerns have been raised that updated government guidance on personal protective equipment (PPE) could put hospital staff and patients at risk. Healthcare workers have been advised to reuse gowns or wear different kit if stocks in England run low. Unions representing doctors and nurses have expressed concerns about the updated Public Health England guidance. Healthcare staff treating patients with Covid-19 have previously been advised to wear long-sleeved disposable fluid-repellent gowns. But Public Health England changed its guidance on Friday, outlining three options if the gowns are not available as "some compromise is needed to optimise the supply of PPE in times of extreme shortages". Read full story Source: BBC News, 18 April 2020
  12. News Article
    An “unprecedented” national suicide prevention plan has been launched by a government advisory group amid concerns suicides could increase during the covid-19 pandemic, HSJ can reveal. The government’s national suicide prevention advisory group has developed the plan to address risks covid-19 could present to vulnerable people. Chair of the group and the national adviser to the government on suicide prevention, Louis Appleby, told HSJ the plan was centred on getting far quicker access to data on suicides and self-harm episodes, which is the strongest indicator of suicide risk. He said: “We are in unprecedented times, we haven’t got a lot of evidence on what happens to suicides rates during pandemics, so we’re having to infer from what we know generally to see where the risk might lie. “This is a serious attempt, in some senses an unprecedented attempt to prevent a [physical health] crisis turning into a mental health crisis." Read full story Source: HSJ, 17 April 2020
  13. News Article
    An acute trust in the Midlands has contacted 136 women who received major treatment from a gynaecology consultant, after initial investigations revealed “unnecessary harm” to several patients. Read full story (paywalled) Source: HSJ, 17 April 2020
  14. News Article
    Dozens of NHS trusts fear running out of disposable gowns this weekend if they do not receive more supplies, while national officials have issued guidance on alternatives to use in extreme circumstances, HSJ has learned. Several well-placed sources in procurement reported widespread concerns, more severe than so far in the COVID-19 outbreak. One had information that at least 60 trusts would run out this weekend without supplies, and that it was likely the large majority of NHS providers were affected. One well-placed source told HSJ the situation today was “not normal even during this pandemic”. Another described the “critical” shortage as “a dire situation for everyone”. Read full story Source: HSJ, 17 April 2020
  15. Content Article
    In this blog, Patient Safety Learning considers the impact of the COVID-19 on the social care sector in the UK. This blog highlights the emerging patient safety issues the pandemic is creating in the sector and recommends some essential steps that need to be taken now to tackle some of the most urgent patient safety concerns.
  16. News Article
    A three-year-old child died after its desperate mother spent more than an hour on hold to the NHS 111 helpline. The ill child suffered a cardiac arrest at its home and died in hospital, according to details of critical incidents affecting children in London amid the coronavirus crisis. Another case saw a six-month-old die from sepsis and liver failure because the parents feared the child could catch Covid-19 in hospital, the Evening Standard reports. Doctors have raised concerns that parents are not seeking treatment for their children amid the outbreak. Read full story Source: 16 April 2020, Mail Online
  17. Content Article
    The pictures of the amazing transformation of the London ExCel Centre into NHS Nightingale exemplify some of the incredible large-scale changes happening across the health service to respond to the Covid-19 (coronavirus) outbreak. In this blog, Beccy Baird highlights some of the amazing, less easily photographed, innovations happening in general practice, which has transformed itself in the space of just a few weeks.
  18. News Article
    Experts have warned giving the public coronavirus antibody tests to be carried out at home could lead to “disastrous results”. A testing manager at an NHS trust told HSJ they feared the public may take the tests too soon for antibodies to appear, which could produce misleading results, while a leading virologist at the British Society for Immunology called for antibody tests to be carried out in GP surgeries. Public Health England has previously said it wants to distribute antibody tests via Amazon and Boots and make them available to the general public. Health secretary Matt Hancock has also promised increased antibody tests will form part of 100,000 of all types of daily COVID-19 tests by the end of April. Read full story Source: HSJ, 17 April 2020
  19. News Article
    The British Dental Association (BDA) has criticised NHS England for “dragging its feet” in setting up an urgent care system for dental patients, putting further strain on already overstretched GPs. At the end of March, dental practices were ordered to suspend all routine treatment, as part of plans to prevent the spread of coronavirus. NHS regions were instructed to set up local urgent dental care centres. However, GPs have told HSJ they have been experiencing a rise in calls from patients with dental problems, but when they direct them to the urgent care centres, appointments appear to be limited. The BDA has said, in some regions, there is “nowhere” to send patients in need of urgent dental care. Sources working in primary care and tech said GPs were dealing with a spike in demand from dental patients who did not know where to go. Read full story Source: HSJ, 17 April 2020
  20. News Article
    Doctors have been warned that crucial drugs used to help sedate and ventilate patients in intensive care are running out due to the demand caused by coronavirus. An alert to hospitals from NHS England today said there were “limited supplies” of muscle relaxant drugs atracurium, cisatracurium and rocuronium, which are used during intubation when patients are sedated and paralysed with a ventilator used to help them breathe. As a result of the shortages, and to help maintain supplies, NHS England said it would now manage existing supplies “centrally”. Its said supplies of atracurium and cisatracurium were likely to be exhausted in coming days, and hospitals would need to switch to alternatives that were still available. A critical care nurse working in ICU in the south of England told The Independent they were already using alternatives but that this had to be used at different concentrations and run for longer to achieve the same sedation. She said changes like this with staff overstretched could increase the likelihood of drug errors. Read full story Source: The Independent, 17 April 2020
  21. News Article
    More than 9 in 10 people dying with coronavirus have an underlying health condition, figures from the Office for National Statistics (ONS) show. The ONS looked at nearly 4,000 deaths during March in England and Wales where coronavirus was mentioned on the death certificate. In 91% of cases the individuals had other health problems. The most common was heart disease, followed by dementia and respiratory illness. On average, people dying also had roughly three other health conditions. The ONS has also looked at the differences in death rates by age and sex, with men twice as likely to die with coronavirus. Unsurprisingly, the risk of dying increases with age, rising sharply from age 60 years onwards. Read full story Source: BBC News, 17 April 2020
  22. Content Article
    On 30 March, in response to the UK Government asking for business to provide thousands of ventilators to help tackle the Covid-19 pandemic, Patient Safety Learning published a blog with recommendations to ensure that ventilators are ‘safe in use’ (this means making sure they are as intuitive and easy to use for frontline staff as possible, reducing the potential for error).[1] In that blog, we outlined how we had brought together human factors/ergonomics and clinical experts to discuss the design, development and use of the equipment.
  23. Content Article
    Rosie Hughes has tested positive for the coronavirus that has killed so many of her patients. In her candid blog, published in the Guardian, she talks about her experiences, fear and the guilt she feels.
  24. Content Article
    New York Times bestselling author Dan Heath explores how to prevent problems before they happen, drawing on insights from hundreds of interviews with unconventional problem solvers.
  25. News Article
    The coronavirus crisis has led to a sharp rise in the number of seriously ill people dying at home because they are reluctant to call for an ambulance, doctors and paramedics have warned. Minutes of a remote meeting held by London A&E chiefs last week obtained by the Guardian reveal that dozens more people than usual are dying at home of a cardiac arrest – potentially related to coronavirus – each day before ambulance crews can reach them. And as the chair of the Royal College of GPs said that doctors were noticing a spike in the number of people dying at home, paramedics across the country said in interviews that they were attending more calls where patients were dead when they arrived. The minutes also reveal acute concern among senior medics that seriously ill patients are not going to A&E or dialling 999 because they are afraid or do not wish to be a burden. “People don’t want to go near hospital,” the document said. “As a result salvageable conditions are not being treated.” Read full story Source: The Guardian, 16 April 2020
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