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Patient Safety Learning

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  1. Content Article
    Deborah Edberg, a family physician, reflects on her experiences working with the dying and offers advice and reassurance to the medical students fast-tracking graduation and the young residents moving into high need areas to fight the pandemic of COVID-19.
  2. News Article
    A leaked letter seen by the BBC has revealed an extensive list of concerns about how the social care sector is coping with the coronavirus crisis. The letter raises fears about funding, testing, personal protective equipment (PPE) and the shielding scheme for vulnerable people. Written on Saturday, to a senior official at the Department of Health and Social Care by the Association of Directors of Adult Social Services (Adass), it says mixed messages from the government have created "confusion and additional workload". On protective equipment for care workers, the letter says the national handling has been "shambolic". Early drops of equipment have been "paltry" and more recent deliveries have been "haphazard", with some even being confiscated by border control for the NHS. And while the rollout of testing for care workers has been generally welcomed, the letter states "testing for care workers appears to be being rolled out without being given thought to who is going to be tested and what we are going to do with the result". Read full story Source: BBC News, 16 April 2020
  3. News Article
    Close family members will be able to see dying relatives to say goodbye under new coronavirus guidelines, Health Secretary Matt Hancock has said. He said the UK would introduce new steps to "limit the risk of infection" and allow goodbyes "wherever possible". Many loved ones have been unable to say goodbye to family and friends since stringent restrictions were introduced on life in the UK on 23 March. Mr Hancock highlighted the death of Ismail Mohamed Abdulwahab, 13, from Brixton, south London. Ismail died alone in hospital last month and his close family were then unable to attend his funeral because they were self-isolating. Speaking at Wednesday's briefing, Mr Hancock said the reports made him "weep". "Wanting to be with someone at the end of their life is one of the deepest human instincts," he said. New government guidelines for social care providers, published shortly after the briefing, say that care homes should still "limit unnecessary visits" but advises that "visits at the end of life... should continue" Read full story Source: BBC News, 16 April 2020
  4. News Article
    The world is likely to face a global crisis in poor mental health after the coronavirus pandemic has passed, experts have warned. Two dozen mental health scientists including neuroscientists, psychiatrists, psychologists, and public health experts have warned of the long-term impact of the virus on people’s mental health and demanded governments prioritise research to come up with evidence-based treatments. They also called for real-time monitoring of mental health in the UK and across the world in order to gauge the severity of the expected increase in poor mental wellbeing. Their warning, in the journal Lancet Psychiatry, comes as a new Ipsos Mori survey carried out at the end of March revealed people’s mental health was already being affected by the UK lockdown and self-isolation policy. Read full story Source: The Independent, 16 April 2020
  5. News Article
    In March, while the UK delayed, Ireland acted. For many this may prove to have been the difference between life and death. The choices our governments have made in the last month have profoundly shaped what risks we, as citizens, are exposed to during the course of this pandemic. Those choices have, to a large extent, determined how many of us will die. At the time of writing, 365 people have died in Ireland of COVID-19 and 11,329 have died in the UK. Adjusted for population, there have been 7.4 deaths in Ireland for every 100,000 people. In the UK, there have been 17 deaths per 100,000. In other words, people are dying of coronavirus in the UK at more than twice the rate they are dying in Ireland. In her article, Elaine Doyle explores why this might be. Read full story Source: The Guardian, 14 April 2020
  6. Event
    COVID-19 brings an enormous set of challenges to hospitals around the world. One challenge in particular, the current mental state of healthcare workers, is now taking centre stage as clinicians face delivering difficult news to patients and their families about what is happening, what to expect, and how to prepare. ECRI and RLDatix have come together to deliver a special webcast led by Dr. Tim McDonald, an expert on Communication and Optimal Resolution (CANDOR). In this much-needed training, Dr McDonald will share the importance of implementing the CANDOR process and demonstrate how the lines of communication for patients and care teams can mitigate the negative consequences of this crisis and help support healthcare workers as they seek emotional first aid, a sense of well-being, and morale. The webinar includes two role-playing videos that address real-world scenarios healthcare workers are facing today. Scenario one illustrates an empathic conversation healthcare workers have with the wife of a COVID-19 patient who needs to be placed on a ventilator due to a rapid decline in his condition. Scenario two demonstrates the pressure and emotional stress healthcare workers experience after a terrible harm event. Further information and registration
  7. Content Article
    Palliative care services are under-resourced at the best of times. The 2017 Lancet Commission on Palliative Care and Pain Relief described the widespread lack of access to inexpensive and effective interventions as a travesty of justice. As health systems become strained under COVID-19, providing safe and effective palliative care, including end-of-life care, becomes especially vital and especially difficult, as discussed in this Lancet editorial.
  8. Content Article
    Sharps injuries are a well-known risk to workers in healthcare and for those who receive them they can cause anxiety and distress and may result in exposure to bloodborne viruses (BBVs) such as HIV or hepatitis B or C. This guide from NHS Employers has been developed to help individuals understand and manage the risks from sharps injuries
  9. Content Article
    This NHS Employers guide has been produced knowing the increasing number of staff in the health sector who work alone in community settings such as patients’ homes or on outreach work. Lone workers can be vulnerable and at increased risk of physical or verbal abuse and harassment from patients, clients, their relatives or members of the public, simply because they don’t have the immediate support of colleagues or security staff. Understand the importance of protecting lone workers as well as your legal duties as a manager for lone workers.The guide includes a list of key things to consider, which acts as a helpful checklist for those who manage staff who work alone.
  10. Content Article
    This guidance from NHS Employers explores: how shift work can impact on health, safety and wellbeing what can employers and employees do the importance of partnership working on shift working patterns.
  11. News Article
    None of the new life-saving mechanical ventilators ordered last month to cope with the increase in coronavirus patients has so far been awarded safety approval. Models by manufacturers such as Dyson have yet to get the green light from the Medicines and Healthcare products Regulatory Agency, the Financial Times reported. It comes a month after the Government issued a rallying cry to put non-medical manufacturers such as Dyson on a "war footing" to make additional machines. The lag is thought to be due in part to changing clinical understanding of how best to manage the virus. Read full story (paywalled) Source: The Times, 14 April 2020
  12. News Article
    Nurses at a hospital run by a major private healthcare provider have been threatened with disciplinary action after apparently refusing to treat coronavirus patients, according to a leaked email seen by HSJ. The email was sent on Sunday by a senior matron at Nuffield Health’s Cheltenham Hospital, which has been made available to the NHS during the COVID-19 outbreak. She said: “I’m hoping to get another undisturbed day as I’m going to have to formally take on everyone who won’t help on the C19 side." “Unfortunately, it will be a disciplinary matter and referral to the [Nursing and Midwifery Council]. I really don’t want to go down that route but they’re giving me little choice.” It is not clear why staff had refused to help with COVID-19 work, but one staff member who spoke with HSJ said nurses had objected to working without personal protective equipment. A spokesman for Nuffield Health said: “We can categorically state that we have been provided with a full supply of PPE from the local NHS trust so that all members of the team are protected when they treat COVID-19 patients. The team has also been given the appropriate training to ensure they can carry out their roles safely.” Read full story Source: HSJ, 14 April 2020
  13. News Article
    All care home residents and staff with COVID-19 symptoms will be tested for coronavirus as laboratory capacity increases, the government has promised. Health Secretary Matt Hancock said he was "determined" to ensure everyone who needed a test had access to one. Care providers have been calling for more testing for weeks, with charities saying the virus is "running wild" amid outbreaks at more than 2,000 homes. At the moment only the first five residents who show symptoms in a care home are tested, to determine whether there is an outbreak of the virus. Providers have also complained that deaths among residents were being "airbrushed" out of official figures and demanded greater support for the industry. Read full story Source: BBC News, 15 April 2020
  14. Content Article
    The medical symptom 'iceberg' and 'trivia' were defined in terms of people's own perceptions of their symptoms and their subsequent referral behaviour. The data were collected by household interviews of patients registered at a health centre and included information on personal and environmental characteristics. Bivariate and multivariate analysis was used to explore associations between those who were part of the symptom 'iceberg' or 'trivia', and factors which might have caused such incongruous referral behaviour.
  15. Event
    Patient Safety is an essential part of health and social care that aims to reduce avoidable errors and prevent unintended harm. Human Factors looks at the things that can affect the way people work safely and effectively, such as the optimisation of systems and processes, the design of equipment and devices used and the surrounding environment and culture, all of which are key to providing safer, high quality care. New for September 2020, this part-time, three year, distance learning course, from the Centre of Excellence Stafford, focuses specifically on Human Factors within the Health and Social Care sectors with the aim of helping health and social care professionals to improve performance in this area. The PgCert provides you with the skills to apply Human Factors to reduce the risk of incidents occurring, as well as to respond appropriately to health, safety or wellbeing incidents. Through the study of Human Factors, you will be able to demonstrate benefit to everyone involved, including patients, service users, staff, contractors, carers, families and friends. Further information
  16. Content Article
    The Surviving Sepsis Campaign panel recently recommended that “mechanically ventilated patients with COVID-19 should be managed similarly to other patients with acute respiratory failure in the ICU.” However, COVID-19 pneumonia, despite falling in most of the circumstances under the Berlin definition of ARDS, is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance. In their paper published in Intensive Care Medicine, Gattinoni et al. hypothesise that the different COVID-19 patterns found at presentation in the emergency department depend on the interaction between three factors: (1) the severity of the infection, the host response, physiological reserve and comorbidities; (2) the ventilatory responsiveness of the patient to hypoxemia; and (3) the time elapsed between the onset of the disease and the observation in the hospital.
  17. Content Article
    BAPEN would like to draw the attention of those dealing with enteral tube feeding during the COVID-19 crisis to a number of important issues.
  18. Content Article
    Drawing on research, best practice guidelines and expert clinical opinions, the COVID Trauma Response Working Group has created rapid guidance for planners putting in place psychological support for staff in the early stages of dealing with the COVID-19 outbreak. The King's Fund has developed this graphic as a quick reference version of the detailed guidance available on the traumagroup.org website.
  19. News Article
    Millions of patients face being left without a dentist as one in five practices are on the brink of collapse this month. A sharp loss of income since the government banned all routine dental care during the coronavirus crisis has crippled practices, with many poised to close permanently. Some have already been forced out of business. A British Dental Association (BDA) survey of 2,800 practices found 71.5% said they could stay “financially sustainable” for only three months at the most. More than one in five, 20.4%, said they would not survive beyond April. Mick Armstrong, who chairs the association, said: “Practices are weeks from a cliff edge. Without meaningful support, the nation’s dental services face decimation.” Read full story (paywalled) Source: The Times, 12 Aril 2020
  20. Content Article
    In this episode of VISION ZERO Podcast, Dr Abdulealah Alhawsawi interviews Susan Sheridan, a family member of two medical error victims and a global patient safety advocate. In this podcast they explore how we can prevent such medical errors and harm from happening again and the importance of patient / family empowerment.
  21. Content Article
    The World Health Organization (WHO) third Global Patient Safety Challenge: Medication Without Harm is to reduce severe avoidable medication-related harm globally by 50% in the next 5 years, as it is estimated the worldwide burden of medication errors is in the region of $42 billion. In support of WHO's campaign, the Department of Health and Social Care commissioned a review of the evidence base on medication errors in England to assess the extent and scale of medication error. The Department also established a Short Life Working Group (SLWG) in September 2017 to provide advice to the Secretary of State for Health and Social Care on the scope of a programme of work to improve medication safety. 
  22. News Article
    GPs are advising patients with respiratory diseases to buy oxygen privately amid shortages of the gas across the NHS. Last week hospitals were warned to urgently consider limiting how many patients were given oxygen simultaneously. Hospitals usually have a pipeline to pump liquid oxygen from a central store to the wards, but most do not have the capacity to meet the demand from the number of patients they are treating with COVID-19. Read full story (paywalled) Source: The Times, 12 April 2020
  23. News Article
    The number of measles infections around the world could surge in the wake of coronavirus as countries are forced to suspend vaccination programmes. The World Health Organization (WHO) has said it fears more than 117 million children could miss out on being vaccinated against measles, which killed 140,000 people in 2018. Officials worry that 37 countries where the deadly virus is a major threat could delay immunisation programmes, with 24 countries already suspending their efforts as attention is focused on containing and preventing the spread of COVID-19. Read full story Source: The Independent, 14 April 2020
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