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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    One in 10 nurses working in acute hospitals are off work due to coronavirus, according to internal NHS figures seen by HSJ. Internal NHS figures from the COVID-19 national operational dashboard state that, on Saturday, English acute trusts reported that 41,038 nurses and midwives were absent . 28,063 (68%) were COVID-19 related. The total nursing and midwifery headcount in acute trusts is about 280,000 — meaning roughly 10% are off on covid-related absence. There are ongoing complaints from staff about their access to COVID-19 tests — which, it is hoped, will hope reduce the absence rates from suspected cases — while national officials say these are now being made available. Read full story Source: HSJ, 14 April 2020
  2. News Article
    Cancer doctors say difficult decisions are having to be made to postpone some patients' care during the coronavirus crisis. Some treatments such as chemotherapy can weaken the immune system, and potentially put patients at greater risk from COVID-19. Some of those affected have been expressing concern. Roisin Pelan is 38 and lives in Lancashire. She has incurable breast cancer and had been taking chemotherapy tablets every day. Every three months she also visits the hospital to receive the drug intravenously. Last month she was told her chemotherapy treatment would be stopped for 12 weeks. "It's terrifying they've stopped treatment that I know is keeping me alive," she says. "To have that taken away is just unbearable. How do we know it's only going to be 12 weeks? This pandemic could go on a lot longer." NHS England has told trusts that all essential and urgent cancer treatments must continue but specialists should discuss with patients whether it is riskier for them to undergo it or delay. Read full story Source: BBC News, 13 April 2020
  3. News Article
    Once COVID-19 seeps into care homes, it is a monumentally difficult job to protect the residents, writes Sky's Alex Crawford. We will look back at this appalling, tragic episode in our global history, and our children and grandchildren will ask us: "Did that really happen? Did you really leave the most vulnerable of our society - the elderly, the infirm, the defenceless, the muddled, sick and weak - in care homes, shut away from their closest relatives? Did you leave them to be ravaged by a deadly virus, and do very little to help them?" Because that is what's happening right now. There are elderly people - many with Alzheimer's, many with dementia, many frail - in thousands of residential homes up and down Britain, and they are very much at risk. Read full story Source: Sky News, 11 Aril 2020
  4. Content Article
    This report from the American Enterprise Institute provides a road map for navigating through the current COVID-19 pandemic in the United States.
  5. Content Article
    This guide from RSSB povides a practical illustration of how fatigue risks can be systematically managed to improve the health and safety of the workforce and operations. Although for the rail industry, it can be applied to other organisations. It sets out key elements of effective fatigue management and illustrates how these can be incorporated into a company's overarching safety management arrangements.
  6. Content Article
    The aim of the World Health Organization (WHO) pharmaceutical newsletter is to disseminate information on the safety and efficacy of pharmaceutical products, based on information received from networks of "drug information officers" and other sources such as specialised bulletins and journals. Download all issues from the link below. To subscribe and automatically receive the electronic version of every new issue of the WHO Pharmaceuticals Newsletter, please send an email to: join.whophn@mednet-communities.net (do not enter subject or message text).
  7. Content Article
    Recently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. In this paper, Prof. Nancy Leveson, Aeronautics and Astronautics Dept., MIT, describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.
  8. Content Article
    Call 4 Concern is a patient safety initiative enabling patients and families to call for immediate help and advice when they feel concerned that they are not receiving adequate clinical attention. Here is the Royal Berkshire NHS Foundation Trust's leaflets for adults and children. You may also be interested in:  NHS Mid and South Essex's 'We're Listening' leaflet
  9. Content Article
    In this blog, Julie Rehmeyer discusses the impact that flawed research results had on patients with chronic fatigue syndrome.
  10. News Article
    Eight in ten coronavirus patients placed on ventilators in New York City have died, according to officials. New York state has recorded more cases than any country other than America itself. The tally rose by 10,000 in 24 hours to 159,937, ahead of Spain and Italy, which at different times have reported the most infections in the world. The US, which now holds the position, had 463,433 confirmed cases yesterday and the national death toll was 16,504. Read full story Source: The Times. 10 April 2020
  11. Content Article
    "We talk about coronavirus all the time, but it’s often in terms of a bigger picture. I find it hard to make sense of that bigger picture from the frontline. In a crisis of scale I want to tell the story I’ve seen – the story of a pandemic unfolding one person at a time." A blog published in the Guardian by Shaan Sahota, a junior doctor working in London.
  12. Content Article Comment
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  13. News Article
    London trusts have been warned not to expect deliveries of gowns from the national supply chain for at least the next few days, HSJ understands. Without central deliveries, providers risk running out of gowns ahead of the Easter weekend. Trusts will have to rely on existing supplies and any new stock they procure independently. Staff performing or assisting aerosol-generating procedures on confirmed or suspected covid-19 patients should wear gowns, according to the latest guidance from Public Health England. But supplies have been an issue for weeks, with trust procurement leads raising concerns about dwindling gown stocks last month. It recently emerged that gowns were not included in national pandemic stockpiles, unlike other forms of personal protective equipment like masks and gloves. Read full story Source: HSJ, 9 April 2020
  14. News Article
    Medical leaders have warned sick patients not to avoid getting help from the NHS after a huge drop in the numbers of people attending A&E departments sparked fears some could die without care. In March, the number of people going to their local emergency department fell by 600,000, or 29 per cent, compared to same month last year, the lowest number of attendances since 2010. While the NHS has battled for years to reduce the number of people going to A&E for unnecessary reasons, the sudden fall during the coronavirus epidemic has worried officials that the pandemic could be deterring people who have genuine need and who could become sicker or even die as a result of staying away. Read full story Source: HSJ, 9 April 2020
  15. Content Article
    A blog from the charity, Picker, on the benefits of patient-centred care and the new challenges the coronavirus pandemic brings. Picker is an independent charity which uses patient experience of healthcare to identify priorities in delivering the highest care quality.
  16. News Article
    Hospitals are turning to the veterinary workforce to fill staffing gaps on intensive care wards ahead of an expected peak of COVID-19 patients, HSJ can reveal. Torbay and South Devon Foundation Trust has recruited 150 vets to enrol as “respiratory assistants”, amid preparations for a 10-fold increase of intensive care patients. Another trust, Hampshire Hospitals FT, has asked vets and dentists to become “bedside support workers” as part of its response to COVID-19 pressures. Read full story Source: HSJ, 9 March 2020
  17. News Article
    A major new model of post-acute care is needed for the discharge and rehabilitation of patients following COVID-19 infection, say Alice Murray, Clare Gerada, and Jackie Morris. A comprehensive plan must be made for the 50% of COVID-19 patients who will require some form of ongoing care following admission to intensive care, with the goal of improving their long-term outcomes and freeing-up much-needed acute hospital capacity. While the current focus is quite rightly on emergent cases, planning should be set in place to create post-acute care resources and facilities for the surge in numbers of people with the physical, psychological and functional consequences of prolonged ITU stays and or hospital admission following COVID-19 infection. One potential solution is to provide mass facilities, on a scale to match the Nightingale Hospitals in so-called “Centres of Excellence”, requisitioned for those who survive but need care and cannot return to their own homes, with both residential and day care units available. Read full story Source: HSJ, 9 April 2020
  18. News Article
    The UK's organ transplant network could be forced to shut down as a result of the coronavirus outbreak, the body that runs the scheme is warning. One factor is the pressure on intensive care beds, according to NHS Blood and Transplant (NHSBT). But there is also the risk to transplant patients, who have their immune systems suppressed so their bodies don't reject new organs. This is a dilemma for those like Ana-Rose Thorpe, from Manchester, who is waiting for a liver transplant. Now aged 29, Ana-Rose has lived with hepatitis almost her entire life after contracting it as a baby. The disease has taken its toll and now her liver is failing and she is in desperate need of a transplant. "Having to go into hospital while there are coronavirus patients there is very worrying," she says. "Whilst my body could withstand the transplant, the longer I'm not being monitored, not being seen as often as I was, the longer I leave it, I could just get sicker and sicker. "I feel like it's patients that are already on the transplant list, patients waiting for other operations, we have just been swept aside." "It's my life - it is a matter of life and death," Ana-Rose says. Read full story Source: BBC News, 9 April 2020
  19. Content Article
    Empower yourself with information and tools to help you ask good questions, connect with the right people, and learn as much as you can to keep you or a family member safe while receiving healthcare. The Canadian Patient Safety Institute (CPSI) have created a 'Questions Are the Answer' toolkit to help you effectively prepare for making decisions about medical treatment options by asking the right questions of your healthcare team. It considers topics for before, during, and after appointments, using past, present, and future medicines, medical tests, and surgeries.
  20. Content Article
    Corporate interests have the potential to influence public debate and policymaking by influencing the research agenda, namely the initial step in conducting research, in which the purpose of the study is defined and the questions are framed. Fabbri et al. conducted a scoping review to identify and synthesise studies that explored the influence of industry sponsorship on research agendas across different fields. The authors concluded that corporate interests can drive research agendas away from questions that are the most relevant for public health. Strategies to counteract corporate influence on the research agenda are needed, including heightened disclosure of funding sources and conflicts of interest in published articles to allow an assessment of commercial biases. The authors also recommend policy actions beyond disclosure such as increasing funding for independent research and strict guidelines to regulate the interaction of research institutes with commercial entities.
  21. Content Article
    In healthcare, leadership is decisive in influencing the quality of care and the performance of hospitals. How staff are treated significantly influences care provision and organisational performance so understanding how leaders can help ensure staff are cared for, valued, supported and respected is important. Research suggests ‘inclusion’ is a critical part of the answer, as Roger Kline explains further in this BMJ Opinion article.
  22. News Article
    Some Welsh NHS staff with Covid-19 have been given wrong test results and were told they did not have coronavirus, BBC Wales has learned. They are among a group of ten who have been given incorrect results - including eight from Aneurin Bevan Health Board and two from elsewhere. It is not clear how many of the ten had Covid-19 and were told they did not, or vice versa. The Gwent-based heath board said the staff were contacted "immediately". It happened when a small number of test samples from a batch of 96 were attributed to the wrong patients. Read full story Source: BBC Wales, 7 April 2020
  23. News Article
    The designs of a new breathing aid developed by engineers at the Mercedes F1 team, University College London (UCL), and clinicians at UCL Hospital have been made freely available to support the global response to COVID-19. It's the latest development in Formula 1’s Project Pitlane effort to help fight coronavirus. The Continuous Positive Airway Pressure (CPAP) devices, which help coronavirus patients with lung infections to breathe more easily, were developed by engineers at the Mercedes team and University College London (UCL), and clinicians at UCL Hospital after a round-the-clock effort to reverse engineer a device that could be manufactured rapidly by the thousands. After patient evaluations at UCLH and across sister hospitals in the London area, the device received regulatory approval last week. An order for up to 10,000 has now been placed by the British National Health Service, and the Mercedes AMG High Performance Powertrains technology centre in Brixworth – the facility where the F1 team’s highly successful power units are developed and built – is now building 1,000 devices per day. Read full story Source: F1, 7 April 2020
  24. News Article
    “Recurrent safety risks” around clinical care at an embattled NHS trust’s maternity service have been identified in a report published on Tuesday. The Healthcare Safety Investigation Branch (HSIB) has been investigating East Kent hospitals university NHS foundation trust since July 2018 after a series of baby deaths. Among those treated at the trust was Harry Richford, whose death was “wholly avoidable”, seven days after his emergency delivery in November 2017, an inquest found. Speaking on Tuesday, Harry’s grandfather Derek Richford said it is clear that sufficient lessons were not learned from his death. The independent report, published on Tuesday by the Department of Health and Social Care, discusses 24 maternity investigations undertaken since July 2018, including the deaths of three babies and two mothers. It said: “These investigations have enabled HSIB to identify recurrent safety risks around several key themes of clinical care in the trust’s maternity services.” Read full story Source: The Guardian, 8 April 2020
  25. Content Article
    A blog from Peter Walsh, Chief Executive at Action against Medical Accidents (AvMA) on the current pandemic.
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