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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    According to a new study, mothers at risk of premature birth could be identified as soon as 10 weeks into their pregnancy. The study, conducted by King's College London and published in the Journal of Clinical Investigation, found that by looking for specific bacteria in the in a pregnant woman’s cervicovaginal fluid, it could reveal warning signs for premature birth, meaning inflammation can be found and treated early to protect mothers and babies. Study author Andrew Shennan OBE, who is Professor of obstetrics at King’s College London, explained: “Premature birth is very hard to predict, so doctors have to err on the side of caution and mothers deemed to be at risk often don’t actually have their babies early, putting undue strain on everyone involved. My team has developed preterm birth prediction tools that are very accurate later in pregnancy, like fetal fibronectin tests – but at that stage, you can only manage the risks, not stop it from happening. The sooner we can find out who’s at risk, the more we can do to keep mothers and babies safe.” Read full story. Source: The Independent, 23 August 2021
  2. News Article
    According to reports, Covid-19 was the 9th biggest cause of death in England in July, and the 26th most common in June, with data showing it was the 22nd leading cause of death in Wales. Figures from the Office for National Statistics show the number of deaths was 7.6% higher than average in England and 10.4% higher in Wales. However, when there isn't a pandemic, the top causes of death are usually heart disease and dementia, but in the months when Covid-19 has been dominant, it has been the leading cause by a long way. Read full story. Source: BBC News, 23 August 2021
  3. News Article
    BBC News Research has revealed disabled and vulnerable adults in England will face a steep rise in the amount they have to pay towards their care, with Directors of council services blaming years of government funding cuts. One woman, Saskia Granville earlier this year was shocked when she found her care charges had increased from £92 to £515 per month. A sum of almost £1,500 was also taken out of Saskia's bank account as a backdated payment, in March, leaving her in debt. Her mother, Bobbie, says: "Without my intervention, she wouldn't have had any food that week. She wouldn't have been able to pay her gas, electricity or water bills." Read full story. Source: BBC News, 24 August 2021
  4. Content Article
    This research was conducted with the aim to reduce the number of poor outcomes for surgical patients with a National Early Warning Score (NEWS) score ≥7 in the author's institution by 50%. Results found that the introduction of the surgical safety huddle supported by the deteriorating patient response team reduced the number of cardiac arrests and poor outcomes in a surgical inpatient cohort.
  5. Content Article
    This research was conducted to explore the relationship between the various types of events that occur in an isolation environment and the associated factors, which may have implications for the likelihood of the event and severity of patient harm. After performing an analysis of event reports submitted by acute care hospitals between January 1 and September 30, 2020, 484 relevant event reports from 94 hospitals for inclusion in our descriptive study (excluding near-miss events) were identified.
  6. Content Article
    This article on quality improvement and accountability in the Danish healthcare system describes how Denmark developed and implemented national quality and patient safety initiatives in the healthcare system. Over the years, Denmark has worked to create a progressive and just culture in quality management and, in order to further develop the Danish governance model, the authors explain that it is important to expand the model to the primary care sector.
  7. News Article
    Midwives at Suffolk Hospital have spoken out in a whistleblowing letter describing problems in their department as ‘demoralising and heartbreaking’. In the letter, written by midwives who declined to give their names "for fear of retribution", describe constant staff shortages, a culture of blame and fear, a high pressure environment and substandard care, saying " We entered midwifery to be able to give women centred, holistic care. Instead it feels like we are being overwhelmed by the unmanageable and relentless workload, and as a result are giving substandard care which is demoralising and heartbreaking. We are all feeling like we are now desperate for change. This change is beyond what we can achieve ourselves so we urge you to please help us to generate it. It should not be accepted or tolerated for us to be forced into giving unsafe care entirely due to unsafe staffing". In response, Karen Newbury, head of midwifery at the trust, said: “We are working exceptionally hard to recruit additional midwives and we are very grateful for the flexibility and dedication of our staff in ensuring that we provide a safe and caring service – this was recognised by our Care Quality Commission inspection in April which found we managed safety well. We have recently completed recruitment so there will be at least two senior midwives on every shift to provide flexible and experienced support to our maternity teams, and we are working with colleagues regionally to recruit staff both locally and internationally as well as running a full student training programme.” Read full story. Source: Suffolk News, 20 August 2021
  8. News Article
    Young people experiencing long Covid have urged people to get their vaccine in a new NHS video, featuring three previously healthy people in their early 20s and 30s. Quincy Dwamena, a 31 year-old a support worker, described himself in the video as a “healthy young guy”, warned “I ended up being hospitalised and thought I was going to die. My advice is to get the vaccine: don’t put yourself and others at risk, I wish I’d got mine as soon as it was offered.” Data from Public Health England has shown young people aged 16 to 29 at more likely to develop long Covid, however, vaccine uptake among this age group is lower than average, particularly within the London area. Speaking in the NHS video, Dr Emeka Okorocha, an emergency medicine physician said, “As an A&E doctor, I’ve seen a lot during the pandemic. But nothing has shaken me like the sight of young, otherwise healthy adults being rushed into our hospitals with Covid-19. As well as their age, many of them have one other thing in common: they are unvaccinated.” Read full story. Source: The Guardian, 23 August 2021
  9. News Article
    A new antibody testing programme has been launched where participants will be sent two finger-prick tests to complete at home and then inform the UK Health Security Agency of the antibody response to different coronavirus variants. The new programme was created in order to generate new data on antibody protections for people following infection by different coronavirus variants, and from Tuesday, anyone over the age of 18 in England, Wales, Northern Ireland and Scotland, will be able to opt into the programme. Health Secretary Sajid Javid has said "Our new national antibody testing will be quick and easy to take part in [and by] doing so you'll be helping strengthen our understanding of COVID-19 as we cautiously return to a more normal life. I'm proud to see all parts of the UK uniting around this new initiative and working together to arm ourselves with even more valuable insights into how COVID-19 vaccines are protecting people up and down the UK." Read full story. Source: Sky News, 22 August 2021
  10. News Article
    There has been a "harrowing" rise in child deaths and serious cases of harm linked to to abuse or neglect of children since the first Covid lockdown, according to reports from the Local Government Association (LGA). Data has revealed there were 536 serious incident notifications in England between April 2020 and March 2021, with LGA saying it was a "huge cause for concern" and it is extremely concerned about children’s safety. Councillor Anntoinette Bramble, chair of the LGA’s children and young people board, has said, "The pandemic has put extra pressure on families, particularly those living in difficult circumstances, which can fuel harmful acts of abuse or neglect on children. Councils have been working hard with their partners to identify this and provide the help children need, but it is vital that children’s social care services are funded to meet this need.” Read full story. Source: The Independent, 21 August 2021
  11. News Article
    Almost 100 members of the army have been brought in to help four ambulance trusts amid staff shortages in the South Central, South West, North East and East areas of England, with Unison saying it was a sign "things were not right". Vicky Court, assistant chief operating officer at North East Ambulance Services has said "It will ensure everyone continues to get the care they need by freeing up paramedics to be more available to attend potentially life-threatening incidents." Read full story. Source: BBC News, 21 August 2021
  12. Content Article
    This resource from the National Institute for Health and Care Excellence includes assessment tools that can be used to evaluate current practice and plan activity to meet recommendations, audit tools which can be used to improve care, a quality standard service improvement template (Excel), resource impact reports and templates that summarise the resource impact of implementing NICE guidance and service planning tools to help those with a role in the strategic planning or delivery of services for a condition (or set of circumstances) that are addressed by NICE guidance.
  13. Content Article
    This document by the National Institute for Clinical Excellence sets out the principles for best practice in clinical audit and includes; preparing for audit, selecting criteria, measuring level of performance, making improvements and sustaining improvement.
  14. Content Article
    This patient-centred report from the Regulatory Horizons Council discusses a route to more effective safety assurance through mechanisms that consider the whole product lifecycle, how adverse events are detected or a long time after use of the device and how to trace and recall patients when needed. In addition, this report also considers a number of ways in which use of data and technology can be smarter and to join up digital systems.
  15. News Article
    Nottingham University Hospitals Trust has been served with a section 29a warning notice by the Care Quality Commission requiring it to ensure a ‘more positive culture’. A CQC spokeswoman confirmed: “The trust was issued with a warning notice requiring it to take action to improve corporate and clinical governance and oversight of risk, and to ensure a more positive, open and supportive culture across the organisation. We will report on the full findings from the inspection as soon as we are able to.” Although it is still not clear why the warning was issued, the trust is currently engaged in concerns over their accident and emergency department and maternity services. “We accept the CQC’s comments and work is already underway to learn from the findings and make improvements so that the organisation is led as effectively as possible and we continue to provide world class care for our patients.” Nottingham University Hospitals Trust acting chief executive and chief finance officer Rupert Egginton has said. Read full story (paywalled). Source: HSJ, 18 August 2021
  16. News Article
    Ashford and St Peter’s Hospitals Foundation Trust, has apologised after nearly 1,000 patients faced delays due to a breakdown of referral systems. It was found 175 of these patients were considered urgent cases by their GPs and are now being reviewed for clinical harm. When the error was discovered, the patients were added to the referral tacker by 9 July, however until that point, they had not been on any patient waiting list, nor were they visible to either operational management or clinical teams. Trust chief executive Suzanne Rankin said in a statement: “We are very sorry for any inconvenience these delays may have caused patients and we contacted all concerned and issued appointments where necessary.” Read full story (paywalled). Source: HSJ, 19 August 2021
  17. News Article
    Fifty senior consultants from a minority ethnic background at University Hospitals North Midlands have written to Tracy Bullock and trust chair David Wakefield asking for action to ‘protect’ staff from bullying behaviours following an internal survey in which 348 medics claimed to have experienced bullying and harassment. In a subsequent letter on 5 August, seen by HSJ, 50 doctors have now said: “We are forced to express our concerns over the prevailing poor culture within our organisation with most senior medical staff presently reporting they have suffered or witnessed first-hand discrimination, bullying, harassment, or victimisation. We… ask for urgent action by the executive and non-executive boards to immediately implement measures to protect senior medical staff from unacceptable ill-treatment.” A separate external review is now understood to have been commissioned amid concerns over bullying within ophthalmology services. Read full story (paywalled). Source: HSJ, 19 August 2021
  18. News Article
    According to new data, those who have been vaccinated against Covid-19, can still harbour virus levels as high as unvaccinated people if infected with the Delta variant. This new data suggests that hitting the threshold for herd immunity remains unlikely. However, it evidence does show vaccination still offers protection against hospitals and infection. “We don’t yet know how much transmission can happen from people who get Covid-19 after being vaccinated – for example, they may have high levels of virus for shorter periods of time, but the fact that they can have high levels of virus suggests that people who aren’t yet vaccinated may not be as protected from the Delta variant as we hoped.” said Sarah Walker, a professor of medical statistics and epidemiology at the University of Oxford. Read full story. Source: The Guardian, 19 August 2021
  19. News Article
    In a positive step towards the future of pathology, NHS Digital has received approval from the Data Alliance Partnership Board (DAPB) for a new set of pathology information standards, and as part of NHS England CCIO7 workstreams, NHS Digital are delivering the ability to share pathology results across health and care. This move will enable clinicians to share and access critical information about pathology tests and results and receive the right information when they need it, which will help support improved clinical decision making and patient safety. Read full story. Source: Wired Gov, 19 August 2021
  20. News Article
    According to recent reports, the number of patients on waiting lists for non-urgent hospital treatment in Wales has again hit record levels. Data has revealed there were 624,909 people waiting in June, and those waiting the longest, more than nine months, rose again to 233,210. A Welsh government spokesperson said: "Waiting times for treatment continue to grow. However, it is encouraging to see progress being made with the number of patients waiting over 52 weeks falling for the third month in a row. We also saw the largest number of specialist consultations completed and treatments started in any month since the start of the pandemic." A&E time performance has been at its worst on record, with 94,176 attendances to emergency units over the month. Health spokesman Russell George said: "To record the worst ever A&E waiting times and the longest NHS treatment waiting list in the same month shows a complete lack of leadership." Read full story. Source: BBC News, 19 August 2021 Related Reading Patient Safety Learning blog: Tackling the care and treatment backlog safely (19 August 2021)
  21. Content Article
    Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. This article considers the results of a review that compared knee replacement with use of a tourniquet versus without use of a tourniquet and non‐randomised studies with more than 1000 participants. It highlights the risks of complications such as blood clots and infections associated with this, and indicates that changing surgical practice to avoid using tourniquets could avoid nearly 2,000 serious complications in the UK each year.
  22. Content Article
    This is the first of two blogs by Patient Safety Learning looking at the key patient safety issues faced by the healthcare system in the UK in tackling the care and treatment backlog created by the Covid-19 pandemic. This blog outlines the scale of the challenge and sets out the key patient safety considerations associated with this. It stresses the need for national and local plans to address the backlog, with an emphasis on patient engagement and placing patient safety at their core.
  23. Content Article
    This issue of the National Health Executive magazine features a wide range of timely health topics, including; improving employee mental health and ambulance services, prioritising staff wellbeing, equitable access to Covid-19 vaccines, military style mental health support and more.
  24. Content Article
    This webpage contains information about local and national clinical audits including: The National Clinical Audit and Patient Outcomes Programme (NCAPOP) National Quality Improvement and Clinical Audit Network (NQICAN).
  25. News Article
    Selena Brash, a clinical team lead with the East Hampshire school nursing team, has spoken out about the controversial plans to cut back public health nursing services in Hampshire. Ms Brash, in response to the Hampshire County Council plans to save £6.8m from its public health budget, started a petition earlier in the summer calling for increased funding “to protect the provision of school nurses”, warning that cuts to to public health school nursing services would “result in a detrimental effect on children and young people’s health and wellbeing, with lifelong consequences”. “If the cuts go ahead, then this could set a precedent for other local authorities to follow suit, meaning there would be a massive impact on the health and wellbeing of our young people and future generations,” Ms Brash told Nursing Times. Read full story. Source: Nursing Times
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