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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this blog Patient Safety Learning outlines the key points included in its response to the consultation on establishing a Patient Safety Commissioner for England. This sets out their feedback to this consultation and describes the powers and resources this role will require if it is to effectively influence change and improve patient safety.
  2. News Article
    Performance data published by NHS England has revealed a big surge in the number of immediately life-threatening incidents ambulance services have responded to. The data also showed average response times have increased and a large number of patients are attending emergency departments. So far, the reason for the increase remains unclear, however, a potential factor could be the return of respiratory illnesses, particularly in children, as the lockdown has eased. In a statement Association of Ambulance Chief Executives said, ”The reasons for the demand increases are complex and will include some patients who have not accessed care as early as they might have done normally and therefore present to the ambulance service as a high acuity patient and many patients who are contacting us for lower acuity issues which in some cases could have been managed by accessing other parts of the UEC system. We continue to work closely with NHS England to mitigate the demand as much as possible and encourage sign-posting of patients to other parts of the UEC system when that is a safe and more appropriate solution to their problem.” Read full story (paywalled). Source: HSJ, 12 August 2021
  3. News Article
    Latest data has revealed more than one million 999 calls were placed in July, showing paramedics were sent out to 82,000 emergencies last month and 8,000 more than the record set in June. This comes after A&E departments became overwhelmed with an influx of new patients over the summer, with many hospitals having to cancel operations due to being dangerously understaffed. Dr Katherine Henderson, president of the Royal College of Emergency Medicine has said, "The NHS has been running hot for months now and these figures show we are nearly at boiling point. We are worried that the public think things are getting back to normal on the virtual eve of a further reduction in restrictions, and messages from the centre that say things are OK are disingenuous – the reality is that the health service is really struggling." Read full story. Source: The Independent, 12 August 2021
  4. News Article
    At a virtual event held by The Independent last night, experts agreed maternity services needed to be overhauled. The panel discussion, NHS maternity scandal: Inside a crisis, laid out the facts surrounding the problems around maternity care and concerns around safety amid repeated examples of poor care in multiple cases. Donna Ockenden, a senior midwife who has been leading the inquiry into maternity services at Shrewsbury and Telford Hospitals explained "I think one of the major issues around maternity services is that we’re not treated in the same way as A&E. I think that people fail to see that actually, maternity is a woman’s A&E department, you can start a shift in any maternity unit, you can plan what you think you’re going to do. But actually you don’t know what is going to come in the front door.” Read full story. Source: The Independent, 12 August 2021
  5. News Article
    New analysis looking at the spread of Covid-19 in hospitals has revealed a massive gulf in ability to contain the virus during the first wave. According to the published data, overall only 1 in 10 people actually caught the virus whilst in the hospital, however 314 UK hospitals showed that ranged from just one in 100 cases caught in hospital, to more than 1 in 4, with an estimate of between 5,700 and 11,900 people who were infected in hospital. Professor Calum Semple, one of the researchers from the University of Liverpool has said, "There will be tragedy behind this story, people that came into hospital with one problem, caught Covid and sadly died." Read full story. Source: BBC News, 13 August 2021
  6. News Article
    New figures show a record number of 5.45 million people are waiting for NHS hospital treatment in England, with many more joining the waiting list who also need treatment, and those who came back to the NHS for healthcare having not done so during the worst periods of the pandemic. Sajid Javid, the Health Secretary has said, "We estimate there's probably some seven million people that ordinarily would have come forward to the NHS that stayed away, understandably, during the height of the pandemic. We want those people to come back. I don't know how many will come back but, even if half of them came to the NHS - and can I just stress I really want people that need to be seen by the NHS to know the NHS is there for them and they should come forward - but as they do I think waiting lists will rise because there will be a huge increase in demand." Read full story. Source: BBC News, 12 August 2021
  7. Content Article
    This article by Robin Aldwinckle discusses the case study of a 61-year-old male patient with severe knee osteoarthritis and hypertension who was admitted for surgery under subarachnoid regional anesthesia. However at the end of the procedure, the patient remained unresponsive and was subsequently diagnosed with Local Anesthetic Systemic Toxicity (LAST). Whilst the patient recovered, this case highlights a lack of communication between the operating room team members concerning the safe dosing of local anesthetics and that the correct diagnosis and treatment of LAST in the operating room is critically important.
  8. Content Article
    This research article focuses on the patient safety aspects of handling and recognising allergic reactions and severe perioperative anaphylaxis, and discusses the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.
  9. Content Article
    This article on sex and gender differences discusses the definitions, general and perioperative implications and how acknowledging differences between men and women relevant to anesthesia is of paramount importance to ensuring perioperative patient safety.
  10. Content Article
    This article describes the case studies of a 65-year-old woman with a history of acute myeloid lymphoma called her oncology physician's office with symptoms of chemotherapy-induced nausea and a 66-year-old woman was prescribed estradiol vaginal tablets for post-menopausal symptoms. Cynthia Li and Katrina Marquez discuss how both patient cases resulted from human error by pharmacy staff and how although most medication errors can be directly attributed to human error, human error is often a result of poor system design and recommend 'The 8 R's' approach to reduce the risk for errors includes development of safeguards at every level of the medication use process.
  11. News Article
    According to the state's health watchdog Health Information and Quality Authority (Hiqa), six out of 10 hospitals inspected last year were non-compliant with aspects of infection-control procedures against Covid-19. Recurring issues such as poor physical infrastructure, capacity issues and workforce challenges were found to hinder efforts to cope with the pandemic, and despite investments, issues around infrastructure and capacity have been worsened by the pandemic. “In most instances, we found an effective approach to adapt to this unprecedented crisis in hospitals. However, hospitals’ efforts were made more difficult due to underlying historic problems with infrastructure, limited bed capacity and unequal or limited access to specialist workforce input and advice – problems that Hiqa’s prior monitoring work against national standards has consistently highlighted.” said Hiqa’s director of regulation, Mary Dunnion. Read full story. Source: Irish Times, 10 August 2021
  12. News Article
    Nursing and maternity staff have reported that they are unable to have water with them whilst working, meaning some are unable to drink water for 12 hours due to work pressures. The Royal College of Midwives in updated guidance are calling for "common sense" from NHS trusts and boards on staff access to water and other drinks, particularly as staff are having to wear more PPE than before the pandemic began. Dr Mary Ross-Davie, director for professional midwifery at the RCM, said: “Some trusts and boards have banned water bottles in clinical areas, which means that our members are often going 12 hours with no break and no water. We are appealing to those services to apply common sense, to recognise that this application of infection control is misguided and to look after the health and wellbeing of their staff.” Read full story (paywalled). Source: Nursing Times, 11 August 2021
  13. News Article
    According to leaked figures, the number of patients ready to be medically discharged has been rising since the spring and is now higher than the winter, but levels are believed to still be substantially lower than pre-covid. These figures come after reports hospitals are facing increased pressure to free up beds for incoming patients. David Oliver, consultant geriatrician and former national clinical director for older people, has said "Thanks to additional funding and capacity in community health and social care services, fantastic collaborative working across systems and new rules and permissions, and innovative service models, we saw far fewer delays and far slicker discharge for patients needing ongoing support outside hospital. Unsurprisingly, it wasn’t sustainable. Both in my local experience and speaking to colleagues from around the country, we are now back to pre-pandemic levels of delays and worse. This is bad for patients, leaving them stranded in hospital when they’d be better off in their own home and other settings and bad for other patients needing hospital care, including those on waiting lists, as flow through acute beds is impaired." Read full story (paywalled). Source: HSJ, 11 August 2021
  14. News Article
    A report published today has revealed the creation of single regional boards to commission ambulance services is under discussion with NHS England and Improvement. According to the report titled Rapid response: the role of the ambulance sector in transforming services and coping with the long-term impact of covid-19, ambulance trusts are to be involved in regional, integrated care system and place-level decision-making to maximise their contribution to more integrated services has also been called for. NHS Providers chief executive Chris Hopson and Association of Ambulance Chief Executives chair Daren Mochrie said: “As well as providing mobile treatment services, ambulance trusts have the potential to be an absolutely crucial co-ordinator on the urgent and emergency care pathway. We think there is a real opportunity there that is being missed." Read full story (paywalled). Source: HSJ, 12 August 2021
  15. News Article
    A new BBC report has found ambulance crews are unable to respond to calls quickly due to the pressure on hospitals to find free beds. Some paramedics are even spending most of their 12 hour shift waiting in the back of their ambulance, waiting to be called. "We know there are people in the community that are screaming out for an ambulance, but as you can see, a lot of ambulances are waiting here. It never ever used to be like this. We used to bring poorly patients in, and we were out on the road again in 15 minutes. We could do 10 jobs a shift, today we've done two. It's so demoralising" Paramedic Osian Roberts has said. Read full story. Source: BBC News, 11 August 2021
  16. News Article
    According to NHSE guidance today, non-essential blood tests should be stopped and GPs should prioritise genomic tests over others. Vitamin D testing should also be stopped in all, but "exceptional circumstances" amid shortages in the blood collection tube stocks. The guidance, issued by the NHSE has advised genomics for testing of unwell neonates, prenatal screening and cancer diagnoses are “a high priority". NHSE have also said changes to testing “should be made in consultation with individual patients” and that “it is important to make clear that routine tests will be deferred only where it is clinically safe to do so”. Read full story (paywalled). Source: HSJ, 10 August 2021
  17. News Article
    According to new data, those sick with Covid-19 are a decade younger than previous waves, with analysis showing the average age of among 2,889 patients admitted to ICU since May was 49, compared to 59 in the previous surges. However, this has been put down to the effects of vaccine programme as older adults were prioritised. Reports have also found hundreds of critically ill patients are having to be moved between hospitals due to the need to remove pressure on beds. The chief executive of NHS Providers, Chris Hopson, said: “Trusts’ experience of Covid-19 has strongly confirmed what we already knew: that the NHS is significantly short of intensive care capacity, both beds and staff. The level of ICU transfers over the last few months, to alleviate pressures in a number of different hospitals, further confirms that." Read full story. Source: The Independent, 10 August 2021
  18. News Article
    The Care Quality Commission has closed mental health hospital, Eldertree Lodge, in Staffordshire after inspectors saw evidence of patients being abused. The hospital, which looked after 40 adults with learning disabilities and autism, was found to have unprofessional and abusive staff members, with incidents being recorded on CCTV where staff slammed doors on patients. Staff were also found to pull or drag a patient in an attempt to move them to a ward seclusion room. Commenting on the latest report, Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said, “In some cases, people were subjected to abuse and interactions that lacked compassion, dignity or respect. This is unacceptable and people deserved better. Additionally, the environment was unhygienic and poorly maintained, as well as blighted by blind spots, which undermined staff observation of patients. Read full story. Source: The Independent, 11 August 2021
  19. News Article
    A report has concluded that significant failings by hospital staff led to the avoidable suffering of Ann Jones, 69, who had bowl cancer, before she died. During their investigation, the Public Services Ombudsman found complications after surgery were not properly identified and weight loss was blamed on psychological factors rather than the pain of a bowel obstruction. Betsi Cadwaladr University Health Board has apologised to Mrs Jones' family. Denbighshire council have also said they were "sincerely sorry" for the distress caused to the family and have issued a written apology to her husband. Read full story. Source: BBC News, 10 August 2021
  20. Content Article
    In this article, Robert Greene, Founder and President of HungerNdThirst Foundation, explains why patient advocacy is a vital aspect during the entire clinical trial process. He discusses how a patient advocates help patients communicate with their healthcare providers in order to make an informed decision about their health care, the positives and negatives of participating in clinical trials and how building trust and collaboration between patients, patient advocates, other stakeholders, and clinical trial professionals is important.
  21. Content Article
    This research focuses on patient advocacy from a nursing perspective. In this qualitative study,15 clinical nurses working in intensive care units (ICUs), coronary care units (CCUs), and emergency units were interviewed regarding patient advocacy with data analysed using content analysis. After data analysis was performed, results showed that patient advocacy consisted of the two themes of empathy with the patient and protecting the patients.
  22. Content Article
    This article describes the importance of an advocate that provide independent support in health and care. An advocate can provide practical advice whilst also ensuring all the rules are being followed and help navigate a patient through the healthcare system. The article also explains how to find an advocate and the different types of support available.
  23. News Article
    Sources have indicated that with staff shortages, including doctors who work in the NHS, in some areas the private sector is prioritising patients who are insured or self-paying, according to the HSJ. A report from the Dorset Clinical Commissioning Group has said that the health system was aiming to use the independent sector to reduce waiting lists, however, there are staff limitations there as well, meaning they have to reduce the amount of capacity they could provide to the NHS. “Amongst a range of initiatives, the Dorset healthcare system is increasing the use of independent providers to help reduce waiting lists, however in common with other providers they are facing their own limitations in terms of capacity and staffing.” A spokesman for the CCG has said. Read full story (paywalled). Source: HSJ, 10 August 2021
  24. News Article
    New data has revealed as many as 14 million people could be on NHS waiting lists in England by the autumn of 2022 unless action is taken now to avoid this outcome. The Royal College of Nursing has confirmed these latest figures confirmed the “immense task that lies ahead” for the profession saying that more investment is needed to help tackle the waiting list crisis. In response to the analysis, Patricia Marquis, RCN England director, said: “These figures confirm the immense task that lies ahead for health and care services in recovering from the pandemic.” Read full story. Source: Nursing Times, 9 August 2021
  25. News Article
    New research has emerged that may be able to diagnose dementia after a single brain scan. Scientists have begun testing a new artificial intelligence system that could identify the condition and predict predict whether it will remain stable for many years, slowly deteriorate or need immediate treatment. Prof Zoe Kourtzi, of Cambridge University and a fellow of national centre for AI and data science The Alan Turing Institute, said "If we intervene early, the treatments can kick in early and slow down the progression of the disease and at the same time avoid more damage". Read full story. Source: BBC News, 10 August 2021
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