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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    New data has revealed doctors are experiencing “worrying levels of abuse” during the Codi-19 crisis. In a survey, doctors (51% of respondents) have reported that they have witnessed violence and abuse against other staff, with 67% showing this was particularly high for those working in general practice. We cannot let people take out their frustration at a system on individual doctors or their colleagues, who truly are doing their best in the most difficult of situations. Even before the pandemic we were vastly understaffed, and abusive behaviour will drive more and more talented and experienced doctors away from the NHS at a time when we need them most . . . We urge our patients to afford the same compassion to staff that they are shown in hospital, after what has been the most horrific year of our careers.” Said The chair of the BMA’s Consultants Committee, Vishal Sharma. Overall results for the abuse questions are here, and broken down by healthcare setting here. Read full story. Source: BMJ, 10 August 2021
  2. Content Article
    This article from the John Hopkins explains the importance of a good healthcare advocate, particularly for older adults who may have more health issues to discuss. When choosing the right healthcare advocate, they should be calm, supportive and assertive and can be a family member, spouse, relative or friend. This article suggests several ways in which to select the right person and lists resources to explore on how best to choose an advocate.
  3. Content Article
    Covid-19 has had a lasting impact on cardiovascular care since the outbreak began. The British Heart Foundation has predicted that the number of people in England waiting for care and diagnosis could more than double within two years, peaking at around 550, 385 in January 2024 if the NHS doesn't get the funding it needs. In order to provide a stronger and more resilient health system that supports healthcare staff, a cardiovascular strategy for England to support recovery from the Covid-19 pandemic is needed.
  4. News Article
    A national shortage in blood collection tubes has meant trusts are having to limit blood tests, with some trusts advising doctors to only order blood tests if they deem it absolutely necessary or using the same tubes for different tests rather than using a different tube of blood for each test. It has also been reported that the global disruption to the supply chain may mean shortages could continue before the supply lines recover. The NHS Supply Chain, has said there was “some improvement in the supply position in September” but that controls on the products "are likely to continue to be applied beyond this until supply stabilises”. Read full story (paywalled). Source: HSJ, 9 August 2021
  5. News Article
    After an unannounced inspection at the Princess Alexandra Hospital Trust in June, the Care Quality Commission (CQC) found an “emergency c-section was being performed without the correct equipment available to monitor the mother”. According to reports, the inspectors stepped in immediately to raise concerns, which was then corrected straight away. In a letter to the trust, the CQC wrote, “Overall, we were concerned that the safety culture in the service was underdeveloped. There were no dedicated maternity safety huddles in line with national guidance. Handovers doubled up as safety huddles. During our observations of handovers, we saw that staff did not discuss safety issues and the format was not safety focused.” Read full story (paywalled). Source: HSJ, 6 August 2021
  6. News Article
    Health leaders have warned the public may be at more risk amid plans to simplify nursing training across the UK. Nursing leaders have also come out in opposition of the proposals by the Nursing and Midwifery Council (NMC) saying bosses could not be sure that the nurses they hired would have the skills required to care patients' safely. Matthew Winn, chief executive of Cambridgeshire Community Services Trust, said "The changes being proposed by the Nursing and Midwifery Council will lead to a watering down of the educational and training standards of these specialist professionals. If courses are developed unilaterally by universities, as an employer I will have no idea if the district nurse is competent to undertake the role I am recruiting them to do.” Read full story. Source: The Independent, 08 August 2021
  7. News Article
    According to the British Heart Foundation, it may take up to five years for cardiac services to return to pre-Covid levels. This warning comes after it was revealed nearly 14 million people could be on NHS waiting lists in England by next autumn. "Tragically, we have already seen thousands of extra deaths from heart and circulatory diseases during the pandemic, and delays to care have likely contributed to this terrible toll. At this critical moment, the government must act now to avoid more lives lost to treatable heart conditions. Addressing the growing heart care backlog is only the start," says Prof Samani, medical director at the British Heart Foundation. Read full story. Source: BBC News, 9 August 2021
  8. News Article
    New figures has revealed serious incidents have occurred in NHS trusts where the wrong bodies of patients were released to families or lost, damaged or kept the organs or bodies of babies without family permission. According to data from the Human Tissue Authority, these incidents have reduced over the years, however, the errors still affected more than 100 families in the latest year to March 2021. Incidents such as these are extremely distressing for the friends and family of the deceased patient, but also for the staff working in the mortuaries involved, who try their best to uphold the highest standards of patient care in often difficult circumstances. The fact that the mortuary profession is not a profession regulated by statute – as other professions such as laboratory staff and paramedics are – makes the maintenance of these quality standards more difficult than it needs to be." Said John Pitchers, chair of the Association of Anatomical Pathology Technology Read full story. Source: The Independent, 8 August 2021
  9. Content Article
    Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. This study in BMC Emergency Medicine sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015. The authors identified the priority areas for intervention to reduce the occurrence of diagnostic error. The study found that system modifications are needed to support clinicians in assessing patients and interpreting investigations. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.
  10. Content Article
    This article discusses how fibromyalgia is a poorly understood condition, and until now, was considered to originate in the brain, however, new research considers that the condition may actually be associated with the body's immune system. New findings published in the Journal of Clinical Investigation may help pave the way for more effective treatments for the millions of people affected by fibromyalgia.
  11. Content Article
    This article discusses red rules, a safety practice used by industries and are associated only with processes that can cause serious harm to employees, customers, or the product line. The article describes red rule criteria, examples in industry, everyday life, in healthcare and when they are misused, concluding that if appropriately implemented, red rules can have the potential to promote an organizational culture of safety that shares accountability for the safe delivery of patient care. 
  12. News Article
    According to data shared with HSJ, the amount of NHS staff taking time off for their mental health has leapt in the past few months. The data, collected by FirstCare and covering 46,000 NHS staff from nine trusts, showed mental health absences from May to June of this year was at least 20 per cent up on April and 35 per cent up on February with more than 40 per cent up on the same months last year. “Trust leaders remain acutely aware of the impact that the pandemic, coupled with existing NHS pressures, is having on the workforce. They are deeply concerned about their staff’s mental health and wellbeing and are doing what they can to look after their staff, but they cannot do this sustainably without a fully costed and funded multi-year workforce plan.” Said NHS Providers chief executive Chris Hopson. Read full story (paywalled). Source: HSJ, 6 August 2021
  13. News Article
    The president of the Intensive Care Society has warned despite the fall in Covid cases, intensive care units in hospitals remain under substantial pressure, with Stephen Webb, a consultant in intensive care and deputy medical director at the Royal Papworth Hospital Trust, describing the situation as "grim". “Cases of Covid infections are coming down but that’s not having much of an impact on hospitals and on intensive care units yet. The situation in ICUs is pretty grim at the moment and it’s grim for a completely different reasons from wave one and two of the pandemic.” Dr Webb told The Independent. Read full story. Source: The Independent, 5 August 2021
  14. News Article
    A new report has found tens of thousands of children are suffering from Long Covid, with experts worried children will be left vulnerable if the vaccine roll-out does not expand to include the 12-15 year old age group. Experts have also warned herd immunity cannot be achieved without the young people taking the jab. "There is no time to waste in getting on with this. We could have had all of this age group [16- and 17-year-olds] vaccinated before September." Said Dr Deepti Gurdasani, an epidemiologist at Queen Mary University London. Read full story. Source: The Independent, 6 August 2021
  15. News Article
    Gateshead Health NHS Trust in the north-east of England are the first NHS body in the UK to manufacture its own protective face masks. This move comes after Filtering Face Piece 3 masks (FFP3), which are used widely in hospitals, were in short supply early in the pandemic. "It's taken us a lot of hard work and investment to get to this stage. Every part and stage has had to be precision-engineered to make sure that these masks meet the standard and are effective at filtration." Said Managing director Anthony Robson. Read full story. Source: BBC News, 6 August 2021
  16. News Article
    The Care Quality Commission have increased the safety rating for the William Harvey Hospital, in Kent, from 'inadequate' to 'requires improvement'. This comes after the hospital was hit with a safety scandal after staff and members of the public raised concerns about a lack of infection control amid outbreaks of Covid-19. “I am pleased to report that since our last inspection, leaders have worked hard to improve infection control practices in the medical care services departments at both hospitals, although some improvements still need to be fully embedded, particularly at William Harvey Hospital. We also found that there was a positive culture in the service across both hospitals, and staff felt empowered to report incidents. These were fully investigated by managers and, importantly, learnings were shared with the wider team.” Amanda Williams, CQC’s head of hospital inspection has said. Read full story. Source: The Independent, 5 August 2021
  17. Content Article
    This paper from Parsons et al. looked at how patients prefer to be addressed by their healthcare providers and assessed their knowledge of their attending medical team's identity. The researchers conducted a survey which included 300 inpatients, with findings showing over 99% of patients prefer informal address and 57% of patients unable to correctly name a single member of their attending medical team.
  18. Content Article
    This study, published in the Journal of the Royal Society of Medicine, analyses safety incidents on acute medical wards in the NHS over a period of 10 years. A total of 377 reports of severe harm or death were confirmed, with the most common types of incident the result of diagnostic errors, medication-related errors and failures monitoring patients.
  19. News Article
    Concerns have been raised amid allegations that hospital managers have told minority ethnic staff to adopt 'Western work names' as their original names were 'too difficult to pronounce'. In a letter from the Care Quality Commission, published in the trust's July board papers, workers at University Hospitals Bristol and Weston Foundation Trust told inspectors about their experiences during an unannounced visit in June. “This is not acceptable, individuals can only truly thrive in a work environment where they feel safe as themselves and belong rather than having to ‘fit in’.” Wrote the CQC’s head of hospital inspections Amanda Williams. Read full story (paywalled). Source: HSJ, 4 August 2021
  20. News Article
    New research examining severe harm incidents and deaths in NHS hospitals has been published today in the Journal of the Royal Society of Medicine. The research, looking at more than 370 incidents has highlighted the risks to patients from fragmented care on busy wards and shortages of staff. According to the findings, “errors occurred due to a lack of clarity regarding responsibilities for patient care coordination, especially during emergency situations or out of hours. Poor documentation of long-term management plans and no reliable review system to ensure follow-up by the most appropriate teams contributed,” with researchers also saying many of the errors in medication happened more often overnight due to a lack of out-of-hours pharmacy support. Read full story. Source: The Independent, 5 August 2021
  21. News Article
    An open letter has been published calling for the end of Covid-related abuse against healthcare staff, with leading health organisations coming together to unite against the rising tide of violence against nurses and other NHS staff. The letter was signed by nine representatives including the Royal College of Nursing and Royal College of Midwives and warned of the “unacceptable behaviours”, a move that comes after he chief executive and general secretary of the RCM, Gill Walton, received online threats after she supported a national appeal for pregnant women to get the Covid-19 vaccine. “To those who issue death threats or incite violence against us, we say enough is enough”, Ms Walton has said. Read full story. Source: The Nursing Times, 4 August 2021
  22. News Article
    New research has found oxygen therapy may help reduce the number of patients needing a ventilator. The research trial, conducted across 48 hospitals in the UK, found that out of the three methods of oxygen delivery, continuous positive airway pressure (CPAP) could be the most beneficial in reducing the need for a patient to go on a ventilator. "The routine use of high-flow nasal oxygenation, which can consume large amounts of oxygen, should be reconsidered, as it did not improve outcomes. By giving patients the most effective treatment to begin with, we can help prevent resource shortages in our NHS and make sure the right type of ventilation is available to patients when it is required." Says Prof Gavin Perkins, from the Warwick Medical School. Read full story. Source: BBC News, 05 August 2021
  23. Content Article
    This article by the Patient Safety Network provides an overview of the impact of diagnostic errors on patient safety. It gives examples of incorrect applications of heuristics and suggests ways to overcome cognitive bias in the diagnostic process.
  24. Content Article
    This original research article describes how patients with mental health issues face similar risks as to those patients in other areas of healthcare, particularly in relation to measures taken to address unsafe behaviours from patients which may result in further risks to their safety. The authors of this research conducted a systematic review and meta-synthesis to identify and synthesise the literature on patient safety within inpatient mental health settings, and found patient safety research in this area of healthcare was under researched in comparison to other inpatient settings that are not related to mental health.
  25. Content Article
    People experiencing mental health issues face unique patient safety issues when receiving healthcare. This document helps the reader understand some of the mental health patient safety issues, including suicide and self-harm, violence and aggressive behaviour, restraint use and seclusion and absconding, all of which directly impact patient care. Learning objectives for this downloadable module aims to help the reader understand systems thinking and understand system-engineering approaches to patient safety in mental health.
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