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Found 54 results
  1. Content Article
    A strong focus on systems thinking and an encouragement to apply insights and expertise from human factors and ergonomics is paramount in how we plan, design and deliver healthcare safely. It’s central to the WHO Global Patient Safety Action Plan, the NHS Patient Safety Strategy, new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care and the National Patient Safety Syllabus.[1-3] It’s something Patient Safety Learning emphasise in our report A Blueprint for Action and is central to the organisational standards for patient safety that we’ve developed.[4] But how should we ‘do’ human factors? How do we apply the concepts, methodologies, tools and techniques in healthcare? What training do we need? How can patient safety managers embed human factors in all of their work, not just a reactive response to incidents of harm? These are some of the questions that patient safety managers have been asking and discussing in the recent Patient Safety Manager Network (PSMN) meetings. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance, providing information, peer support and safe space for discussion. You can find out more about the network here.
  2. Content Article
    This case story about placental abruption, published by NHS Resolution, highlights the importance of regular risk assessments throughout labour to help prevent harm to mother and baby. It provides learning points and considerations that can be applied across all maternity units.
  3. Content Article
    This article, published in Simulation and Gaming proposes a strategy for ensuing simulation training following the implementation of a thorough Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) training initiative. The strategies include observing Teams in the workplace to facilitate the construction of organisation-wide, follow-on simulation training.
  4. Event
    This conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit. Twitter @HCUK_Clare #DeterioratingPatient hub members receive a 20% discount. Email info@pslhub.org
  5. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the HSIB Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #DeterioratingPatient
  6. Content Article
    Monitoring and responding to deterioration in social care settings is critical to providing safe, effective and responsive care. Front-line staff are pivotal for highlighting change to wider teams and managing low to medium risk individuals in their place of residence. However, there is a core set of principles that most systems use which may not be used by non-clinical staff in residential settings. This case study explores an intervention to empower non-clinical staff to take observations. The Whzan blue box contains a digital tablet and equipment to take temperature, pulse, oxygen saturation levels and blood pressure measurements. Staff were trained and supported on site to use the system and set up a digital platform to share measurements with wider teams. Staff fed back that they felt empowered and able to better engage in conversation with health care professionals, highlighting the importance of having a common language. This case study was submitted to the Care Quality Commission (CQC) by North East and North Cumbria ICB.
  7. Content Article
    According to the UK Sepsis Trust, sepsis affects 245,000 people every year in the UK alone, and 48,000 people die of sepsis-related illnesses. Sepsis arises when the body’s response to an infection injures its own tissues and organs. It may lead to shock, multi-organ failure, and death – especially if not recognised early and treated promptly. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together six useful resources about sepsis that have been shared on the hub. They include advice on recognising and managing sepsis along with educational materials.
  8. Community Post
    I would be interested to know, if overnight, patients who score 0-2 on NEWS which has not changed with no concerns since the last set of observations, what your trust policy is on observation frequency? Does your trust require observations to be carried out 4 hourly minimum regardless of patients NEWS score and stability? Or if there are no concerns and the patient is clinically stable with consecutive NEWS 0-2 that they do not have observations taken overnight? Looking forward to hearing what other trust practices are.
  9. Community Post
    Lets talks NEWS... Nurse and carer worry, I like to think that Critical Care outreach teams take this very seriously and that the 'worry' has a heavy influence in our management. Many of our patients may score 0, but warrant a trip to the ITU (AKI patients for instance). However, as part of our escalation policy it states that staff should alert the doctor and or the Outreach team when NEWS is 5 or 3 in one parameter. This causes the 'radar referral effect'. We often have a group of these patients on our list. Personally, I find them difficult to prioritise as they are often receiving frequent observations and have a plan. By concentrating on this group and make sure they have everything in place can take time, but... what about those not scoring in this threshold? Do they get pushed to the bottom of the list? Should nurses follow this protocol to safeguard themselves as well as the patient or are we not looking for sick patients in the right place? Don't get me wrong, the NEWS has been revolutionary in the way we deal with deterioration, but as a tool to prioritise this may not be the case. There are softer signs at play here....has anyone got any solutions to deal with the 'radar referals' Lots to discuss @Ron Daniels @Emma Richardson @LIz Staveacre @Danielle Haupt @Kirsty Wood
  10. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient
  11. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 not only in an acute setting but also in the community and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk Follow on Twitter @HCUK_Clare #deterioratingpatient hub members can receive a 20% discount. Email info@pslhub.org discount code.
  12. Event
    This Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the Covid-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. Attending this conference will enable you to: Network with colleagues who are working to improve Hospital at Night Practice Learn from developments as a results of Covid-19 Improve your skills in the recognition management and escalation of deteriorating patients at night Understand and evaluate different models for Hospital at Night Examine the role of task management solutions for Hospital at Night, including handover and eObservations Ensuring effective and safe staffing at night, including adequate breaks Examine Hospital at Night team roles, competence and improve team working Improving safety through the reduction of falls at night Supporting staff and reducing fatigue at night Develop the role of Clinical Practitioner and Advanced Nursing Practice at night Identify key strategies to change practice and ways of working in Hospital at Night Understand how hospitals can improve conditions for night workers and support Junior Doctors Improve the management of pain at night Work across whole systems to improve support for patients out of hours Self assess and reflect on your own practice Gain CPD accreditation points contributing to professional development and revalidation Evidence Register There are a limited number of free places for hub members. Email: info@pslhuborg if interested. Follow on Twitter @HCUK_Clare #hospitalatnight
  13. Content Article
    In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents.
  14. Content Article
    An investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life. Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information. Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.
  15. Content Article
    This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here
  16. Content Article
    On 23 April 2020 Jaqueline Lake commenced an investigation into the death of Eliot Harris aged 48. Eliot had schizophrenia and diabetes. Eliot had not been taking medication for several days and his condition deteriorated. He was admitted to Northgate under the Mental Health Act after assessment on 5 April. He was initially in seclusion then on the ward from 6 April, he spent a lot of time in his room and only ate cheese sandwiches. He only accepted medication in intramuscular form and on 9 April by depot injection. His physical observations were recorded as being normal, and a blood test on 7 April showed he did not have diabetes. His intake of food and fluid remained minimal but he was not put on a chart to monitor this. Staff last entered his room at 17:46 on 9 April. He was last seen conscious at 18:10 on 9 April. He was found unresponsive at 01:33 and declared dead at 02:00.  The investigation concluded at the end of the inquest on 8 August 2022. Medical cause of death: 1a) Unascertained Conclusion: Open – the evidence does not reveal the means by which Eliot Harris came by his death.
  17. Content Article
    Responding to abnormalities in patients’ vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study from Smith et al., in the journal Resuscitation, aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and the failure to respond promptly to patients’ abnormal physiology. The authors found that RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.
  18. Content Article
    This article from Delaveris et al. outlines one health system's experience implementing a bundle to reduce sepsis-related mortality and the observed connection between adherence to the bundle and improved sepsis care.
  19. Content Article
    Implementation of high reliability principles in healthcare delivery is recognized as an effective strategy for reducing harm to patients and healthcare workers. With the coronavirus disease 2019 (COVID-19) pandemic upon us, our emergency departments (EDs) are facing an unprecedented safety threat. How does a high reliability ED function during a pandemic, and what are the most important strategies for keeping ourselves and our patients safe? Thull-Freedman et al. discuss this in a commentary in the Canadian Journal of Emergency Medicine.
  20. Content Article
    A Pareto chart is a type of bar chart in which the factors that contribute to an overall effect are arranged in order from most frequent to least. This ordering helps identify the "vital few" — the factors that warrant the most attention. It also includes a line showing the cumulative % (so you can see easily for example that the top three causes account for 80% of incidents). According to the "Pareto Principle," in any group of things that contribute to a common effect, relatively few account for the majority of the effect.
  21. Content Article
    An honest account from a junior doctor on moving from paper to electronic observation charts and why user testing should be done before rolling it out in hospitals.
  22. Content Article
    The reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery. The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
  23. Content Article
    In this blog, Claire discusses the use of NEWS2 in coronavirus patients and the importance of recognising, tracking and alerting the appropriate team that your patient has an increasing oxygen demand to ensure that the risk of more people being exposed to the virus is minimal.
  24. News Article
    A private healthcare provider has been ordered to pay more than £1.5m – the largest fine issued for such a case – after pleading guilty in a criminal prosecution brought by the Care Quality Commission (CQC) over the death of a young woman at Cygnet Hospital Ealing in July 2019. It is the highest ever fine issued to a mental health service following a prosecution by the CQC. The firm pleaded guilty to one offence of failing to provide safe care and treatment, acknowledging failures to: provide a safe ward environment to reduce the risk of people being able to use a ligature; ensure staff observed people intermittently in line with the company procedures; and train staff to be able to resuscitate patients in an emergency. The offences related to the case of a young woman who was admitted to a ward in Cygnet Hospital Ealing in November 2018. In July 2019, she took her own life while on the ward. CQC said Cygnet Ealing had been aware the young woman tried to harm herself in an almost identical way four months earlier, but had failed to mitigate the known environmental risk she was exposed to. Read full story (paywalled) Source: HSJ, 21 September 2023
  25. News Article
    Priory Healthcare faces legal action following the death of a vulnerable man who was hit by a train after leaving Birmingham’s Priory Hospital Woodbourne in September 2020. Matthew Caseby, 23, detained under the Mental Health Act, escaped the hospital by climbing a 2.3-metre fence. The inquest jury, which heard the University of Birmingham graduate should have been under constant observation but was left alone, reached a conclusion that his death “was contributed to by neglect”. Concerns were raised about the hospital's record-keeping, risk assessments, and fence safety. Following the inquest, the Care Quality Commission (CQC) charged Priory Healthcare with two offences under the Health and Safety Act 2008, related to failing to provide safe care and treatment, and exposing a patient to avoidable harm. Read full story Source: ITV, 6 November 2023
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