Evidence Bite – Pressure ulcers and moisture lesions

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time.

“The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) defined moisture lesions as a separate category; while acknowledging moisture damage can contribute to the formation of pressure ulcers”

Date of publication: May 2018

Evidence Bites: Technology on ward rounds

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Why are ward rounds a patient safety concern? Ward rounds are complex clinical activities, critical to providing high quality, safe care for patients in a timely, relevant manner. They provide an opportunity for the multidisciplinary team to come together to review a patient’s condition and develop a co-ordinated plan of care, while facilitating full engagement of the patient and/or carers in making shared decisions about care.

Date of publication: May 2018

Evidence Bites: Patient Discharge

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Why is patient discharge a safety issue? A 2016 report published by the Parliamentary and Health Service Ombudsmen found that some NHS patients were being discharged unsafely from hospital. Case studies highlighted that patients were being discharged before they were well enough to go home, without a home care plan and without informing their family and carers. NICE’s social care guidance, ‘Transition between inpatient hospital settings and community or care home settings for adults with social care needs’ aimed to address these concerns and gaps in care.

Date of publication: Mar 2018

Evidence Bites: Staffing Pressure

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Why is staffing pressure a patient safety concern? Ensuring NHS providers are staffed with the appropriate number and mix of clinical professionals is vital to the delivery of quality care and in keeping patients safe from avoidable harm. Pressure on staffing may have implications for patient safety incidents relating to human factors and interruptions / distractions in the clinical environment.

New publication: The risks to care quality and staff wellbeing of an NHS system under pressure
A report commissioned by The King’s Fund in Jan 2018 summarises the research evidence on the direct and indirect impact of staff health, wellbeing and engagement on patient care.

Date of publication: Feb 2018

Evidence Bites: Decisions Regarding CPR

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Why is decision-making regarding Cardiopulmonary Resuscitation (CPR) a patient safety concern? Failures in Do Not Attempt CPR (DNACPR) policy, and gaps between policy and practice, are likely to lead to adverse consequences for patients and their families.
What guidance is available on decisions relating to CPR? The British Medical Association (BMA), the Resuscitation Council (UK), and the Royal College of Nursing (RCN) have issued guidance regarding anticipatory decisions about whether or not to attempt resuscitation in a person when their heart stops or they stop breathing.

Date of publication: Jan 2018

Evidence Bites: Ligature points in hospital

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

What is a ligature point? A ligature point anything that could be used to attach a cord, rope or other material for the purpose of strangulation. Ligature risk in an acute setting: Much of the literature around ligature risk is from a mental health setting; however there may be some learning that can be applied to an acute hospital setting. A national clinical survey of suicide cases published in 2012 describes the ligature points and ligatures used in inpatient suicides and identifies trends over time. The most common ligature points and ligatures were doors, hooks/handles, windows, and belts or sheets/towels, respectively.

Date of publication: Dec 2017

Evidence Bites: Human Factors

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

What is human factors? Human factors (sometimes called ergonomics) is the scientific study of the behaviour of individuals, their interactions with each other and with their environment. Human factors offers ways to minimise and mitigate human limitations to reduce error.

Date of publication: Nov 2017

Evidence Bites: Druggles

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

What is a druggle? A druggle is a team huddle to discuss medications. The medical and nursing staff meet with the pharmacist to review medication harm, risks and near misses, so that processes can be improved. Who is using druggles? The druggle emerged from the SAFE programme being run by the Royal College of Paediatrics and Child Health, driven by the use of huddles to embed situational awareness on the ward

Date of publication: Sept 2017

Evidence Bites: Red Bag initiative

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

What is the Red Bag initiative? Sutton Homes of Care Vanguard Programme (Sutton CCG) developed the approach in response to NICE guidance. When a [care home] resident becomes acutely unwell and needs to be taken to hospital, this new pathway ensures they are transferred with a set of standardised paperwork which details all necessary health and social care information about that resident to support staff in providing the right care. This is contained in a “red bag” which also holds their medicines and personal belongings.

This month, NICE have added information regarding the initiative to their website for care home managers. There is a lack of UK evidence for the effect of hospital discharge or transitions training for health and social care practitioners.

Date of publication: Sept 2017

Evidence Bites: Patient Identification

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Why is correct patient identification important? The failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families. The main areas where patient misidentification can occur include drug administration, phlebotomy, blood transfusions, and surgical interventions.

Date of publication: Sept 2017