International Journal of Risk & Safety in Medicine - Volume Pre-press, issue Pre-press

Authors: Milionis, Charalampos | Ilias, Ioannis | Venaki, Evaggelia | Koukkou, Eftychia

Article Type: Research Article

Abstract: BACKGROUND: Gender dysphoria is characterised by a sense of distress because of discordance between the self-perception of gender identity and the assigned sex. Hormonal treatment of transgender males uses testosterone to induce and preserve masculinisation. OBJECTIVE: The study investigated the safety of testosterone therapy in transgender males. METHODS: The present study used a retrospective file review of transgender male subjects who were treated with testosterone (initially transdermal testosterone gel and subsequently parenteral testosterone undecanoate) for at least 18 months and had subsequently achieved a serum testosterone level within the normal range of cisgender male counterparts. Changes …in somatometric data and blood biomarkers were investigated. RESULTS: The mean testosterone serum levels after approximately 18 months of treatment were about 545 ng/dL (SD ± 94 ng/dL). There was a statistically significant rise in body mass index (𝜒d = +1.23 kg/m2 ) with a reduction in blood glucose (𝜒d = −5.33 mg/dL) as well as statistically significant increases in aspartate transaminase (𝜒d = +4.3 U/L), haemoglobin (𝜒d = +1.72 g/dL) and haematocrit (𝜒d = +4.76%). In contrast, there were no significant changes in the lipidaemic profile of the subjects. CONCLUSIONS: Treatment with testosterone is routinely used for the promotion of virilising physical changes in transgender males. However, the likelihood of adverse effects of continuous administration treatment is still unclear. This study contributed to the notion that achieving testosterone levels within the target range is a prerequisite for the safety of the gender-affirming treatment. Show more

Keywords: Transgender persons, testosterone, evidence-based medicine

DOI: 10.3233/JRS-200087

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. 1-8, 2022

Authors: Del Fabro, Giovanni | Mileto, Palmiro | Castelli, Francesco | Quiros-Roldan, Eugenia

Article Type: Case Report

Abstract: BACKGROUND: Two-drug regimens antiretroviral therapies are increasingly prescribed to HIV patients, as they are recommended by international guidelines, and they show an excellent efficacy, safety, and tolerability profile. Regimens administered as single tablets (STRs) are usually preferred by patients and they are associated with higher adherence. CASE REPORT: We report two cases of drug-induced hypersensitivity (DIH) that occurred after switching from dolutegravir (DTG) plus rilpivirine (RPV) in separate pills to a fixed dose combination containing the same molecules (DTG/RPV; Juluca® ). Following the DIH event, DTG/RPV coformulation was discontinued. At symptomatic resolution, they continued to receive DTG plus …RPV in separate pills uneventfully. The component present only in the DTG/RPV coformulation was iron oxide red (E172), contained in the film-coating. Iron oxide red is an approved colorant, used as drug excipient. Patch test with DTG/RV coformulation performed several months after the DIH event was negative. Drug allergy to excipients remains underappreciated and underreported and frequently leads to inappropriate medication discontinuation. CONCLUSION: Our case underscores the role of meticulous medication allergy history in differentiating true medication allergy from excipient allergy. This observation may be useful in the era of antiretroviral simplification to two-drug regimens. Show more

Keywords: Drug induced hypersensitivity, single tablet regimen, DTG/RPV, iron oxide red, excipient

DOI: 10.3233/JRS-220022

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. 1-5, 2022

Authors: Quiney, Gabriella | Colucci, Gianluca

Article Type: Research Article

Abstract: BACKGROUND: Morbidity and Mortality meetings (M&Ms) are a fundamental element of surgical practice. However, there has been little investigation into best practices, to maximise education and improvement outcomes. OBJECTIVE: Create a new, evidence-based M&M methodology, that facilitates standardised analysis of errors in a non-judgemental fashion, and highlights areas for improvement. METHODS: A Quality Improvement (QI) methodology was used. This project encompassed a literature review and two sequential QI cycles. A literature review and initial survey highlighted best practice and identified areas for improvement. From this information, a new standardised format was created, which centred around a …new modified Fishbone framework, incorporating the London Protocol methodology. The project then sequentially tested new formats, with feedback collected for every new format. RESULTS: The literature review and surveys guided improvement of the M&M. The need for standardisation was highlighted. The new PowerPoint template and modified Fishbone ensured presentations and analysis were consistent and systematic. Participants reported that M&Ms were more engaging, interactive and structured, ensuring improved discussion of errors. The modified Fishbone framework reinforced a blame-free, system-focused analysis. CONCLUSION: M&Ms are a critical aspect of patient safety. This project utilised simple QI tools to encourage collaborative reflection, learning and improvement. Show more

Keywords: M&M, quality improvement, fishbone, healthcare

DOI: 10.3233/JRS-210077

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. 1-10, 2022

Authors: Patel, Samit | Utting, Isabel | Ang, Wan Wei | Fautz, Tessa | Radmore, Rebecca | Vourou, Panayiota | Beaumont, Lara | Reyland, Paula | Lillis, Ashling

Article Type: Research Article

Abstract: BACKGROUND: Discharge summaries (DCS) are vital in facilitating handover to community colleagues. Unfortunately, at Whittington Health, General Practitioners (GPs) found it difficult to identify relevant information in DCS, and use of medical jargon meant patients did not understand details of their admission. With this quality improvement project, the team aimed to improve DCS to enhance patient-centered care. OBJECTIVE: The aim of this quality improvement project (QIP) was to improve the quality of DCS by critiquing the ones produced within our trust and implementing various interventions. METHODS: Multiple Plan-Do-Study-Act (PDSA) cycles were completed. A multi-disciplinary meeting was …conducted to identify the needs of each party in a DCS. A new template was subsequently launched. Teaching was conducted and educational leaflets were disseminated hospital-wide. Quality of written communication was audited quarterly, and evaluated against quality indicators. Problems with DCS were identified via GP and patient feedback, and these became the focus of subsequent PDSA cycles. RESULTS: From March 2019 to February 2020, all the audited categories improved, with an overall improvement from 67% to 92%. We also received positive feedback from GPs. CONCLUSIONS: Quality of DCS can be improved with appropriate interventions, leading to improved patient care. A similar PDSA cycle could be utilized elsewhere to achieve similar results. Show more

Keywords: Discharge summary, quality improvement, PDSA cycle, patient satisfaction, audit

DOI: 10.3233/JRS-227026

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. S1-S5, 2022

Authors: Politis, Anna | Cook, Hannah | Cohen, Hugo M.L. | Pullyblank, Anne

Article Type: Research Article

Abstract: BACKGROUND: The General Medical Council (GMC) states that all intimate examinations should have a chaperone offered. Documentation of chaperone identity, or patient’s refusal, is essential. OBJECTIVE: This project aimed to improve documentation of chaperones during intimate examination of patients based in a Surgical Admissions Unit (SAU) within a large tertiary hospital in the Southwest of the UK. METHODS: A Plan-Do-Study-Act (PDSA) cycle structure was used. Initial data collection and planning occurred in December 2019. Intervention implementation and analysis occurred from January 2020 to March 2021. Intervention 1 involved presenting results at a clinical governance meeting. Intervention …2 was information posters in the SAU and intervention 3 involved training sessions for nursing staff. Intervention 4 was editing the surgical clerking proforma. RESULTS: Prior to interventions, chaperone identity or patient’s refusal was correctly documented only 9.7% (N  = 7 out of 72) of the time. Intervention 1 increased this to 34.6%. Following intervention 3 and 4, correct documentation was 25.0% and 28.6% respectively. After intervention 4 correct documentation was at 59.1%. CONCLUSIONS: Initial documentation of chaperones was poor. Interventions 1 to 3 were successful in educating clinicians how to document accurately, but engaging individuals in person was more successful than passive education through posters. Changing the proforma structure was the most successful intervention. This suggests a visual reminder for clinicians at the point of contact with the patient is the most effective way to encourage correct documentation of chaperones, improving patient care and clinical practice. Show more

Keywords: Documentation, chaperones, intimate examination, surgery, proforma

DOI: 10.3233/JRS-227031

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. S1-S5, 2022

Authors: Jayaraajan, Keerthanaa | Sivananthan, Ahrabbey | Koomson, Abeku | Ahmad, Aznavar | Haque, Mohammed | Hussein, Mohammod

Article Type: Research Article

Abstract: BACKGROUND: Previous reports have shown that there are long waiting times to commence therapy in the community-based mental health programme, IAPT (Improving Access to Psychological Therapies). OBJECTIVE: This study aimed to explore both causes and potential solutions to alleviate the burden of these waits. METHODS: A Systematic Literature Review (SLR) and Semi-Structured Interviews (SSIs) were conducted to identify causes and effects of these waits. Consequently, meaningful recommendations were made and tested with the aim of improving IAPT’s waiting times. RESULTS: SLR and SSIs revealed high ‘Did Not Attend’ (DNA) rates and a lack of …support between initial appointments as being both a cause and effect of long waits. The identified issues were tackled with the development of an App design. Expert interviews and a mass survey fuelled the iterative process leading to a final prototype. Notable features included: therapist profile page, smart appointment reminders and patient timeline. Positive feedback was received from university students and ICS Digital, with scope to trial the App within Manchester CCG. CONCLUSIONS: In the long run, the App aims to indirectly shorten waiting times by addressing treatment expectations and serving as an IAPT companion along the patient journey, thus reducing anxiety and consequently DNAs. Show more

Keywords: Anxiety, depression, waiting times, CBT, improving access to psychological therapies (IAPT), non-attendance

DOI: 10.3233/JRS-227033

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. S1-S8, 2022

Authors: Pathan, Aly Zaheer | Barwell, Jennifer | Kastrissianakis, Artemis | Awan, Kiran | Abila, Anie | Lim, Amelia | Wickramasinghe, Rucchira | Pathare, Anuj | Deakin, Susan

Article Type: Research Article

Abstract: BACKGROUND: Since the outbreak of the coronavirus (SARS-Cov-2), wearing personal protective equipment (PPE) has become necessary. Patients’ ability to recognize staff is disrupted impacting on the relationship between healthcare worker and patient. OBJECTIVE: Assess the patients’ perspective of healthcare workers wearing PPE and its effect on communication. METHODS: Admitted Orthopaedic patients during the first wave of SARS-Cov-2 were surveyed about the experience with staff wearing PPE. In response to feedback, individual badges with large pictures and names were introduced to wear over PPE. Patient views and response to the badges was collected from surveying admitted patients. …RESULTS: Patients encountered staff wearing face masks and felt this was appropriate in the context of the pandemic. 44% responded that they would prefer staff wearing badges with names, roles and pictures more visible. Following the introduction of badges, patients were better able to recognize staff roles and remember names. Hospital staff felt this was a positive change to help improve rapport while wearing PPE. CONCLUSION: Wearing PPE affects patients’ ability to recognize individuals in a fast-paced environment such as an acute hospital. Introducing badges was an intervention based on patient feedback and an important adaptation to sustained PPE use to improve the patient’s experience. Show more

Keywords: COVID-19, SARS-Cov-2, PPE, patients’ perception, communication

DOI: 10.3233/JRS-227032

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. S1-S5, 2022

Authors: Woolford, Megan | Todd, James

Article Type: Research Article

Abstract: BACKGROUND: The Nightingale North West (NNW) was a UK temporary field hospital set up during the COVID-19 pandemic. Policies and standard operating procedures were undeveloped. Visitors were permitted only in exceptional circumstances, resulting in heightened anxiety for patients and next of kin (NOK). OBJECTIVE: Recognising the importance of effective NOK communication, a quality improvement project (QIP) was undertaken to improve communication between doctors and NOK. METHOD: NOK satisfaction with communication received from doctors (scored 1–5) was the primary outcome measure and data was collected through standardised phone-calls. A wide four point (1–5) variability in satisfaction was …identified. PDSA methodology was used to introduce interventions: (1) ‘Gold standard’ for frequency of NOK updates; (2) Record date of NOK update on the doctors’ list. RESULTS: Early post-intervention data showed reduced variability in satisfaction with 82% of NOK scoring ‘4’ or ‘5’. Process measures demonstrated excellent uptake of interventions. CONCLUSION: Conclusions are limited by the project’s short time-frame but there is a promising role for these interventions in enhancing doctor-NOK communication. Show more

Keywords: Communication, COVID-19, Nightingale Northwest, Quality improvement project, Next-of-kin

DOI: 10.3233/JRS-227034

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. S1-S5, 2022

Authors: Landin, Madeleine | Palmer, Charlotte | Paul, Nadine | Shahrjerdi, Puneh

Article Type: Research Article

Abstract: BACKGROUND: Patients in psychiatric inpatient settings are at increased risk of developing physical health complications due to the structure of inpatient wards, the metabolic side-effects of antipsychotic medications and socioeconomic factors. Robust physical health monitoring and interventions are paramount in reducing this health inequality. OBJECTIVE: To improve the quality of physical health interventions in the ward environment and empower patients to follow healthy lifestyle guidance to reduce their risk of metabolic syndrome. METHODS: Patient weight and waist circumference data were collected at baseline and weekly throughout the 8-week intervention period. A questionnaire was recorded from baseline …to week-5 to assess patient understanding. Two PDSA cycles were completed: (1) Series of weekly psychoeducation sessions and group exercise and (2) Implementation of healthy living diaries. RESULTS: Our data did not demonstrate any definitive impact upon the waist circumference and weight of participants. However, analysis of the questionnaires showed a consistent trend in knowledge improvement. CONCLUSION: Whilst our aim of reducing patient weight and waist circumference was not realised, there was a significant impact on participant’s knowledge, demonstrating a subjective benefit of our interventions. Our project also highlighted inconsistencies in physical health measurements and data collection, providing vital information for further quality improvement measures. Show more

Keywords: Physical health, patient education, metabolic risk factors, inpatient psychiatry, forensic psychiatry, intellectual disability psychiatry

DOI: 10.3233/JRS-227030

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. S1-S6, 2022

Authors: Turton, Emily | Myles, Liam | Lee, James | Saffin, Victoria | Lawson, Amy

Article Type: Research Article

Abstract: BACKGROUND: In 2011 Mrs A assaulted two people, one who died. In the hours prior to the attack she made multiple attempts to gain help including attending accident and emergency, contact with an inpatient service and the police. Subsequent investigation highlighted that her risk was not well documented or understood. OBJECTIVE: This quality improvement project aimed to improve knowledge and awareness of HCR-20 risk assessments amongst mental health professionals. METHOD: The Quality Improvement approach was taken and various initiatives were introduced to improve knowledge of the location and purpose of the HCR-20 and to ensure that …these risk assessments were regularly updated. RESULTS: The results indicated that knowledge relating to the HCR-20 significantly improved amongst staff and breaches of deadlines for updating these risk assessments dramatically declined after the induction of the interventions. CONCLUSION: Including the ‘risk formulation’ and ‘scenarios’ from the HCR-20 in clients’ crisis plans, introducing training relating to the HCR-20, and including discussions relating to the HCR-20 at the beginning of CPA meetings resulted in improved MDT awareness and knowledge of the HCR-20. A broader understanding and awareness of risk factors enabled the service to move towards a culture of risk being everyone’s business. Show more

Keywords: Forensic psychology, forensic psychiatry, HCR-20, multidisciplinary risk assessment, quality improvement

DOI: 10.3233/JRS-227029

Citation: International Journal of Risk & Safety in Medicine, vol. Pre-press, no. Pre-press, pp. S1-S5, 2022