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  1. Today
  2. Content Article
    This video provides an introduction to Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF). The PCREF aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment.
  3. Yesterday
  4. Content Article Comment
    Hi Katy, @katy.fisher Thanks for sharing your experience, it was really interesting to read. Could you tell us a bit more about creating appreciative inquiries from audit and investigations? Thank you, Rachel
  5. Content Article
    On 17 and 18 April 2024, government ministers, high-level representatives and health experts from all over the world gathered in Santiago, Chile for the Sixth Global Ministerial Summit on Patient Safety. In this long-read article, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the key themes and issues discussed at the event.
  6. Last week
  7. Content Article
    The debate about fairness of artificial intelligence (AI) in health care is gaining momentum. At present, the focus of the debate is on identifying unfair outcomes resulting from biased algorithmic decision making. This article in The Lancet Digital Health looks at the ethical principles guiding outcome fairness in AI algorithms.
  8. Content Article
    This Office for National Statistics (ONS) report provides in-depth analysis of Winter Coronavirus Infection Study (Winter CIS) data looking at trends in self-reported symptoms of Covid-19 including ongoing symptoms and associated risk factors. Winter CIS was a joint study with the UK Health Security Agency (UKHSA), carried out between November 2023 and March 2024 for England and Scotland. The study was structured as a longitudinal panel survey, with each participant sent a questionnaire and asked to take a lateral flow device test every four weeks for the detection of Covid-19.
  9. Content Article
    This report is a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001). It finds that diagnosis, and in particular the occurrence of diagnostic errors, has been largely unappreciated in efforts to improve the quality and safety of healthcare. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, healthcare organisations, patients and their families, researchers and policy makers. The report's recommendations contribute to the growing momentum for change in this crucial area of healthcare quality and safety.
  10. Content Article Comment
    Thank you for sharing & for your commitment many would be too tired/scared to continue. I am sure you will not be alone in your personal experience and the response that you got. It is a sad situation to find ourselves in & one could argue with the lack of transparency we have learnt nothing from Francis, Morecombe Bay & many more public/large enquiries. PSIRF has encouraged learning through different routes/methodologies and that includes through, and with our patients/families & staff. However, like your experience, it has not equipped those wanting to listen, learn & share with the 'negative' fall out of those more worried by their 'reputation.' My view is that 'reputations' will be very short-lived compared to the long term impact on patients, families & staff when they are harmed in NHS care. I just hope that the future leaders of the NHS can see the value of inclusion and learning rather than 'judging' and 'numbers'; sometimes you have to be brave & 'air your dirty laundry' in order to learn and move forward; that is how reputations will be remembered, not by what you choose to 'hide' or 'manipulate' for a good look.
  11. Content Article
    The Patient and Carer Race Equality Framework (PCREF) was a recommendation following the national Mental Health Act Review in 2018. This video by South London and Maudsley NHS Foundation Trust (SLAM) explains PCREF and how it is being applied at the Trust.
  12. Content Article
    Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF) aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. This video was produced by SHSCFT to guide staff in having conversations about collecting information on ethnicity from patients and carers.
  13. Content Article
    Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF) aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. This video was produced by SHSCFT to help staff, service users and their families understand the importance of sharing information around their ethnicity and protected characteristics.
  14. Content Article
    These patient safety professional standards aim to support pharmacists when responding to patient safety incidents. They describe good practice and provide a broad framework for continually improving services, shaping future services and roles and delivering high-quality care across all settings and sectors. They have been developed by the Royal Pharmaceutical Society (RPS), Association of Pharmacy Technicians UK and Pharmacy Forum NI, with the support of an expert steering group and public consultation. Pharmacists, pharmacist prescribers, pharmacy technicians and the wider pharmacy team across the United Kingdom will find these standards useful. They may also be of interest to the public, to people who use pharmacy and healthcare services, other healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
  15. Content Article
    Clive Treacey, who had a learning disability, epilepsy and complex mental health needs, died in 2017 aged 47, having spent his adult life in residential social care and inpatient settings. In 1993, he was placed by Staffordshire County Council into the David Lewis Centre in the borough of Cheshire East, where it is alleged he was sexually abused by a member of staff. Cheshire East Safeguarding Adults Board (CESAB) and Staffordshire and Stoke-on-Trent Adults Safeguarding Partnership Board (SSASPB) jointly commissioned a Discretionary Safeguarding Adults Review (D-SAR) to look at Clive's case. Authored by Professor Michael Preston-Shoot, the review relates to historical incidents of abuse and examines what is now in place to protect adults at risk since adult safeguarding became a statutory duty under the Care Act in 2014. The SAR makes 14 recommendations to the boards.
  16. Content Article
    This toolkit is a practical guide for system leaders that will help to inform future spending on health inequalities and support implementation of high-impact changes within integrated care boards (ICBs) to address health inequalities. It aims to build system leaders’ confidence in their ability to tackle inequalities in their organisations and is accompanied by a research report that looks at the approaches systems took to spending health inequalities money. It is structured in line with the four main stages of quality improvement methods:  Culture, leadership and governance Understanding the problem Developing the best solution Evaluating success
  17. Content Article
    Healthcare services improvisation relies heavily on collaborating with patients and caregivers by acknowledging their feedback to enhance quality and safety. The 2023 World Patient Safety Day underscores the significance of co-production with patients in safety strategies. In accordance with this, a crucial tool that involves patients and caregivers is the “Patient-reported experience measures (PREMs)” that help in assessing healthcare delivery in terms of quality, safety and performance. These tools for various healthcare processes offer valuable insights into treatment effectiveness and areas needing improvement. PREMs are surveys used to assess patients' care experiences objectively, aiding in pinpointing the areas for improvement. Unlike patient satisfaction measures, which reflect only subjective evaluations, PREMs offer an objective view of care encounters. In view of the importance of a standardised tool for Indian health care organisations, CAHO in collaboration with various stakeholders and patients unveil the White paper on Patient-Reported Experience Measures (PREMs) tool development process. This white paper was released by the honourable governor of West Bengal, Dr C.V Ananda Bose at the recently concluded CAHOCON 2024 at Biswa Bangla, Kolkata.
  18. Content Article
    Computerised provider order entry (CPOE) prompts can provide patient-specific risk estimates for multidrug-resistant organisms (MDROs). This JAMA Network study aimed to find out whether CPOE prompts could reduce empiric extended-spectrum antibiotic use in patients admitted with pneumonia. The authors found that prompts promoting standard-spectrum antibiotics for patients at low risk of infection with MDROs reduced extended-spectrum antibiotic use by 28.4%, without increasing intensive care unit transfers or length of stay for patients with pneumonia.
  19. Content Article
    This White Paper sets out the Labour Government's proposals to reform and expand community health and social care services in order to meet local needs, especially in poorer deprived communities. Four key objectives are highlighted in the White Paper: better health prevention services with earlier intervention; increased patient choice; tackling inequalities and improving access to community services; and increased support for people with long-term needs to live independently. Specific measures include: expansion of local care settings outside hospitals; increased joint commissioning between PCTs and local authorities to improve service integration; the introduction of practice based commissioning, where GPs are given more responsibility for local health budgets; increased provision for new primary care providers to compete for PCT contracts; and the introduction of a new NHS ‘Life Check’ to promote healthier lifestyles with a pilot scheme in spearhead PCTs by 2007-08.
  20. Content Article
    Measures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team. To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration.
  21. Content Article
    Measures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognize or respond to deterioration. The current study explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalised deteriorating patients.
  22. Content Article
    Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Despite these, 7% of the deaths reported to the National Reporting and Learning System from acute hospitals in 2015 related to a failure to recognise or respond to deterioration. Interventions have been developed that allow patients and relatives to escalate patient deterioration to a critical care outreach team. However, there is not a strong evidence base for the clinical effectiveness of these interventions, or patients’ ability to recognise deterioration. The aims of this study were to (a) identify methods of involving patients in recognising deterioration in hospital, generated by health professionals, and (b) to develop and evaluate an identified method of patient involvement in practice, and explore its feasibility and acceptability from the perspectives of patients. The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.
  23. Content Article
    At a recent meeting of the 'Safer Healthcare Biosafety Network' (SHBN), members learned of a new initiative designed to improve the safety of healthcare workers in the event of a future pandemic. It should also greatly reduce nosocomial (healthcare acquired) infection. David Osborn explained that the intention is to shift the focus for respiratory protective equipment (RPE) away from FFP3 respirators more towards powered air-purifying respirators (PAPRs). Although FFP3s provide efficient protection, they have several disadvantages for use in the healthcare sector, particularly when providing prolonged care of infectious patients. At the height of the pandemic, given the shortage of respirators, a new type of PAPR was developed at Southampton University and used to great effect. Staff reported that, whilst previously they had been coming to work in fear of infection, they now felt safe and secure in the knowledge that they were well protected. David is supporting Professor Kevin Bampton (Chief Executive, British Occupational Hygiene Society) and Professor Paul Elkington (Director, Institute for Medical Innovation, Southampton University). Following the SHBN, David prepared a briefing note (attached below) providing more details of the project.
  24. Content Article
    Children being subjected to lethal medical experiments sounds like the plot of a dystopian horror film. Yet that is exactly what happened in the UK in the 1970s and 80s. New documents seen last week by the BBC reveal the extent to which children with haemophilia and other blood clotting disorders were enrolled in clinical trials, often without their parents’ consent. Most of them were infected with HIV or hepatitis C as a result of being treated with blood products that doctors knew could kill them. At one boarding school for boys with haemophilia used by the doctors conducting these trials, Treloar College in Hampshire, 75 out of the 122 pupils who attended between 1974 and 1987 have died as a result of their HIV or hepatitis C infections. The independent inquiry on the contaminated blood scandal estimated that 1,250 people contracted both HIV and hepatitis C as a result of these agents, and between 2,400 and 5,000 people hepatitis C alone. Others contracted these viruses after receiving blood transfusions following surgery or childbirth; it is thought that up to 100 people were infected with HIV this way, and 27,000 people with hepatitis C. Around 2,900 people have died so far. One gets a sense of the horrific trauma the state inflicted on people by reading the evidence those affected gave the inquiry.
  25. Content Article
    In this blog Dr Henrietta Hughes, Patient Safety Commissioner for England, outlines the activities included in the Patient Safety Commissioner Business Plan 2024-25.
  26. Content Article Comment
    Thank you very much for writing this account. I too admire your tenacity and courage in doing what is right. Being so transparent and open is new and scary for some organisations and people still so we need pioneers like yourself. The reactions I get around the country in response to using After Action Review with patients and families participating illustrates the same concerns. Some trusts are all for it, others, are very hesitant.
  27. Content Article
    'Vinney' died of pulmonary thromboemboli due to deep vein thrombosis with a background of metastatic carcinoma of the base of the tongue following cardiac arrest on 25 January 2019 at HMP Lewes (Cell 216 on C-Wing), whilst on remand. He was pronounced dead at 9.16 am. The jury considered that Vinney’s care was affected by the following issues, the absence of which may have delayed or changed the circumstances of his death. There was confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne, leading to an over reliance on Vinney’s own statements. Some poor record keeping on SystmOne and confusion over when to reference the system. This affected both plans and reporting of interactions. Failures in communication between agencies and shifts, not helped by the numbers of different staff and agencies involved, high demand and challenging workloads and associated delays in accessing healthcare. This was particularly relevant between 21 and 24 January 19. In particular a lack of quantifiable evidence, e.g. NEWS scores or notes of proportionate follow-ups and recorded observations between 21 and 24/1/19 which may have allowed any deterioration in Vinney’s condition to be missed. On 25/1/19, there was a grave and unacceptable failure in communications with two or three emergency radios switched off in contravention of prison rules and protocols. This was then compounded by a delay in timely response, i.e. the proposal of a phone call rather than an in-person response, which may have been longer had it not been for decisive intervention from comms. This was followed by unacceptable indecision on calling an ambulance, in which perceptions of Vinney’s mental health were a factor, and should have been automatic on account of his head injury.
  28. Content Article
    This podcast looks at preventing respiratory syncytial virus (RSV) outbreaks within healthcare facilities and strategies to minimise transmission of RSV among healthcare workers and patients during an outbreak. 
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