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  1. Yesterday
  2. Content Article
    On Wednesday 1 May 2024, the National NatSSIPs Network hosted a webinar to discuss the NHS England consultation on the Never Events framework. The consultation is concerned with whether the existing framework is an effective mechanism to drive patient safety improvement. This blog gives an overview of the discussion at this webinar, which had over 200 participants.
  3. Content Article
    Local authorities fund many of the services—such as housing, education and social care—which either support or tackle the drivers of health inequalities. The Institute of Health Equity (IHE) has looked at every local authority in England and plotted levels of health, inequalities in health and cuts in their spending power. This report provides information from 17 local authorities with statistically significant increases in inequalities in life expectancy. The report shows, since 2010, central government spending cuts to local authorities were highest in areas with lower life expectancy and more health inequalities, further harming health in these places. It also confirms widening inequalities in life expectancy between regions in England and within local authorities since 2010.
  4. Content Article
    In this article, Radar Healthcare provides a summary of the main sessions, messages and themes emerging from the Care Show London and the Digital Healthcare Show 2024, which both took place in April 2024. It discusses these topics: Embracing technology in care provision Mastering CQC-ready feedback processes The importance of integration between social care and the NHS Leveraging social media AI: The challenges and opportunities Avoiding digital fatigue:  Fostering patient safety In this final section, the article highlights a presentation given by Patient Safety Learning's Chief Executive Helen Hughes and Chief Digital Officer Clive Flashman about the organisation's patient safety standards. They spoke about the standards and accompanying online patient safety assessment toolkit, an easy-to-use resource designed to help organisations establish clearly defined patient safety aims and goals, support their delivery and demonstrate achievement. The article also highlights the contribution of the hub to improving patient safety, saying, "Patient Safety Learning's platform is recognised for its excellence in sharing knowledge on patient safety. It provides a comprehensive suite of tools, resources, case studies, and best practices to support those striving to improve patient care."
  5. Content Article
    This study in JAMA Network Open aimed to determine whether magnetic seizure therapy (MST) has comparable efficacy to modified electroconvulsive therapy (ECT) for bipolar mania. The results suggest that MST is associated with a high response rate and fewer cognitive impairments in bipolar mania and that it might be an alternative therapy for the treatment of bipolar mania.
  6. Content Article
    Little Voices is a project run by Walsall Healthcare NHS Trust to amplify the voices of children who were patients at the Trust. Little Voices helped inform and support the Trust's ambition to deliver care in a setting that is child-friendly and equitable for all children. Getting input directly from children of a young age enhanced the Trust's understanding of what accessing care is really like for a child, seen through their eyes and not those of a parent or carer. Specific improvements are being implemented in the areas of hand hygiene, mealtimes that matter, play that is engaging and reducing fear and anxiety.
  7. Content Article
    Health inequities are systematic differences in the health status of different population groups. These inequities have significant social and economic costs both to individuals and societies. In this blog, Nichola Crust, Senior Safety Investigator at the Health Services Safety Investigations Body, shares how one primary care network in the north of England is tackling health inequity by building relationships beyond traditional healthcare boundaries, with patient-centred leadership.
  8. Last week
  9. Content Article
    In March 2024, the Professional Standards Authority (PSA) convened a roundtable discussion entitled ‘Accountability, fear and public safety’ to explore some of the recent NHS safety culture initiatives in England and their relationship with professional health regulation. In this blog, Anna van der Gaag, Visiting Professor in Ethics & Regulation at the University of Surrey, reflects on this discussion and how to bring the best of safety culture initiatives and the best of regulatory processes together to do more for patient safety.
  10. Content Article
    This narrative review aimed to investigate adverse events in trauma resuscitation, evaluate contributing factors and assess methods, such as trauma video review (TVR), to mitigate adverse events. The authors found that, when integrated with standardised tools, TVR shows promise for identifying adverse events. They suggest that future research should prioritise linking trauma team performance to patient outcomes and developing sustainable TVR programs to enhance patient safety.
  11. Content Article
    The NHS Constitution sets out the principles, values, rights and pledges underpinning the NHS as a comprehensive health service, free at the point of use for all who need it. The Department of Health and Social Care is seeking views on how best to change the NHS Constitution, as part of the process of completing its 10 year review. They are requesting feedback from patients, carers, NHS staff and the public on the proposals set out in this consultation document. This consultation closes at 11.59pm on 25 June 2024.
  12. Content Article
    This article tells the story of 61 year-old Susannah Constantine who was diagnosed with a rare neurological condition after her MRI was not looked at by her GP surgery for over a year. Susannah decided to have a private MRI when doctors couldn't diagnose why she’d been suffering from tinnitus and pins and needles in the fingers of her left hand. The results were sent to her GP, and Susannah heard no more, so struggled on for another year—she gradually became weaker and her muscles atrophied. She called her GP surgery to check if the MRI held any clues and learnt no one there had ever looked at the results—they had just been sat there for a year. She was told she needed to see a neurosurgeon immediately and was diagnosed with arteriovenous malformation (AVM), a rare neurological condition that disrupts the flow of blood and oxygen to the brain. If not spotted and treated in good time there is a one in three chance of suffering a brain haemorrhage, paralysis or stroke.
  13. Content Article
    Abbie experienced a high-risk pregnancy with her twin girls. They were born at 27 weeks gestation and weighed in at just 677g and 500g. After 150 nights in Neonatal Intensive Care Unit (NICU), both of Abbie’s daughters came safely home.  In this blog, Abbie highlights the importance of building a trauma-informed, clinical network around women whose babies have spent time in NICU. Drawing on her own experience and insights, she offers suggestions for how midwives, GPs and health visitors can support their mental health postnatally. 
  14. Content Article
    This Washington Post article looks at the lack of error and accident reporting in the US reproductive health and fertility industry. Unlike any other area of healthcare, no outside authority or agency regulates Never Events that happen at fertility providers. The authors highlight a case that allowed a glimpse into the industry, when legal action was taken against a San Francisco fertility centre where a storage tank imploded, damaging or destroying 4,000 human eggs and embryos. A jury later found that a manufacturing defect was largely to blame for the disaster but also implicated the actions taken by staff at the centre. The authors also highlight that patients are often asked to sign nondisclosure agreements as part of a legal settlement, which further restricts transparency when something goes wrong.
  15. Content Article
    The health needs of the population are changing as it ages. Health services, particularly in secondary care, have traditionally been designed to deal with patients with a single disease, but for a growing number this is no longer a suitable model of care. Primary care has been at the vanguard of delivering more person centred and whole-person care, but many of the existing policy measures and incentives within it are outdated and aimed at managing single diseases. This report by Future Health sets out a series of recommendations for developing the Major Conditions Strategy to encompass a wider range of long-term and multiple conditions, putting patients rather than specific conditions at the centre. It also provides new data on the rising challenge of long-term conditions and in particular multiple long-term conditions.
  16. Content Article
    In this HSJ blog, Ken Jarrold highlights three key things he learned during his ten years as chair of NHS trusts: Focus on the people that matter—service users and frontline staff Keep an appropriate level of contact and relationship with the chief executive Live the values of the trust. He emphasises chairs keeping their focus on the people they serve and ensuring they feel at home interacting with staff and service users, as well as other leaders. He also states his hope that the Leadership Competency Framework for conducting annual appraisals of NHS chairs published by NHS England in February 2024, if applied appropriately, will result in improvements in how chairs serve their organisations.
  17. Content Article
    This presentation looks in detail at Never Events, which it defines as serious, largely preventable patient safety incidents that should not occur if relevant preventative measures have been put in place. It sets out their history and development in the NHS in England, outlines different types of Never Events and considers how they can be tackled and prevented.
  18. Content Article
    Never Events are serious, largely preventable patient safety incidents that should not happen if the available preventative measures have been implemented by the healthcare provider. This document sets out the NHS approach to Never events and includes a list of recognised Never Events in 2012/13.
  19. Content Article
    This article reflects on the death of Wayne Jowett and the impact this had on how the NHS approaches patient safety. Wayne died after the cytotoxic drug vincristine, intended for intravenous injection, was instead injected into his spine. The circumstances around his death informed the subsequent development of Serious Reportable Events in the NHS, and later the Never Events Framework.
  20. Content Article
    This framework establishes a standardised approach to the annual appraisal of chairs, including ICB, NHS trust and foundation trust chairs. The appraisal should be a valuable and valued undertaking that provides an honest and objective assessment of a chair’s impact and effectiveness, while enabling potential support and development needs to be recognised and fully considered. The framework is aligned with the NHS Leadership Competency Framework and informed by multi-source feedback. It establishes a standard process, consisting of four key stages, to be applied to the annual appraisal of chairs.
  21. Content Article
    Fatigue is a perpetual risk in safety-critical industries. If that risk is not managed appropriately, it can result in a significant reduction in human performance, with associated impacts on safety. This paper from the Chartered Institute of Ergonomics & Human Factors (CIEHF) aims to present a roadmap for improving fatigue risk management in health and social care to improve patient safety and individual health workers' health and wellbeing. It makes a case for UK health and social care national bodies and organisations managing fatigue as a systemic risk.
  22. Content Article
    A growing number of patients with eating disorders are reporting having treatment withdrawn by services, often without notice and without their consent. We spoke to eating disorder campaigner Hope Virgo about how pressures on services, enduring stigma around eating disorders and dangerous new narratives are leading to the practice of treatment withdrawal. Hope explains how this is affecting vulnerable patients and highlights that as the number of people developing eating disorders increases, the risks to patient safety will only get worse.
  23. Content Article
    Disordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating.
  24. Content Article Comment
    Hi Rachel, @Rachel Pool yes of course. I have created Appreciative Inquiry within a STEIS investigation looking at the period of time that a critical incident had been declared. Initially the focus was to review the harm incidents within the critical incident time period, however I built within a full audit the mandatory field 'what went well?'. You could not bypass the field without putting something in. From there I used the results of the 'what went well?' mandatory field to identify potential appreciative inquiries. I was able to identify 6 formal appreciative inquiries where we were able to name around 60 people who had been part of excellent care and the learning from the care delivered. We then delivered the appreciative inquiries both to the staff mentioned to thank them but also the the Executive team. After that time, I have used 'what went well?' in numerous audits, however there are other examples within the book 'Appreciating Health and Care' where for example, research nurses reviewed the sepsis care of patients looking for positive examples of care (antibiotics given in one hour etc) and then created appreciative interviews with the staff they identified to find out the environmental aspects and behavioural aspects of delivering excellent care. In the new ebook being released alongside 'Appreciating Health and Care', I have provided a detailed overview of the appreciative inquiry in StEIS investigations and can post it in here if that helps? Thankyou so much for asking for more information though. Always happy to assist people to appreciate.
  25. 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.
  26. 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.
  27. Earlier
  28. 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.
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