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Community PostThis new qualitative study might be of interest to those who have experienced dental diagnostic error or diagnostic failure. It's a start in building research evidence around the harms that can be caused. Patients’ experiences of dental diagnostic failures: A qualitative study using social media (April 2024)
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Community Post
Painful hysteroscopy
AgatheC replied to Claire Cox's topic in Patient stories
- Patient harmed
- Stress
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Reading all these testimonials is both comforting and horrifying. I didn't get the procedure in UK but in France and it was the worst pain I've ever experienced in my life. And I didn't even go all the way through with it - I fainted and came back (they still didn't stop) then I had an anxiety attack. Anxiety attack manifest in full body tetany with me, so they had to stop. Every doctor I've talked to about it told me it would be like period cramps. What an unimaginable lie. I read someone describing it has having your something cut from within, that's what it felt like. On top of being excruciatingly painful, I felt violated. The days that followed I was in a daze and kept bursting in tears. The pain that followed the days after was no walk in the park, I had fainting spells, terrible cramps and feeling like someone was punching me from inside. It has been two months and I still cannot have intercourse without being in pain afterwards. I still have to get an appointment but they probably did some damage, I'd imagine at best some scars in the uterus. I would never had undergone that procedure if I had known. At least not without proper anesthesia. It is also probably because of my very understandable reaction of panic that something got damaged down there - probably from the instruments still being in me as I had my tetany attack. Any post checkup ? Of course not. Gynecology is goddamn shame.- Posted
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- Patient harmed
- Stress
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Community Post
Medication supply issues: have you been affected?
Patient_Safety_Learning replied to Patient_Safety_Learning's topic in Medication
- Medication
- Pharmacy / chemist
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An interview published today on the hub that may be of interest:- Posted
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- Medication
- Pharmacy / chemist
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Community Post
Expert patients and repeat medications
Lucas27 replied to Clive Flashman's topic in GP and primary care
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Ugh, that sounds frustrating! Dealing with unnecessary hoops for a simple inhaler replacement can be a real hassle. The idea of classifying experienced patients as 'expert patients' is brilliant – could save a lot of time and streamline the process- Posted
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Community PostReaching out to NHS professionals involved in transporting and delivering drugs is a smart move. Collaborating with them can provide valuable insights and help streamline procedures.
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Community PostLast week in Geneva the World Health Organisation Executive Board approved the “draft global action plan for infection prevention and control, 2024‒2030: draft global action plan and monitoring framework” and this will now proceed to the World Health Assembly in May for ratification by all WHO Member States. This very detailed action plan with its set of indicators, outlines a plan for countries and health care facilities to achieve the global vision that by 2030, everyone accessing or providing health care is safe from associated infections. A set of annexes go into the detail on the indicators and key players that will be instrumental in implementation of the plan once it has been ratified. There's a big focus on ensuring that in each country, IPC programmes are aligned with and contribute to other complementary national programmes’ strategies and documents, this is where the IPC-patient safety-quality-AMR interlinkages, relationships and collaborations (to name but a few programmes) come into play. The plan also addresses the need for political commitment, health worker knowledge, data for action, advocacy and communications, research and development and collaboration and stakeholders’ support. A theory of change is available. 2024 offers to be an interesting year for those working to improve infection prevention and control as one part of patient and health worker safety and quality.
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Community PostI agree Hannah. The issues with the green book are so frustrating. So many of us deserve and need the VDPS payment yet we have no chance of getting it as there is no recognition of our reactions. I’ve only just got any note on my NHS records - a “new event” apparently despite it being over 2.5 years ago. But at least there seems to be a code for it now, and my GP has accepted a private diagnosis of MCAS. It really shouldn’t be this hard and require us to go private however.
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Community PostThe latest stat I heard is that each hospital generates more information than the Library of Congress. That is meant to store all media created (although I think that excludes Tik Tok videos and social media). I don't have a timescale for this but, if true, it's pretty impressive and also somewhat intimidating.
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Community Post
PSIRF Small Provider
Andy L replied to Andy L's topic in Improving patient safety
I have created a policy using the templates. I've submitted it but had no feedback as yet. Will report back on my success/failure- Posted
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Community Post
Pain during IUD fitting
Patient_Safety_Learning replied to PatientSafetyLearning Team's topic in Women's health
Hi @Sabrinapsychologist Thank you for reaching out via the forum. Capturing lived experience will be an important part of understanding the issues and how improvements can be made. We will also add your information about the study to the main 'Learn' library so we can share your research request via our other channels.- Posted
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Community PostThis case study focuses on a North Staffordshire Combined NHS Trust project. The lead consultant for the service was concerned that the clinical pathways were not optimised and bottlenecks were delaying access, assessment and diagnosis of patients. As a result there were delays to initiating treatment. In addition to potential harm to patients this was resulting in inefficient and wasteful use of resources. Following pathway changes, value and efficiency impact was noted in the following areas: Because head CT scans are provided by a neighbouring acute trust, reducing the number of patients referred had a direct impact on service cost as well as releasing capacity in the wider system. Comparing baseline activity with the review period showed a 30% reduction in CT scan referrals and a £7,800 direct cost saving. The number of patients not attending appointments reduced from 572 in the baseline period to 379 after implementing pathway changes. While not a cash releasing saving this improved overall efficiency and productivity for the service and contributed to a reduction in overall unit price per attendance. At the start of the project, the average unit price for patients attending the memory service was £280.93. Through a combination of direct cost savings and efficiency and productivity gains arising from the revised pathway, this figure had reduced to £205.12 in the review period. Do you have a cost-saving or efficiency case study to share? What were the patient safety implications? Do you have resources or knowledge to share that can help others make positive changes? Comment below (sign in or register here for free first), or get in touch with us at content@pslhub.org to tell your story.
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Community Post
PSIRF Training
Patient-Safety-Learning replied to Callum Brown's topic in Investigations, risk management and legal issues
Hi Fiona, As you are already a member of the hub, please email support@PSLhub.org with a request to be added to the group.- Posted
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Community Post
Do you have a 'good catch' reporting system?
Patient_Safety_Learning posted a topic in Good practice
"One of the best examples I saw involved a case in which a worker was about to move a vehicle and trailer. The keys were in the ignition, but before starting the vehicle, he decided to perform a walkaround and discovered a mechanic was working underneath the trailer. Together, they agreed to take the keys out of the ignition and established a tagging system to ensure nobody else would inadvertently move the equipment while it was being worked on."[1] According to this article by Safety Management Group, just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns an organisation's safety philosophy into a clear reality. Do you use a 'good catch' reporting system in your health and social care setting? Has it made a difference to safety culture or behaviour? How easy was it to implement? Do you recognise and/or celebrate staff for reporting incidents? Or perhaps this is something you'd like to implement. What would you like to ask others who have tried it? Share your experiences and questions in the comments below. You'll need to register for free first. Related reading: Near-Miss and Good-Catch Reporting Promote a culture of safety with good catch reports Using good catches to increase worker ownership of safety 5 Examples of good catches in healthcare and how to implement a near miss campaign [1] SMB. Using good catches to increase worker ownership of safety. Accessed online 9/08/23. -
Community PostStrategy - NHS Culture Change.pdf
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- Culture of fear
- Patient safety strategy
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Community Post
Better use of data for medication safety in hospitals
Kenny Fraser replied to Kenny Fraser's topic in Medicine management
- Hospital ward
- Pharmacist
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- Hospital ward
- Pharmacist
- Integrated Care System (ICS)
- Decision making
- Information processing
- Knowledge issue
- Non-compliance
- Omissions
- Climate change
- AI
- Digital health
- Innovation
- Interoperability
- Precision medicine
- Start-Up
- Safety assessment
- Safety behaviour
- Safety management
- Improved productivity
- Medication - related
- Patient identification
- Patient safety strategy
- Policies
- protocols and procedures
- User-centred design
- Workforce management
- Information sharing
- Staff engagement
- Training
- Time management
- Allergies
- Deep vein thrombosis
- Falls
- Parkinsons disease
- Substance / Drug abuse
- Urinary tract infections
- Antimicrobial resistance (AMR)
- Benchmarking
- Dashboard
- Indicators
- Meta analysis
- Task analysis
- Workload analysis
- NRLS
- Policies / Protocols / Procedures
- Quality improvement
- Risk management
- Healthcare
Thanks Clive - love to hear thoughts from those dealing with this in clinical practice- Posted
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- Hospital ward
- Pharmacist
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(and 46 more)
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- Hospital ward
- Pharmacist
- Integrated Care System (ICS)
- Decision making
- Information processing
- Knowledge issue
- Non-compliance
- Omissions
- Climate change
- AI
- Digital health
- Innovation
- Interoperability
- Precision medicine
- Start-Up
- Safety assessment
- Safety behaviour
- Safety management
- Improved productivity
- Medication - related
- Patient identification
- Patient safety strategy
- Policies
- protocols and procedures
- User-centred design
- Workforce management
- Information sharing
- Staff engagement
- Training
- Time management
- Allergies
- Deep vein thrombosis
- Falls
- Parkinsons disease
- Substance / Drug abuse
- Urinary tract infections
- Antimicrobial resistance (AMR)
- Benchmarking
- Dashboard
- Indicators
- Meta analysis
- Task analysis
- Workload analysis
- NRLS
- Policies / Protocols / Procedures
- Quality improvement
- Risk management
- Healthcare
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Community Post
Patient safety research collaboration
perbinder replied to perbinder's topic in Improving patient safety
@Tom Rose @Rosanna Hunt @JonathanK @Pramjit @Avashinee @Emma W I am sorry I have not followed this up. Please get in touch with me at perbinder@gmail.com or my LinkedIn profile www.linkedin.com/in/perbindergrewal. I am very interested in how behaviours and culture impacts on PS. Thanks- Posted
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Community Post
Long waits for ADHD diagnosis and treatment - share your experience
Patient-Safety-Learning replied to Patient-Safety-Learning's topic in Conditions
@BDF @Jo Griffin @Greenfingers @Stefanie If any of you would be interested in sharing your perspectives as a parent in a blog about these issues, please do get in touch with us at content@patientsafetylearning.org. We can offer editorial support and blogs can be anonymous -
Community PostHi @Flávia Thank you for responding. Your collaborative project sounds very interesting, we would love to hear more. Please do get in touch via content@pslhub.org.
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Community PostResearch suggests that women may receive poorer medical attention when it comes to pain, including being misdiagnosed or undertreated. This may be due to historical lack of representation of women in clinical trials for pain medication and implicit biases held by healthcare providers. To address this issue, it is important to raise awareness among healthcare providers and ensure that women are adequately represented in clinical trials. Patients can also advocate for themselves by being open and honest about their symptoms and advocating for the pain treatment they need.
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Community PostInfiltration is when fluid or intravenous drugs are administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign, to improve awareness of infiltration and extravasation and reduce avoidable harm. Do you have insights to share on this topic? Perhaps you are a patient who has had an extravasation injury? Or a healthcare professional who has insights to share around making improvements? Share your thoughts below (you'll need to register for free here first).
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Community PostThanks for sharing Sian. We have some resources on the hub from AHRQ on TeamSTEPPS which uses CUS if hub members want to find out more: AHRQ course- TeamSTEPPS® for diagnosis improvement AHRQ - TeamSTEPPS teamwork system AHRQ: TeamSTEPPS® – tools and tactics for good teamwork
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Community Post
Choice of words ...
Sian Hayes replied to lzipperer's topic in Disasters averted/near misses
I worked in the USA for 20 years and as an ED manager, we started a "Phew" campaign in my department. Basically, any near miss ,where inside, you literally have that "Phew, thank goodness that did not happen" moment, then that is reported as a near miss. Staff easily recognised that feeling, either kept it internally or shared with colleagues but we asked staff to report these on our patient safety software, so we could address patient safety issues, trends or system issues. Staff were commended for their openess and rewarded for their contribution to patient safety and prevention of a bad outcome. Happy for anyone to emulate. 🙂 -
Community Post
Independent hospitals
Blodwen replied to Blodwen's topic in Women's health
Thank you but I’ve tried everything you mention and more. because I wasn’t really told the full extent of my complication ( enterocutaneous fistula), I never complained, I assumed it would heal or could be fixed. When I did take it up with the hospital they said they had no responsibilities for patients, private hospitals are merely hosts. The consultant was and is still seeing me, as I was private there are no other means of support. ( no PALS, no Community Health Council, no ombudsman ). AvMA have been helpful but say my only option is the legal route but I’m out of time. Phin just provided statistics to help you decide what hospital or surgeon to chose in the private sector. the regulatory body for Independent hospitals is ISCAS who will only help if you’ve put in a first tier complaint. But as I say I was told I had nothing to complain about. ( 3 stoma bags !). I cannot see where private patients are advised of any of this prior to surgery. How can that be right, I would have certainly managed my expectations better . thank you for taking the trouble to reply, it is much appreciated.- Posted
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Community Post
Harm grading for anaphylaxis and severe drug reactions
ClaireMurphy posted a topic in Miscellaneous
Good morning, I am hoping to gain some insights into how other organisations assess the level of harm for incidents of anaphylaxis or severe drug reactions? I work within a private homecare setting with the vast majority of our patients receiving administration of medication via a clinician - ranging from antibiotics to chemotherapy. Currently, within our organisation incidents reporting a severe drug reaction/anaphylaxis are graded as moderate-severe harm. There has been some discussion recently around the harm grading of these incidents, and I was hoping to seek guidance from external patient safety colleagues as to how their organisations assess the harm level for these types of incidents? Many thanks