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Patient Safety Learning

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Posts posted by Patient Safety Learning


  1. @Anne1010 I'm so sorry to hear that your last procedure was a painful experience and can understand your fears for the hysteroscopy. If you take a look at the comment posted in this thread by @Katharine Tylko on the 6 August (a few comments up) it gives the guidance from the RCOG on hysteroscopy procedures. It also highlights the facebook group -  Campaign Against Painful Hysteroscopy - which might be helpful to you and offer support and advice.


  2. A new blog, published on the hub, tells the story of Jenny who passed away from pulmonary embolism, having been misdiagnosed.

    Her son Tim is campaigning for improvements in pulmonary embolism awareness and care to reduce the risks of misdiagnosis. 

    Have you, or someone you know, been affected by a pulmonary embolism? 

    Was there a misdiagnosis? 

    Please share your experiences, and thoughts on Tim's blog, in the comments below. 

    You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.


  3. On 11/05/2022 at 14:11, Guest Anon said:

    Prior to attending a hysteroscopy appointment, I looked up other patient experiences and read through the personal testimonies on this website.

    I stopped reading after the third one, anxious about my coming procedure.

    I telephoned the hospital to discuss pain relief and the level of discomfort and they reassured me that if at any point it became too painful they would stop.

    With some trepidation I loaded up on painkillers, - paracetamol and codeine combined with ibuprofen and made sure I was not driving.

    Hoping for the best but planning for the worst, I was relieved to find the procedure straightforward, a little uncomfortable, and almost pain-free.

    The removal of the polyps gave a momentary stab of pain but really very little. To have had a general anaesthetic would have been more problematic, time consuming, and no doubt higher risk.

    Whilst I do understand the need to convey bad experiences, it is important to let people know that for many women this may not be a particularly traumatic experience.

    Creating the expectation of extreme discomfort and pain may be counter-productive as the stress and anxiety prior to the procedure will almost certainly contribute to the discomfort experienced.

    Some hours after, and back at home, I I feel back to normal and I’m experiencing no discomfort or pain.

    It's good to hear that you had a positive experience and you're recovering well. Many women have no pain or mild to moderate pain.  However it's important hospitals follow the RCOG guidance and do offer general anaesthetic from the outset if that's what the woman wants, and stop the moment the patient is in pain. Women should be given all the information and options so they can make an informed choice. Unfortunately this isn't always the case.

    Thank you for sharing your experience.


  4.  

    An investigation by The Sunday Times has found that the drug sodium valproate is still being handed out to women in plain packets with the information leaflets missing, or with stickers over the warnings.

    Sodium valproate, has been given to women with epilepsy for decades without proper warnings, and has caused autism, learning difficulties and physical deformities in up to 20,000 babies in Britain.

    The government is refusing to offer any compensation to those affected by sodium valproate, despite an independent review by Baroness Cumberlege concluding in 2020 that families should be given financial redress.

    Read the Twitter thread from Rebecca Bromley who has been working with families who have suffered:

     


  5. Have you attempted to access treatment for a urinary tract infection (UTI), or recurrent UTIs? We'd love you to share your experiences with us.

    • Did you feel listened to by your doctor or healthcare professional?
    • Did they take your symptoms seriously?
    • Did you receive timely and appropriate treatment?

  6. I was subjected to an excruciating hysteroscopy in outpatients without being made aware of all the pain options. I was denied local analgesia when I asked about it beforehand and told it wouldn't be necessary as the pain would be slight cramping. It wasn't.

    I noticed some light spotting about 6 weeks ago. I reported this to my GP, who sent me for an internal ultrasound. This identified slight thickening of the lining of my uterus (7mm), so I was sent for a hysteroscopy at Nevill Hall hospital, in Abergavenny. I received a leaflet in advance, which said 'some patients experience discomfort. If you find the procedure uncomfortable, please discuss this with the clinician'. it also stated that one of the frequent risks was pain. However, on the same page it said 'You will be offered local analgesia', so I didn't worry too much.

    When I met the clinician in advance of the procedure, he explained any discomfort would be like period cramps. I asked about pain relief, but he repeated it would just be like period pains, if I experienced any pain at all. As I used to have dreadful period pains, have had coils inserted and removed, and have given birth naturally twice - once without pain relief - I thought I'd be fine with this. I'm usually pretty tough when it comes to pain, in any case. 

    When the procedure started, I felt some discomfort when the hysteroscope went through my cervix, and remember saying 'Ow'. Then the most incredible, searing, tearing pain I have ever experienced - I guess it must have been the pressure of the saline. I found the arms of the bed to grab onto, and could hear myself shouting -No no no no no, stop stop stop-. The plan had been to take some pictures, followed by taking a sample of the lining of my uterus lining, but the clinician stopped the procedure having had a look and taken some pictures. They may have spoken to me and asked questions during this time, but I have no recollection of anything except the pain. When I finally opened my eyes, the clinician was nowhere to be seen, and the two nurses were asking if I was OK. I was extremely shaken and very out of it, from the pain and the shock.

    After I'd recovered for a few minutes, still with my legs in the supports, and lying back in the examination chair, the nurses told me I should go and get dressed, which I did, very shakily. They then showed me out of the room to the clinician's room opposite. Another doctor was standing in the doorway of his office, and I wasn't asked in, or asked to take a seat. I just stood in the doorway, still dazed and very shaken. The clinician looked up at me from his desk and said everything looked fine and joked that he would give me a 10 year warranty, as all seemed in order. The nurse then pointed me towards the exit door and I was on my way out of the department, to drive myself home. There was no offer of anywhere to sit and recover. I felt a complete wimp, and as if I'd made a terrible fuss about nothing. And very confused. As I mentioned earlier, I'm usually really brave but this was the worst pain I'd ever experienced.

    I had phoned the hospital the day before the procedure, as I'd noticed in the patient leaflet that it said I needed someone with me to take me home. The person I spoke to said that was because I would be given local anaesthetic, and if I had an accident on the way home, my car insurance would be invalidated. She said it was at my own risk if I attended on my own and drove myself home. Having driven many times after local anaesthetic, coming home from the dentist, I took the decision to attend the hospital on my own, as it was short notice to find someone to drive the 40 mile round trip, and I wanted this done as soon as possible in case there was a risk of cancer. As a result of this conversation I had fully expected to be given a local anaesthetic for the procedure. 

    I got home and looked up 'Painful Hysteroscopy' online and was appalled (and partly reassured) to see that up to 25% of women experience severe pain. I had no idea there was an option to have this procedure done under general anaesthetic, although I probably wouldn't have gone for it anyway, as I was only expecting period pain type cramps. I have regular lower gastrointestinal endoscopies and sigmoidoscopies without anaesthesia and bear the discomfort pretty well. So I assumed this would be similar. 

    I have gone from being pretty fearless and confident to being terrified of going back. I wrote this on the day it happened while it was still fresh in my mind.

    63 year old woman. Procedure 16 Sept 2021 at Nevill Hall Hospital, Abergavenny


  7. There are a number of initiatives for walking frames.

    Medway NHS Foundation Trust have teamed up with their orthotics department to use Funky Frames. Staff can order a Funky Frame kit which contains the yellow lagging and various coloured tape. It can be removed once the patient is discharged. 

    https://www.nursingtimes.net/news/hospital/trust-to-pimp-walking-frames-to-try-and-reduce-falls-07-04-2017/

    And users at Coverage Care’s Woodcroft home in Market Drayton have been personalising their walking aids by spray painting them different colours including pink, orange, blue and purple or decorating them with stickers so they can easily identify their own frame.

    https://www.coveragecareservices.co.uk/news/pimp-my-zimmer-project-to-reduce-falls-at-shropshire-care-home/


  8. Rachel Daykin, Lead Specialist Nurse for Dementia at Kent Community Healthcare NHS Foundation Trust is currently working on a QI project with Samantha, a physiotherapist. 

    "We are in the early stages of a project to examine whether providing patients with dementia coloured mobility aids improve their ability to use them appropriately. We are using the colour red.

    I have previously worked with patients living with dementia in care home and day service settings where WZF were personalised so that they were easily recognised, however in the current climate we are more aware than ever of infection prevention control.

    I hope that this information is useful and we  would be more than happy to share the outcome of our project."


  9. Two vaccines for COVID-19 have now been approved. Health organisations are doing their upmost to workout how best to store and administer the vaccines safely and avoiding errors.

    The Chartered Institute of Ergonomics and Human Factors (CIEHF) are preparing strategic guidance for health authorities and operational guidance for people setting up vaccine programmes applicable internationally.

    In a recent LinkedIn post, Chief Executive Noorzaman Rashid asks: "What are the Human Factors and Ergonomic issues that should be considered?" And asks you to share your ideas:

    https://www.linkedin.com/posts/noorzamanrashid_the-economist-on-twitter-activity-6750290388721926144-h8XV/

    #ciehf #covid #patientsafety


  10. Thank you 'Gerdayoga' for your post and I'm sorry to hear you're struggling with this.

    Here's the link to the Iyengar Yoga covid recovery programme you mention: https://iyengaryoga.org.uk/covid-19-a-suggested-recovery-programme/ so others can take a look.

    If you would like to continue the discussion please do post again or you can email us directly at content@pslhub.org. We are collating all feedback and can maintain your anonymity if you prefer.


  11. See Rob Hackett's video on the hubIndistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world.

    Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality. 

    Chlorhexidine.thumb.png.bcd06d76ceb5a07466d2274bfd506322.png

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