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Patient Safety Learning

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  1. News Article
    A coroner has raised concerns about how a family was allowed to bring a restricted item that contributed to a man's death into a mental health unit. Joshua Sahota, 25, died as a result of asphyxia and psychosis in Bury St Edmunds, Suffolk, on 9 September 2019. Suffolk coroner Nigel Parsley said Mr Sahota's relatives were not told the item they brought in when visiting was on a restricted list. The NHS trust which runs the unit said it had improved its internal processes. Mr Sahota, from Kennett in Cambridgeshire, was taken to the Wedgewood Unit on the West Suffolk Hospital
  2. Content Article
    Joshua Sahota had been admitted to Southgate Ward at Wedgewood House on 9 August 2019 following a stay as an inpatient at Addenbrookes Hospital, where he had been seen by a psychiatrist and deemed to be at a continuing high risk of self-harm. His family were asked to take fresh clothes to the Southgate Ward, which they did so in a plastic carrier bag. It had not been communicated to them that this was a ‘restricted item’ on the ward. Joshua was subsequently transferred to Northgate Ward, also within Wedgewood House, on the 15 August 2019. On the 9 September 2019, Josh was found in his roo
  3. Content Article
    Each report seeks to increase the number of people living with dementia with a diagnosis by: reducing regional variation in diagnosissupporting those from an ethnic minority community to access a diagnosisincreasing diagnosis for people residing in a care home or hospital setting.The reports set out a roadmap in how to achieve this change. But a diagnosis is not done in isolation. It requires all health and social care professionals involved in dementia care to recognise the symptoms of dementia and to initiate the process to diagnosis, which itself facilitates access to vital care and support
  4. Event
    until
    The aim of this day is to further enhance the understanding of delegates in the causes of surgical wound breakdown, the recognition and management of wound infection and the management of dehisced surgical wounds. Learning Objectives At the end of this study day, delegates will have: An awareness of national guidance and best practice with regard to prevention of surgical wound infection. A good understanding of how to recognise unusual signs of infection in surgical wounds including wound swabbing, how to do it when and why. A basic understanding of NPWT (Negativ
  5. Image Comment
    Left is Calcium Gluconate solution, the right is Sodium Chloride solution. In a reply to the tweet asking why this was a concern the doctor said: "One is a calcium based drug that could be really dangerous if given in too large quantities... The other is a saline solution that we often given as a flush after injecting other medications and things through a cannula."
  6. Image Comment
    Why isn't the generic name on medication labelling bigger than the trade and company name to make it easier to read?
  7. Content Article
    Putting quality and safety above all else is the first NHS Wales core value. This focus has been strengthened more recently through the Health and Social Care (Quality and Engagement) (Wales) Act (2020), the National Clinical Framework for Wales (2021) and the Quality and Safety Framework (2021). Collectively these set out an aspiration for quality-led health and care services, underpinned by prudent healthcare principles, value-based healthcare and the quadruple aim. In response, and in the context of the challenges at this stage of the pandemic and moving into a recovery phase, Improvement C
  8. Content Article
    Emergency Department Safer Nursing Care Tool makes an innovative and valuable contribution by providing the following: Establishment set by Annual Attendance as well as Acuity and Dependency Care Hours to Contact metrics on the current and recommended establishments A Deployment arm showing the hourly staffing requirement aligned to the acuity & dependency. In response to the COVID-19 pandemic, the tool has been further developed to consider the implications of COVID-19 on staffing. From major trauma centres to district general hospitals with emergency departments
  9. News Article
    Many patients are being prescribed unnecessary and even harmful treatments, a new report warns. The review, in England, suggests one-tenth of items dispensed by primary care are inappropriate or could be changed. Around 15% of people take five or more medicines a day - some are to deal with the side-effects of the others. The government is appointing a prescribing tsar to help with the issue and stop waste. Overprescribing can happen when: a better alternative is available but not given the medicine is appropriate for a condition but not the individual patient
  10. Content Article
    What can you learn from the Nimrod disaster? At a superficial level, the specifics of this event were unique, but by delving deeper into the ‘why?’, the Review team revealed that history does in fact repeat itself. Nimrod XV230: Parallels with healthcare. By discussing the relevance of the Nimrod XV230 event to healthcare, Martin aims to illustrate that the organisational lessons from this event are applicable to almost any industry. There are parallels with several major healthcare events. Success, complacency and failure. The track record of the Nimrod aircraft led to a high level
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