Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. Content Article
    The rise in opioid overdoses warrants a review of the symptoms of akathisia writes Russell Copelan.
  2. Content Article
    Healthcare organisations strive to improve patient care experiences. One way is to use one-on-one provider counselling (shadow coaching) to identify and target modifiable provider behaviours. Quigley et al. examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban US health centre. They found that shadow coaching improved providers' overall performance and communication immediately after being coached. However, these gains disappeared after 2.5 years. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed.
  3. Event
    until
    Professor Pascale Carayon, the author of the Systems Engineering Initiative for Patient Safety (SEIPS), will talk about the development, history and use of SEIPS in healthcare. SEIPS is one of the most widely recognised and used human factors and ergonomics (HFE) approaches within the field of patient safety. The model is widely used to understand how complex socio-technical systems such as healthcare work. SEIPS places the patient at the centre of the system. It enables the description of the parts of the system (people, environments, tools, tasks, processes and outcomes), and how these interact to create safety, efficiency and effectiveness. SEIPS can also be used by practitioners to identify the deficiencies in a healthcare system which impact the ability to deliver high quality and safe care. SEIPS can also be used to contribute to the design of systems and processes. This event will focus on the practical application of SEIPS within healthcare and speakers include: Prof. Pascale Carayon - The SEIPS journey - developing, expanding and deepening the model Chris Hicks and Andrew Petrosoniak - St Michaels Hospitals Toronto - How simulation can break the shackles of bad design Gill Smith - Kaizen Kata - The effectiveness of SEIPS during Covid19 in ICU Jonathan Back - HSIB's Safety Incident Research database Prof. Tom Reader - University of Nottingham Prof. Richard Holden - Indiana University School of Public Health Register
  4. Event
    Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. It can be used to assess why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This virtual masterclass, facilitated by Mr Perbinder Grewal, General Vascular Surgeon, will guide you in how to use Human Factors in your workplace. Programme and registration hub members receive a 20% discount. Please email info@pslhub.org for discount code
  5. Event
    A recent report published by the BMJ found that many doctors have difficulty in DNACPR discussions. Chaired by Davina Hehir Director of Policy & Legal Strategy Compassion in Dying, conference will focus on the important issue of effective person centred practice in CPR decisions and communication. By attending you will have the opportunity to hear from Rosie Benneyworth Chief Inspector of Primary Medical Services and Integrated Care Care Quality Commission who will discuss what we've learnt from the pandemic, including: the rapid review of how cardiopulmonary resuscitation decisions were used during the coronavirus pandemic; improving involvement of people using services, record keeping, and oversight and scrutiny of the decisions being made. Register 20% Discount now available with code HCUK20CPR when booking
  6. Content Article
    For over a decade, the preoperative timeout procedure has been implemented in most paediatric surgery units. However, the impact of this intervention has not been systematically studied. This study from Muensterer et al. evaluates whether purposefully introduced errors during the timeout routine are detected and reported by the operating team members. The study found that errors in the timeout routine go unnoticed by the team in almost half of cases. Therefore, even if preoperative timeout routines are strictly implemented, mistakes may be overlooked. Hence, the timeout procedure in its current form appears unreliable. Future developments may be useful to improve the quality of the surgical timeout and should be studied in detail.
  7. Content Article
    Watch this animation and find out how the Healthcare Safety Investigation Branch (HSIB) works.
  8. Content Article
    Ann Geraghty was being treated for heart failure at Good Hope Hospital and subsequently died following a cardiac arrest. In their report, the Coroner raised patient safety concerns relating to two periods of ventricular standstill (this is a rare issue when the heart stops beating and stands perfectly still), which were missed due to a combination of policy, staffing, workplace and equipment issues.
  9. Content Article
    As part of a Patient Safety in Surgery Webinar Series held by Massachusetts General Hospital’s COMPASS (Center for Outcomes and Patient Safety in Surgery), Vivian Lee, president of Verily Health Platforms, shares strategies for leading quality improvement and change to work toward a healthcare system that provides better care, more efficiently and at a lower cost.
  10. News Article
    "Bodies would have been piling up" if the Covid vaccine had not been available, the director of intensive care at Belfast City Hospital has said. Dr George Gardiner, a consultant, also said his biggest fear would be having to stop routine cancer surgery. He has called for an end to "tribal politics" in Northern Ireland to allow transformation of the health service, so that cancer and coronavirus can be tackled in tandem. He said the system was currently "one step from chaos" and warned hospitals will not cope with winter if Covid numbers continue to rise. "We need to get everyone who can take a vaccine to take it now before the winter pressures are on us," Dr Gardiner added. "The cancer surgery that we are doing at the minute is life saving. A few more Covid admissions, which could be prevented, will cause us to stop operating because we simply haven't got the capacity to do both." Read full story Source: BBC News, 7 September 2021
  11. News Article
    A new snapshot survey by the Royal College of Emergency Medicine has found that in August 2021 half of respondents stated that their Emergency Department had been forced to hold patients outside in ambulances every day, compared to just over a quarter in October 2020 and less than one-fifth in March 2020. The survey, sent out to Emergency Department Clinical Leads across the UK, also found that half of respondents described how their Emergency Department had been forced to provide care for patients in corridors every day, while nearly three-quarters said their department was unable to maintain social distancing every day. One-third said that the longest patient stay they had had in their Emergency Department was between 24 and 48 hours, with 7% reporting the longest stay to be more than 48 hours. Dr Ian Higginson, Vice President of the Royal College of Emergency Medicine, said: “It is shocking to see the extent of the challenges faced by Emergency Departments across the UK. Holding ambulances, corridor care, long stays – these are all unconscionable practices that cause harm to patients. But the scale of the pressures right now leaves doctors and nurses no options. We are doing all we can to maintain flow, maximise infection prevention control measures, and maintain social distancing. Our priority is to keep patients safe, and ensure we deliver effective care quickly and efficiently, but it is extremely difficult right now." Read full story Source: The Royal College of Emergency Medicine, 6 September 2021
  12. News Article
    Doctors at a hospital in Birmingham mistakenly terminated a healthy unborn baby in a procedure instead of its sickly twin. The unidentified mother decided to abort one of the fetuses because it was suffering from restrictive growth, which increases the chances of stillbirth and puts the healthy baby at risk. During the procedure at Birmingham Women's and Children's NHS Foundation, surgeons accidentally terminated the wrong twin. The 2019 incident emerged in a Freedom of Information Act survey of hospital blunders. Dr Fiona Reynolds, chief medical officer at Birmingham Women's and Children's NHS Trust, said: "A full and comprehensive investigation was carried out swiftly after this tragic case and the findings were shared with the family, along with our sincere apologies and condolences." "The outcome of that thorough review has led to a new protocol being developed to decrease the likelihood of such an incident happening again." Read full story Source: The Independent, 6 September 2021
  13. News Article
    GP surgery staff are facing abuse from patients who are “angry and upset” that their blood test has been cancelled because of the NHS-wide chronic shortage of sample bottles. “Patients are angry when we ring them up and say, ‘Sorry we can’t do your blood test after all’. A lot of people are quite angry and concerned about their own health,” Dr David Wrigley, the deputy chair of council at the British Medical Association, said. “Patients are quite rightly upset and some get quite aggressive as well. They are worried because they don’t know what the implications of their cancelled test are for their health.” GP practices in England had begun cancelling appointments because the NHS’s main supplier could not deliver stocks as planned for one to two weeks because of “unforeseen road freight challenges”. NHS England has responded to the shortage of blood sample bottles by telling GPs to cancel all but clinically urgent blood tests and hospitals to cut back the tests they do by at least 25%. Read full story Source: The Guardian, 6 September 2021
  14. News Article
    A hospital has admitted liability for the death of a baby who was delivered stillborn three days after his mother’s complaints of fluid loss and severe pain were dismissed as wetting the bed. Jacob Jackson could have been born healthy, Shrewsbury and Telford hospital trust (Sath) has accepted, if it had arranged an earlier delivery in October 2018 as his mother, Charlotte, had suggested. The incident happened 18 months after an external review had been ordered into serious maternity failings at the trust, which are now known to be the biggest maternity scandal in the history of the NHS. Charlotte said: “It makes me feel sick to my stomach that they knew there were problems – this sort of thing had been going on for decades. We keep getting fed the same lines that ‘lessons have been learned’. If lessons had been learned parents and babies wouldn’t be going through this.” Read full story Source: The Guardian, 6 September 2021
  15. Event
    New guidance for digital transformation across the health service has been published by NHSX. The framework sets out seven ways for NHS organisations to ensure success, including: being well led, ensuring smart foundations, safe practice, supporting people, empowering citizens, improving care, and healthy populations. It includes 49 specifics, spanning ensuring technology has been assessed against the DTAC, to making consistent use of national tools such as the NHS app and putting in place ICS-wide professional development for digital. Join the Institute of Health & Social Care Management's (IHSCM) free webinar, to hear Roy Lilley ask those who developed the guidance and those who will need to implement it: 'What Does Good Look Like?' He will be posing his and your questions to: Sonia Patel, CIO, NHSX Sakthi Karunanithi, Director of Public Health & Wellbeing, Lancashire County Council Liz Ashall-Payne, Founding CEO, ORCHA June Hall, Chair, Digital Health Special Interest Group, IHSCM Register
  16. Event
    until
    The World Patient Safety Day (WPSD) is observed globally on 17 Sept every year. The objectives of WPSD are to increase public awareness and engagement, enhance global understanding, and work towards global solidarity and action by all stakeholders to improve patient safety. The theme of WPSD 2021 is “Safe maternal and newborn care". WPA has initiated a campaign to celebrate WPSD all over the world. As part of this campaign, WPA is organising a regional webinar series in September 2021. WPA will conduct webinars in EURO, Asia Including EMRO, Latin America and AFRO Region. Monday 6 September 2021 - WPSD Regional Webinar for EURO Thursday 9 September 2021 - WPSD Regional Webinar for Latin America Monday 13 September 2021 - WPSD Regional Webinar for Asia including EMRO Tuesday 14 September 2021 - WPSD Regional Webinar for AFRO
  17. Event
    This webinar will focus on how to harness the vast experience of the voluntary sector and advocate locally appropriate strategies to improve patient safety, through a network of Ambassadors. Who should attend? Patient safety can only be achieved by collaboration between the professionals, patients, families, community members and stake holders. So, whatever your background you are most welcome. Objectives To raise awareness about the burden of unsafe health care. To bring together the voluntary sector with a stake in health improvement programmes, to adopt a charter for patient safety and integrate safety strategies into their programmes. Speakers Neelam Dhingra, Unit Head, WHO Patient Safety Flagship/A Decade of Patient Safety 2020-2030, World Health Organization, Geneva Dr. Abdulelah Alhawsawi, Global Ambassador, The G20 Health and Development Partnership; Former Director General, Saudi Patient Safety Centre Dr. Zakiuddin Ahmed Founder, Riphah Institute of Healthcare Improvement & Safety and Healthcare Quality & Safety Association of Pakistan Ms Regina N. M Kamoga, Executive Director, CHAIN Uganda Register
  18. Content Article
    With remote consultations with a doctor becoming more frequent, Trish Greenhalgh explores why this can be difficult and looks at the ways it can be improved.
  19. Content Article
    Surgical mesh is a medical device that is used to provide additional support when repairing weakened or damaged tissue. The majority of surgical mesh devices currently available for use are made from man-made (synthetic) materials or animal tissue. This page on the US Food and Drug Administration (FDA) website outlines the types and uses of surgical mesh and the latest update on mesh manufacturers ordered to stop selling devices for transvaginal repair of pelvic organ prolapse.
  20. Content Article
    Patients for Patient Safety US (PFPS US) is a network of people and organisations aligned with the World Health Organization (WHO) and focused on making healthcare safe in the United States. It is led by people who have experienced medical error as a patient or in their families, and is committed to implementing the World Health Organization Global Patient Safety Action Plan in the USA.  Read their 'Stories That Impacted Change'
  21. Content Article
    Daily safety briefings, also referred to as “huddles,” are conducted within hospitals in efforts to minimize errors and improve patient safety. These briefings are intended to be quick, efficient, and meaningful to health care workers. The purpose of this research is to assess current and perceived best practices related to safety huddles in health-system pharmacy departments, including timing, location, persons involved, and topics covered.
  22. Event
    until
    This event will mark the 2021 World Health Organisation’s World Patient Safety Day and aims to showcase the patient safety work happening in the NHS and with partners, to improve the safety of maternal and neonatal care. Speakers: Introduction from Aidan Fowler, National Director of Patient Safety (chair) Presentations from the National Maternity Champions, Matthew Jolly, National Clinical Director for Maternity and Women's Health and Professor Jacqueline Dunkley-Bent OBE, Chief Midwifery Officer Hear from AQUA (the Advancing Quality Alliance) about its safety culture programme for maternity and neonatal board safety champions Dr Nicola Mackintosh, Associate Professor in Social Science Applied to Health, SAPPHIRE Deputy, University of Leicester will present on ‘What a good maternity safety culture looks like’, providing an overview of a considered analysis of maternity and neonatal safety culture surveys Tony Kelly, National Clinical Lead for the Maternity and Neonatal Safety Improvement Programme will provide an introduction to the national Maternity Early Warning Score (MEWS) tool and Newborn Early Warning Trigger and Track (NEWTT) Expected Audience: NHS provider and commissioning staff, particularly those working in maternity and neonatal care and in patient safety roles. Register
  23. Content Article
    Part of the Justice Matters podcast series.
  24. Content Article
    When healthcare worker infections at The Royal Melbourne Hospital in Australia seemed to be spiralling out of control despite strict protocols being adhered to by expertly trained staff, Professor Kirsty Buising and her colleagues took action. To inform future responses in the Australian setting, Kirsty and her colleagues present in this paper a description of healthcare worker infections at their institution and the suite of interventions they used to control the outbreak.
  25. Content Article
    When good people raise serious concerns employers can welcome them as gold dust, as "canaries in the mine" or do the opposite. This is an unfinished account of what happened when Karen Rai, Strategic Research & Innovation Manager at The Christie Hospital NHS Trust, wrote to the Trust Chair setting out concerns about governance, financial conduct, and bullying...
×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.

 Accept Cookies  Reject Cookies