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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Community engagement is an iterative, on-going, long-term investment that is foundational to the work of demonstrating trustworthiness. It’s more than building trust in one project or community interaction, but rather building trust in the organisation and in the system. This guide from the Association of American Medical Colleges is for personal self-reflection or as a tool to help your organisation reflect upon all 10 Principles of Trustworthiness as you engage with your community. 
  2. Content Article
    After an investigation of an event, it’s important to touch base with the healthcare team and everyone involved so they can get some closure. This is an important part of the healing process that we have neglected too often. Alberta Health Services provide tips on how to support staff involved in adverse events.
  3. Content Article
    Diagnostics function as a compass in healthcare. They help determine the cause of a person’s condition, thus steering the healthcare provider towards the appropriate treatment or care pathway to address a disease and determine whether the approach is working. Despite their value in the healthcare delivery system, innovation, implementation, reimbursement and accessibility include barriers that constrain the use of diagnostics, particularly in low- and middle-income countries (LMICs), where increased availability could lower healthcare costs while saving lives. How can leaders increase affordable access to essential diagnostics globally? How can diagnostic advances be supported without contributing to growing disparities across the globe? This report seeks to address these questions through a landscape review of the global diagnostic ecosystem – including identifying key stakeholders, barriers and enablers along the product life cycle and the effectiveness of diagnostics – while highlighting the various challenges, opportunities and potential solutions across high-income countries and LMICs.
  4. Content Article
    Psychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that highlight both resilience (“we avoided failure”) and vulnerability (“we nearly failed”). Near misses offer learning opportunities for addressing underlying causes of potential incidents, and it is crucial to understand what facilitates near-miss reporting. This study by Jung et al. found near misses are not processed and reported equally. The effect of psychological safety on reporting near misses becomes stronger with their increasing proximity to a negative outcome. Educating healthcare workers to properly identify near misses and fostering psychological safety may increase near-miss reporting and improve patient safety.
  5. Event
    This Westminister Education Forum policy seminar will examine priorities, policy and best practice for improving child mental health in England - with a particular focus on the impact of the pandemic Overall, key areas for discussion in this conference include: immediate priorities for supporting children’s mental health following the pandemic and a return to in-person education identifying root causes of poor mental health, and best practice for prevention assessing child mental health services, and looking at how they can be improved, including the role of inspections in raising standards. Agenda Register
  6. Content Article
    The surge in the need for invasive ventilation during the covid pandemic has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan‐London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, the Department of Cardiac Surgery, St Bartholomew's Hospital, outline their experience of setting up and delivering a pan‐regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID‐free in‐hospital environment. In doing so, they hope that other regions can use this as a starting point in developing their own region‐specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom
  7. Content Article
    Various research articles have reported that the science of Human Factors is of vital importance in improving human-machine systems. However, what is lacking is a fundamental historical outline of why Human Factors is important. This article from deWinter and Hancock provides such a foundation, using arguments ranging from pre-history to post-COVID.
  8. Event
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    A triennial event featuring over 200 sessions all available on demand plus 800 papers on over 30 themes from healthcare ergonomics, organisational design and management to biomechanics and human modelling and simulation. The Executive Panel will address the Congress theme "HF/E in a Connected World" which raises urgent scientific and professional challenges concerning human interaction with technology in the era of automated and ubiquitous cyber-physical technologies. Register
  9. News Article
    The highest number of alcohol-related deaths in England and Wales since records began was seen in 2020, official data shows. A survey by the Office for National Statistics (ONS) showed that alcohol killed more people in 2020 than in any of the previous 20 years. The data also showed a rise of 20 per cent compared to 2019. Overall, there were 7,423 deaths from alcohol misuse last year, compared to 6,209 in 2019. Deaths increased from March 2020 onwards, when the coronavirus pandemic forced the UK into a series of national lockdowns. Read full story Source: The Independent, 6 May 2021
  10. News Article
    Police are investigating allegations around the death of a patient who was under the care of Hertfordshire Partnership University Foundation Trust. The probe by Hertfordshire Constabulary relates to the case of Margaret Molyneux, 69, who according to a review by the trust’s commissioners, was prescribed doses of anti-psychotic medication which were significantly higher than recommended limits. Police said the investigation is ongoing and no arrests have been made. Ms Molyneux had been admitted to the trust’s mental health unit in Radlett in 2017, after which her physical health declined and she was admitted to Watford General Hospital with pneumonia and dysphagia, which relates to difficulties swallowing. She was discharged back to the Radlett unit, but died several weeks later at Watford General Hospital, after choking on her food and developing aspiration pneumonia. An inquest in February 2018 ruled she died from natural causes, but an investigation into her case commissioned by East and North Hertfordshire Clinical Commissioning Group, seen by HSJ, subsequently suggested high doses of Olanzapine, an anti-psychotic drug, were “likely to have at least contributed to some of the physical problems she experienced… including low blood pressure, falls and dysphagia”. Read full story (paywalled) Source: HSJ, 6 May 2021
  11. News Article
    Pressure is growing on the government to change its stance on coronavirus infection rules which it is feared may leave NHS staff and patients at risk from airborne transmission. Experts told The Independent the current guidance from Public Health England (PHE), which effectively says staff working on general wards can rely on just surgical masks for protection, was “outdated and potentially misleading” and put NHS staff at risk. At the start of the pandemic the emphasis on stopping infection was focused around droplets containing the virus both in the air over short distances and on surfaces. Increasingly scientists have begun to warn the virus can also spread through much smaller aerosols which can remain airborne for a lot longer and over further distances. On Friday, the World Health Organisation updated its information on how Covid spreads to acknowledge the risk of aerosols and last month papers released by the government’s Scientific Advisory Group for Emergencies (Sage) said health workers may need to use better protection for longer. Read full story Source: The Independent, 6 May 2021
  12. News Article
    Pregnant women are struggling to get the coronavirus vaccine because clinics are unable to guarantee they will have the right type of jab available, Labour MP Stella Creasy has said. The Pfizer-BioNTech or Moderna jabs are preferable for pregnant women because there is more safety data available. But the online booking system in England does not allow them to specify which vaccine they require. Pregnant women are advised to speak to their GP instead of booking online. But Ms Creasy, 44, said GPs do not always know when local vaccination centres will have specific types of the jab available. The MP for Walthamstow, who is currently pregnant with her second child, said she had received five invitations to be vaccinated but she could not take them up because there is no system to specify she needs the Pfizer or Moderna jab. "I don't think it's been made enough of a priority because there's a presumption it will become more of a priority as they move through the age groups, which is a misreading of the data about pregnancy," she told the BBC. Read full story Source: BBC News, 7 May 2021
  13. News Article
    Spending on the NHS, social care and public health needs to rise by £102bn over the next decade, funded by big tax rises, to improve Britain’s health in the wake of the coronavirus pandemic, an inquiry has said. The massive funding boost would cut avoidable deaths from cancer and heart disease, tackle glaring health inequalities and rebuild the NHS after Covid exposed weaknesses such as a lack of beds and staff, a team of experts have urged ministers. The money would come largely from increases in income tax, national insurance and VAT, which evidence suggests the public is willing to pay, according to a four-year commission of inquiry by the London School of Economics and the Lancet medical journal. “Without concerted action and increased funding we risk the UK falling further behind other high-income countries in health outcomes and life expectancy, continued deterioration in service provision and worsening inequalities, increased reliance on private funding and an NHS that is poorly equipped to respond to future major threats to health,” said Dr Michael Anderson of the LSE, the commission’s joint research lead. Read full story Source: 6 May 2021
  14. Content Article
    There are estimated 24 000–60 000 women who are pregnant and incarcerated worldwide and they often lack access to antenatal care at the same level as that available in their communities. Despite clear international standards that mandate equivalent care for people in prison, pregnant women in these settings face significant barriers to adequate antenatal care. The needs of pregnant women are often overlooked in prisons designed to house men . We must not forget this vulnerable and hidden cohort of women. Molly Skerker et al. explore the challenges for pregnant women in prisons worldwide.
  15. Content Article
    Two new factsheets from the Centers for Disease Control and Prevention (CDC) are intended to help healthcare workers, managers and purchase agents ensure the safe handling and disposal of sharps during the US's COVID-19 mass vaccination effort.
  16. Content Article
    While COVID-19 has worsened patient waiting times across the NHS, patients with pelvic disorders have long been an under-served population experiencing unacceptable delays in care. Pelvic floor disorders are varied and can be complex, but treatment is available. However, patients, particularly those requiring surgery, can wait years from presentation before receiving the treatment they need. 
  17. Content Article
    Citizens Online promote an inclusive and equal society, reducing the digital divide by helping organisations and communities ensure the switch to online doesn’t exclude people. To implement successful digital transformation, inclusion and accessibility must sit at the heart of any changes. Citizens Online help to ensure that clients, residents and service users are supported to participate in the digital age, leading to increased take-up of your digital services.
  18. News Article
    Women and younger adults were more likely to feel depressed during the second UK coronavirus peak than men and other age groups, Office for National Statistics (ONS) data suggests. Four in 10 women aged between 16 and 29 were affected, compared to 26% of men. One in five adults experienced depression in early 2021 - more than double pre-pandemic levels. But GPs in England diagnosed fewer cases of depression in adults in 2020 compared with the year before. Many people may not be seeking medical help, the ONS says. Health experts have always warned that the combined effects of ill health, isolation and job losses during the pandemic would have a negative impact on people's mental health and wellbeing. Read full story Source: BBC News, 5 May 2021
  19. News Article
    The first new hospital cleaning standards for 14 years have been outlined by regulators, including confirmation of new food hygiene-style star ratings. Wards and theatres will be given ratings from one to five stars – based on audits which score the cleanliness of areas against safe standards – and these ratings will be made visible to patients. The plans for the new star ratings, which are expected to be easier for patients to understand than the current cleanliness percentage scores, were first revealed by HSJ in 2019. The ratings are also designed to encourage a more collaborative approach, by reflecting the cleanliness score for whole areas, as opposed to the performance of individual parties responsible for cleaning certain elements. Areas rated one to three stars would require improvement plans and be automatically placed under review, with “immediate action” being required in one-star rated areas. Read full story (paywalled) Source: HSJ, 6 May 2021
  20. News Article
    The number of people being diagnosed with cancer early in England has plummeted during the Covid pandemic, sparking fears that many will only be treated when it is too late to save them. Official figures show a third fewer cancers were detected at stage one, when the chances of survival are highest, in the early months of the pandemic than during the same months a year before. Cancer experts fear that the figures, which have been collected by Public Health England’s National Cancer Registration and Analysis Service, mean thousands of people have the disease but have not yet started treatment because of “a shift to later diagnosis”. They urged anyone with possible symptoms of the disease to get them checked out immediately. “While it’s fantastic that Covid rates are dropping and lockdown is easing, the knock-on impact of the pandemic on cancer care cannot be overstated,” said Steven McIntosh, the executive director of advocacy and communications at Macmillan Cancer Support. “We are likely to be dealing with Covid’s long shadow for many years to come.” Read full story Source: The Guardian, 5 May 2021
  21. Content Article
    This paper from Samson et al. discusses the properties of complex systems and a systems approach to incident investigation, describes the differences between reactive and proactive safety approaches and describes some of the system-focused models applied to patient safety incident investigations.
  22. News Article
    Two doses of the Pfizer-BioNTech vaccine can provide more than 95% protection against infection, severe illness and death from Covid, according to a groundbreaking study in Israel. The middle eastern country currently leads the world in its inoculation programme, with more than half (56 per cent) of its population having already received both doses of the Pfizer vaccine. The research, published today in The Lancet journal, also concluded that a single dose of the jab provides 58 per cent protection against infection, 76% against hospital admission, and 77% against death. The researchers said their study highlights the importance of fully vaccinating adults against the virus but acknowledged challenges remain to get the pandemic under control – including uncertainty around how long immunity lasts, from both vaccines and natural infection, and the emergence of variants that may be resistant to jabs currently on the market. Read full story Source: The Independent, 6 May 2021
  23. Event
    This virtual masterclass, facilitated by Mr Perbinder Grewal, will guide you in how to use Human Factors in your workplace. All medical and non-medical staff should attend. 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. Perbinder Grewal is a Consultant Surgeon. He is a human factors and patient safety trainer. He leads on medical education both locally and nationally. He is a Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh. He has a passion for training and medical education. He is a Module Tutor for the ChM in Vascular Surgery for the University of Edinburgh and Tutor for the ChM in General Surgery for the past 5 years. He has Postgraduate Certificates in Leadership and Coaching. Further information and to book your place or email kerry@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org
  24. Event
    This virtual masterclass, facilitated by Mr Perbinder Grewal, will focus on Patient Safety and how to setup a proactive safety culture. It will look at what patient safety is and how we can set up and improve the safety culture. It will look at Human Factors and how we can mitigate some of the common errors. Can we have a system with zero patient safety incidents or errors? For more information  and to book or email kerry@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org
  25. Event
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    This two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. For further information and to book your place or email kate@hc-uk.org.uk hub members receive 20% discount code. Email info@pslhub.org
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