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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This report, written in collaboration with the Royal College of Nursing (RCN), sets out proposals to reduce the number of preventable natural deaths in prisons. It identifies how natural deaths occurring in prison might be prevented, where possible, and end-of-life care managed with dignity and compassion.
  2. Content Article
    This report from the Samaritans finds that there is no consistently effective support available to people who self-harm. The research identified four key support needs for people who self-harm, which are seen as essential to providing effective care: distraction from immediate self-harm urges emotional relief in times of stress developing alternative coping strategies addressing the underlying reasons for self-harm.
  3. News Article
    GPs’ warnings about restricted services may have put patients off seeking treatment, delaying diagnoses and worsening existing illnesses, the health and care watchdog has said. The Care Quality Commission (CQC) said that millions of people had struggled to see their doctors during the pandemic, which had magnified inequalities and risked “turning fault lines into chasms”. Between March and August 119.5 million GP appointments were made in England, down from 146.2 million last year, according to NHS Digital. Ian Trenholm, the CQC’s chief executive, said: “The number of lost GP appointments translates into millions of people potentially . . . not getting conditions diagnosed early enough, not getting those referrals on for diagnoses like cancer and other conditions.” Read full story (paywalled) Source: The Times, 16 October 2020
  4. Content Article
    From acute delirium to long term fatigue, COVID-19 has serious neuropsychiatric effects. Viral infections of the respiratory tract can have multisystemic effects, including on the central nervous system (CNS), and thus may precipitate a spectrum of psychiatric and neurological disorders. Some patients with COVID-19 are now known to develop various CNS abnormalities with potentially serious and long term consequences, including stroke and isolated psychiatric syndromes. As COVID-19 cases rise again worldwide, Butler et al. review what we know and don’t know about the acute and chronic neuropsychiatric sequelae and their potential mechanisms.
  5. Content Article
    Providers deliver: Resilient and resourceful through COVID-19 is the third report from NHS Providers which celebrate and promote the work of NHS trusts and foundation trusts in improving care for patients and service users. This report showcases eight examples of great ideas put into action by trusts through the dedication and ingenuity of staff. One of the main themes in the report is the value of staff empowerment, where trust leaders support ideas and approaches developed within their workforce. Other themes such as innovation and collaboration also emerge. The case studies in this report are a timely reminder of the resilience and resourcefulness that has characterised the response of trusts and their staff to the challenges posed by the pandemic.
  6. Content Article
    The safety huddle has become an important way for hospitals to surface safety concerns affecting patients and the workforce. The best huddles are multidisciplinary, highly structured, brief (15 minutes or less), take place early in the morning and focus on incidents from the day before and risks to safety in the day ahead. Is the safety huddle effective? Have organisations grown lax with the process over time? Some participants have observed that, over time, safety huddles tend to become "just another meeting" or "another box to check off." Dr. James Reinertsen, who has spent decades coaching clinical leaders and staff about safety, says too many huddles allow department leads to report "no safety issues today." That's impossible, says Reinertsen. Every department has safety risks; it's a matter of being proactive and looking for them. In this podcast, Ronette Wiley shares the story of the turnaround with the safety huddle and the tools they use at Bassett Medical Center in upstate New York, USA, and Dr Helen Mackie educates us about the safety huddle at Hairmyres Hospital in Scotland where issues are flagged daily in a rigorous process known as The Onion. 
  7. Content Article
    Parents know better than anyone if their child is not behaving as they usually do or seem different in some way. Studies have shown that caregivers are often the first people to spot changes in the health of their child, even when in a clinical environment. You should feel able to raise any concerns if you think something is ‘just not right’ with your child. Great Ormond Street Hospital has produced guidance on what to look out for and how to raise a concern if you are worried about your child when in hospital.
  8. Content Article
    People aged under 60 who are hospitalised with COVID-19 are more likely than expected to experience severe psychiatric symptoms. Research found that altered mental states such as psychosis are being reported in these younger patients. It confirmed that strokes and other neurological symptoms are common in severe COVID-19. The authors are gathering and analysing more detailed clinical information about the patients reported in this study, and others reported since (540 are now included). They are seeking funding for a further study to include more clinical investigations such as analysis of spinal fluid, blood and brain imaging. Author Benedict Michael is co-chairing a World Health Organization commissioned task force which will consider how to use the information from the ongoing research project in guidance for clinicians. The task force will consider whether people with new-onset altered mental state or another acute neurological problem should be tested for COVID-19. Some patients with few respiratory signs present with this symptom. They will consider which tests and investigations people with COVID-19 and neurological symptoms should undergo. Doctors need to be sure COVID-19 is the cause of the symptoms, and to know how patients should be managed.
  9. Content Article
    The latest ECRI and the Institute for Safe Medication Practices PSO Deep Dive explores one of the areas that accounts for a large portion of healthcare volume: surgical care. Annually, surgery accounts for 7 million inpatient hospital stays and 36 million procedures in the outpatient setting. Although surgical safety has been the subject of guidelines, patient safety and quality improvement projects, and attention in the literature, adverse events continue to occur with relative frequency, putting patients at risk.
  10. Content Article
    In this blog, Patient Safety Learning considers the need for global action to improve patient safety and sets out its response to the WHO’s consultation on the draft Global Patient Safety Action Plan 2021-2030.
  11. Content Article
    Work-as-disclosed is what we say or write about work, and how we talk or write about it, either casually or more formally. Work is disclosed by many people, both those who do the work, and those who do not, based on more or less knowledge of work-as-done. Work-as-disclosed will tend to be different to work-as-done in several ways and for several reasons, including lack of knowledge about the work, difficulties in communicating about the work (e.g., the technical details), or fear about the consequences of disclosure. In this blog, Steven Shorrock explains three spaces for work-as-disclosed that are relevant to trying to reduce the gap between work-as-disclosed and work-as-done, or at least to understand why such a gap exists.
  12. Content Article
    When you are starting out on your Quality Improvement (QI) journey and setting up a healthcare collaborative, there are a range of preparations you can carry out to help ease the way. There are a lot of QI collaboratives out there already, so you could prepare for your journey by reading about and learning from other teams who have already been through the collaborative process. You are going to be instrumental in the success of your collaborative, and if you have a motivated team that is accountable, your collaborative is more likely to be successful. Here are some top tips from Life QI to consider before starting your healthcare collaborative. Life QI is the global web platform where tools, people and data come together to make improvement happen.
  13. News Article
    Intensive care units in Liverpool’s hospitals are more than 90% full, according to a local health leader, as the city braces for a second wave of COVID-19 infections. Councillor Paul Brant, cabinet member for adult health and social care at Liverpool City Council, warned that hospital services were once again being forced to care for patients critically ill with coronavirus. "Our intensive, critical care beds are filling up very fast,” he told BBC Radio 4's Today programme. "The most recent figures I've seen suggest they are over 90 per cent full and our acute hospital trusts have occupancy levels of Covid-positive patients of over 250. At the current rate of increase, we would expect Liverpool to surpass the peak of the first wave probably within the next seven to 10 days." Addressing the intensive care situation, he added: "They are not all Covid patients, I should say, but they are running very full and they are running with an increasing number of people who are Covid-positive." He added: "It has become clear that the intensity of the demand on hospital services here in Liverpool is crowding out anything other than dealing with Covid." Read full story Source: The Independent, 14 October 2020
  14. Event
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    The 2020 MindTech Symposium (#MindTech2020) will be held online as a virtual event for the very first time. The Symposium topic is ‘Digital Mental Health in the Age of Covid-19’ The session times are as follows: Wednesday 2nd December 2020: 8.00pm - 9.00pm: The digital mental health response to COVID-19: A global Perspective Thursday 3rd December 2020: 1st Session 10.00am - 11.30am: A rapid digital response to a global pandemic 2nd Session 1.15pm - 2.30pm: Virtual PPI: the way forward? 3rd Session 3.00pm - 4.00pm: Rethinking mental health services for a brave new world post-COVID-19 Wednesday evening’s opening session will embrace a global perspective on the digital mental health response to COVID-19 and includes international expert panellists Helen Christensen (Australia), John Torous (USA) and Sally Merry (New Zealand). Thursday’s sessions will cover emerging technologies and how they can be harnessed in the ‘new normal’ of mental healthcare in the post-Covid world. Thursday will also host a dedicated session encompassing Patient & Public Involvement (PPI) and user-centred co-design in a virtual world. This session will be delivered by MindTech’s own PPI group. Register
  15. Content Article
    A study of more than a half-million people in India who were exposed to the novel coronavirus SARS-CoV-2 suggests that the virus’ continued spread is driven by only a small percentage of those who become infected. Furthermore, children and young adults were found to be potentially much more important to transmitting the virus — especially within households — than previous studies have identified, according to a paper by Laxminarayan et al. in the journal Science. Lead researcher Ramanan Laxminarayan, a senior research scholar in PEI, said that the paper is the first large study to capture the extraordinary extent to which SARS-CoV-2 hinges on “superspreading,” in which a small percentage of the infected population passes the virus on to more people. The researchers found that 71% of infected individuals did not infect any of their contacts, while a mere 8% of infected individuals accounted for 60% of new infections. “Our study presents the largest empirical demonstration of superspreading that we are aware of in any infectious disease,” Laxminarayan said. “Superspreading events are the rule rather than the exception when one is looking at the spread of COVID-19, both in India and likely in all affected places.”
  16. Content Article
    A national bespoke system, called NHS e-Review, has been developed and launched as part of the NHS Covid Incident Recovery programme. The online system has been developed to support clinicians record the clinical priority of patients on a waiting list and to identify alternative pathways for patients if required.
  17. Event
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    The Westminster Health Forum is a division of Westminster Forum Projects, an impartial and cross-party organisation which has no policy agenda of its own. Forums operated by Westminster Forum Projects enjoy considerable support from within Parliament and Government. The agenda: The impact of investigations in the NHS and the priorities of the Healthcare Safety Investigation Branch Progress of improving patient safety in the NHS Maintaining patient safety during COVID-19 - rapid learning to respond to the virus, continuity of care, and adapting care delivery practices Delivering safe care in the NHS - preventing errors, utilising data and technology, supporting the workforce, and promoting high quality leadership Learning from the voice of parents and families How to improve patient safety by reducing unwarranted variation and learning from clinical negligence claims The role of technology in reducing errors, enhancing care, and ensuring safety in remote healthcare and telemedicine Taking forward the National Patient Safety Syllabus and supporting the workforce to deliver care safely during the presence of COVID-19 Learning from harm, reducing the cost of litigation in the NHS, and the impact of COVID-19 Assessing findings from the Independent Medicines and Medical Devices Safety Review The role of the regulator in reducing avoidable harm and informing future practice Register
  18. Content Article
    In his blog, Steve Turner consider the difference between accountability and bullying.
  19. Event
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    UCL has been working on developing their Centre for co-production as a mixed group of members of the public, researchers, patients, carers, healthcare practitioners, charities, local authorities and students (really anyone who wants to get involved or is interested in co-production!), since back in October 2017. After almost exactly 3 years they are officially launching it This event will be a celebration of all things co-production, highlighting the importance of this approach to research, policy-making and service development/improvement. It will include short snippets from UCL's ’Share your Co-pro Story’ campaign, the unveiling of their new strategy and new name, logo, and identity, and a chance to meet other likeminded people and have a chat... Find out more and register
  20. Content Article
    When an organisation stops innovating, it is only a matter of time before it fails. But what causes a company to cease coming up with new ideas? Over the last 20 years, Timothy Clark, founder and CEO of LeaderFactor, has studied many failed organisations and one of the things he consistently sees is an almost imperceptible erosion of intellectual bravery. Intellectual bravery is a willingness to disagree, dissent, or challenge the status quo in a setting of social risk in which you could be embarrassed, marginalised, or punished in some way. When intellectual bravery disappears, organisations develop patterns of willful blindness. Bureaucracy buries boldness. Efficiency crushes creativity. From there, the status quo calcifies and stagnation sets in. The responsibility for creating a culture of intellectual bravery lies in leadership. As a leader, you set the tone, create the vibe, and define the prevailing norms. Whether or not your company has a culture of intellectual bravery depends on your ability to establish a pattern of rewarded rather than punished vulnerability. Timothy share two examples in this blog.
  21. Content Article
    Healthcare settings have been using collaboratives to improve quality in healthcare, enhance patient safety and drive organisational change since the mid-1990s, when they became popular via the Institute for Healthcare Improvement’s (IHI) Breakthrough Series model. QI Collaboratives are groups of people from different units or organisations who work together in a structured way and share learning and experience in order to create more efficient services. Collaboratives are generally set up to enhance patient safety, quality and efficiency of care. This Life QI article gives tips on how to run an Improvement Collaborative. Life QI is the global web platform where tools, people and data come together to make improvement happen.
  22. Content Article
    Ensuring quality of care during pregnancy and childbirth is crucial to improving health outcomes and reducing preventable mortality and morbidity among women and their newborns. In recent years, Perinatal Quality Collaboratives (PQCs) have been driving improvements in perinatal care across the United States. PQCs are state or multistate networks of teams working to improve the quality of care for mothers and babies. PQCs do that by advancing evidence-informed clinical practices and processes using quality improvement principles to address gaps in care. PQCs work with clinical teams, experts and stakeholders, including patients and families, to spread best practices, reduce variation and optimise resources to improve perinatal care and outcomes. The goal of PQCs is to achieve improvements in population-level outcomes in maternal and infant health. In this article, LifeQI outlines the PQC approach, tools LifeQI can offer and some examples of PQCs being run. Life QI is the global web platform where tools, people and data come together to make improvement happen.
  23. Content Article
    The health literacy field has evolved over several decades. Its initial focus was on individuals who had poor literacy skills. Now there is a broad recognition that everyone—not just those with limited literacy—face challenges in understanding health information and navigating the healthcare system. Acknowledging that the healthcare system is overly complex, healthcare organisations have started to take responsibility to ensure that everyone, especially the vulnerable, is able to find, understand, and use health information and services. The Agency for Healthcare Research Quality (AHRQ) provides national health literacy leadership. AHRQ’s health literacy work spans from developing improvement tools, to designing professional training and education, to funding and synthesising health literacy research. You can find health literacy improvement tools, educational and training, and publications on the AHRQ Health Literacy website.
  24. News Article
    The government has been told it is ‘not sustainable’ to continue to delay its response to a major review on patient safety as ‘babies are still being damaged’. The Independent Medicines and Medical Devices Safety Review spoke to more than 700 people, mostly women who suffered avoidable harm from surgical mesh implants, pregnancy tests and an anti-epileptic drug, and criticised “a culture of dismissive and arrogant attitudes” including the “unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. The review’s author Baroness Julia Cumberlege told HSJ that “time is marching on” for the Department of Health and Social Care to implement the recommendations of her July report, which include setting up a new independent patient safety commissioner. The Conservative peer said pressure was building on government to adopt the findings of the review, since it had been endorsed by Royal Colleges and has already been adopted by the Scottish government. She said the government had given “evasive” answers in parliament on the issue. In an exclusive interview with HSJ, Baroness Cumberlege said: There is a crowded field of regulators but “there’s a void” for a service that listens and responds to patients’ safety concerns. She feels “diminished” that women’s concerns are still being dismissed by clinicians, but said young doctors are a cause for hope. She is “very optimistic” report will be implemented – but the NHS has to have the will to make changes. Read full story (paywalled) Source: HSJ, 13 October 2020
  25. Content Article
    What Your Patient Is Thinking (WYPIT) is a BMJ series led and edited by patients and carers. The articles are written by patients and carers and are a key part of The BMJ’s campaign to increase partnership with patients and public in healthcare. They contain messages that are thought provoking, and challenging for clinical readers of The BMJ, who mainly consist of doctors from across the world. Articles can be about any aspect of patient or carer experiences. This might include what it is like for you to live with your condition or as a carer or your experience of an appointment or procedure. This might be in relation to a single healthcare appointment to those from a lifetime of managing a long term health condition. It is important for the piece to include lessons for doctors. They can focus on a particular aspect of care or treatment, offer a new angle on a familiar situation, or ask controversial questions from the patient or carer's perspective. They can be triggered by good or bad experiences but all of them should give healthcare professionals and, or policy makers practical things that they can do differently tomorrow as a result of reading the article. The BMJ patient and clinical editors will work with you to develop your piece and to suggest specific questions to prompt reflection and action from the readership, that follow from the key points of your article. Guidance if you would like to contribute to the "What Your Patient is Thinking" series.
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