Patient Safety Learning
AdministratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient Safety Learning
-
Content ArticleThe African Partnerships for Patient Safety (APPS) is a WHO Patient Safety Programme concerned with building sustainable hospital to hospital patient safety partnerships. The programme is focused on countries of the WHO African Region but has also opened the network and programme resources to all hospitals in all regions of the world. It sits within the programmatic area of Global Partnerships for Patient Safety. APPS is concerned with advocating for patient safety as a precondition of health care and catalyzing a range of actions that will strengthen health systems, assist in building local capacity and help reduce medical error and patient harm. The programme acts as a channel for patient safety improvements that can spread across countries, uniting patient safety efforts. APPS has taken place in a dynamic context in which insights are emerging on multiple dimensions of patient safety in African settings and political changes have seen shifts in approaches to patient safety in the United Kingdom. What is clear however is that the published literature on evidence-based patient safety interventions in the African context still lags behind high-income countries. This report highlights that issues and solutions from high income settings cannot simply be applied to African countries, and there is a need to understand the insights presented here from front-line partners to ensure that culture and context are addressed and the necessary adaptation made to existing approaches moving forward.
-
Content ArticlePatient Experience in England rounds up twelve months of reporting, and summarises key findings. As well as a review of the national patient surveys, this thematic overview of recent research draws out cross-cutting learning on matters such as online engagement, patient safety and the evidence-practice gap in patient experience. "Listening to patients should not be seen as a chore, or a tick box" says Shaun Lintern in the foreword to this year's Patient Experience in England report.
-
News Article
‘Long covid’ clinics still not operating despite Hancock claim
Patient Safety Learning posted a news article in News
The government and NHS England appear unable to identify units set up to treat ‘long covid’, contrary to a claim by Matt Hancock in Parliament that the NHS had ‘set up clinics and announced them in July’. There are growing calls for wider services to support people who have had COVID-19 and continue to suffer serious follow-up illness for weeks or months. Hospitals run follow-up clinics for those who were previously admitted with the virus, but these are not generally open to those who were never admitted. Earlier this month the health secretary told the Commons health committee: “The NHS set up long covid clinics and announced them in July and I am concerned by reports from Royal College of General Practitioners that not all GPs know how to get into those services.” Asked by HSJ for details, DHSC and NHS England declined to comment on how many clinics had been set up to date, where they were located, how they were funded or how many more clinics were expected to be “rolled out”. However, two charities and support groups — Patient Safety Learning and the Long Covid Support Group — told HSJ they were not aware of dedicated long covid clinics for community patients. An enquiry from Patient Safety Learning to NHS England has not been answered. The number of people affected by long covid is unclear due to a lack of research but there are suggestions it could be half a million or more. Symptoms can include fatigue, sleeplessness, night-time hypoxia, “brain fog” and cardiac problems. It appears to affect more people who were not hospitalised with coronavirus than those who were were. There is some evidence that small clinics have been set up locally on a piecemeal basis, without national funding. HSJ has only been able to identify only one genuine “long covid clinics” open to those who have never been in hospital with covid. Trisha Greenhalgh, an Oxford University professor of primary care health sciences who has interviewed around 100 long covid sufferers, told HSJ: “Nobody I have interviewed had been seen in a long covid clinic but there is an awful lot of people who would like to be referred and who sound like the need to be but they haven’t.” Read full story (paywalled) Source: HSJ, 23 September 2020 Read the letter Patient Safety Learning sent to NHS England hub Community thread - Long Covid: Where are these clinics?- Posted
- 2 comments
-
- (and 2 more)
-
Content ArticleHealthcare worldwide is faced with a crisis of patient safety: every day, everywhere, patients are injured during the course of their care. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. Mary Dixon-Woods and Peter J Pronovost propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors – organisations, individuals, groups – each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. Efforts by individual actors, including local quality improvement projects, may have the paradoxical effect of undermining system safety. Many challenges cannot be resolved by individual organisations, since they require whole-sector coordination and action. The authors call for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.
-
Content ArticleTo celebrate the second annual World Patient Safety Day, the Canadian Patient Safety Institute (CPSI) are proud to premiere the documentary, Building a Safer System, showcasing the 17-year impact of the Canadian Patient Safety Institute. The film is followed by an expert panel discussion of the theme, Health Worker Safety – A Priority for Patient Safety.
-
Content ArticleBarnsley NHS Trust Head of Nursing Quality Gavin Portier and Patient Safety Learning Founder and Chair Jonathan Hazan sit down to discuss how positive messaging and learning around patient safety produces positive outcomes.
-
Content ArticleBubble PAPR is an innovative PPE respirator designed to keep NHS staff safe while caring for patients during COVID-19. In this video, Brendan McGrath, an NHS Intensive Care Consultant, describes how Manchester University Foundation Trust, Manchester University and Designing Science Ltd came together to re-invent the Powered Air Purifying Respirator for the covid era.
-
Content ArticlePresentation from Dr Andrew Hider, Clinical Director, Consultant Clinical and Forensic Psychologist, Ludlow Street Healthcare, on mental health during the pandemic.
-
Content ArticleThis handbook provides tools for designing a structure for a management system, as well as the tools for documenting processes within it. The starting point is based on current safety research. The book is designed for medical professionals, managers, project members, politicians, public officials, and executives-all who work with patient safety matters. The content shows a new way to healthcare management, presenting an alternative approach together with concrete advice on how healthcare executives and practitioners can begin to think and act differently in order to provide safe healthcare.
-
Content Article
Canadian Institute for Health Information
Patient Safety Learning posted an article in International patient safety
The Canadian Institute for Health Information (CIHI) provides comparable and actionable data and information that are used to accelerate improvements in health care, health system performance and population health across Canada. Stakeholders use the broad range of health system databases, measurements and standards, together with the evidence-based reports and analyses, in their decision-making processes. -
Content Article
NHS England: Support for prescribers
Patient Safety Learning posted an article in Medication administration
NHS England has commissioned the Specialist Pharmacy Service to provide prescribers with all the support they need to: Stop prescribing medicines which are not clinically-effective or cost-effective Provide clear information to patients to help them make meaningful choices and decisions about their treatment Help people to get the benefits they want from their prescribed medicines Encourage people to ‘self-care’ and choose not to take a medicine if they don’t really need one Take positive action to reduce waste so we stop throwing away so many medicines. -
EventISQua is holding a World Patient Safety Day event which will look at how healthcare safety is important for patient safety too. Speakers: 1. Dr Zainab Yunusa-Kaltungo, Consultant Plastic Surgeon, Former Patient Safety Lead, Federal Teaching Hospital Gombe, Gombe, Nigeria 2. Dr Gbonjubola Abiri, Consultant Psychiatrist and Medical Director Tranquil and Quest Behavioural Health 3. Chika Odioemene, RN, CEO & Founder Utopian Healthcare Agenda: 11:00 AM – 11:10 AM Welcome address/introduction 11:10 AM – 12:10 PM Panel discussion: mental health of health workers, concept of 2nd victim and workplace bullying: how do these affect patient safety? (Chika, Gbonjubola and Zainab) 12:10 PM – 12:25 PM Wrap up: Opportunities surrounding quality and safety improvement and how to get started (Zainab) 12:25 PM – 12:30 PM Closing remarks Registration
-
Content ArticleA report from MedStar Health National Center for Human Factors in Healthcare on the work and research they do in human factors.
-
Content ArticleIn July 2015 five NHS Trusts were selected to work with Virginia Mason Institute (VMI) to develop localised versions of the Virginia Mason Production System (an adaption of the Toyota Production System, a continuous improvement approach commonly known as Lean). The goal was to develop a sustainable culture of continuous improvement capability in each of the five partner NHS hospital Trusts, and to share lessons from the partnership with NHS system leaders. Here are a series of video interviews with the CEOs of these NHS Trusts and the Virginia Mason Institute.
-
Content ArticleInsight into medical device and system failure and the teachings of Henry Petroski, a professor of civil engineering at Duke University, who wrote about failure analysis and design theory.
-
News Article
Flu and COVID-19 at same time significantly increases risk of death
Patient Safety Learning posted a news article in News
Having flu and COVID-19 together significantly increases your risk of death, say government scientists who are urging all those at risk of getting or transmitting flu to get the vaccine in the coming weeks and months. The evidence for the double whammy is currently limited and comes mostly from a study with small numbers – 58 people – carried out in the UK during the early phase of the pandemic. “As I understand it, it’s 43% of those with co-infection died compared with 26.9% of those who tested positive for Covid only,” said England’s deputy chief medical officer, Prof Jonathan Van-Tam. These were people who had been hospitalised and had been tested for both viruses, he said, and so were very ill – but the rate of death from Covid alone in the study between January and April was similar to the known rate of Covid hospital mortality generally of around 25% or 26%. "I think it is the relative difference in size of those rates that’s rather more important than the absolute rate,” he said. The study may have been small and they would be doing further studies this season, but the findings tallied with other work that has been done, he said. “If you get both, you are in some serious trouble, and the people who are most likely to get both of these infections may be the very people who can least afford to in terms of their own immune system, or their risk for serious outcomes. So please protect yourself against flu, this year,” says said Prof Yvonne Doyle, medical director of Public Health England The government has bought 30,000,000 doses of flu vaccine, which is more than ever before. They will arrive in batches, so the elderly – over 65 – and those with medical conditions will be called for immunisation first. Relatives of those who are on the shielding list will also be called up. The letters will begin to go out this week. Because of the threat of Covid and the risk that people with flu could be infected if admitted to hospital, all those aged 50-64 will be offered flu vaccination, but not straight away. They should wait to be called by their GP. Read full story Source: The Guardian, 22 September 2020 -
News Article
Overcrowded A&Es ‘much more dangerous now because of covid’
Patient Safety Learning posted a news article in News
Emergency departments across England are reporting ‘dangerous’ overcrowding similar to levels seen pre-covid, and struggling to maintain social distancing, A&E leaders have warned. The Royal College of Emergency Medicine said it was concerned about covid spreading among the most vulnerable patients, as overall transmission rates continue to rise sharply across the UK. It was always anticipated that A&E activity would return to pre-covid levels this winter, following a significant drop-off in A&E activity during the spring and early summer, and that service transformation would be needed to help maintain social distancing. But the emergence of widespread overcrowding so far ahead of winter is of serious concern to system leaders. A&E staff were already being forced to make difficult trade-offs over which patients to isolate, the college’s vice president told HSJ. He also urged NHS leaders not to place unrealistic expectations on the impact a new model involving walk-in patients booking slots by phone could make on addressing overcrowding in emergency departments. RCEM vice president Adrian Boyle said the NHS was “largely back to the pre-covid levels of crowding” but it was “much more dangerous now because of covid”. He said: “We are hearing that most emergency departments can’t maintain social distancing safely and staff are having to make fairly difficult trade-offs about which people need to be isolated. No one can be safely social distanced in a corridor.” Read full story (paywalled) Source: HSJ, 21 September 2020 -
News Article
'I'm traumatised now': Covid bereaved call for inquiry into NHS 111
Patient Safety Learning posted a news article in News
Hundreds of people believe the helpline failed their relatives. Now they are demanding their voices be heard. Families whose relatives died from COVID-19 in the early period of the pandemic are calling for an inquiry into the NHS 111 service, arguing that many critically ill people were given inadequate advice and told to stay at home. The COVID-19 Bereaved Families for Justice group says approximately a fifth of its 1,800 members – more than 350 people – believe the 111 service failed to recognise how seriously ill their relatives were and direct them to appropriate care. “We believe that in some cases it is likely these issues directly contributed to loved ones dying, due to causing a delay in receiving treatment, or a total lack of treatment leading to them passing away at home,” said the group’s co-founder Jo Goodman, whose father, Stuart Goodman, died on 2 April aged 72. Many families have said they had trouble even getting through to the 111 phone line, the designated first step, alongside 111 online, for people concerned they may have COVID-19. The service recorded a huge rise in calls to almost 3m in March, and official NHS figures show that 38.7% were abandoned after callers waited longer than 30 seconds for a response. Some families who did get through have said the call handlers worked through fixed scripts and asked for yes or no answers, which led to their relatives being told they were not in need of medical care. “Despite having very severe symptoms including skin discolouration, fainting, total lack of energy, inability to eat and breathlessness, as well as other family members explaining the level of distress they were in, this was not considered sufficient to be admitted to hospital or have an ambulance sent out,” Goodman said. Some families also say their relatives’ health risk factors, such as having diabetes, were not taken into account, and that not all the 111 questions were appropriate for black, Asian and minority ethnic people, including a question to check for breathlessness that asked if their lips had turned blue. Read full story Source: The Guardian, 21 September 2020 -
Content ArticleIn this blog, Patient Safety Learning look at why complaints are important to improving patient safety and sets out its response to the Parliamentary and Health Service Ombudsman (PHSO) consultation on a new Complaint Standards Framework for the NHS.
-
Content ArticleThe Irish College of General Practitioners (ICGP) Doctors' Health in Practice Programme aims to promote and support the good physical health, occupational health, psychological health and wellbeing of GPs. It encourages primary health care for doctors' healthcare in the first instance and supports the aim that every GP and GP Trainee should have a GP. You can find a list of directories, contacts and supports for doctors and your families, and resources that can be used for personal self-reflection, education, research or to help colleagues.
-
Content ArticleIn these times where the pressure of track and trace is ramping up around the world in the wake of expectations of a return to normality, Matt Pattison talks with Professor Effy Vayena from ETH Zurich about her work with the Swiss government in ethics, digital and the risks and rewards viewed under an ethical lens in the TEN podcast.
-
Content Article
Nigeria: World Patient Safety Day 2020
Patient Safety Learning posted an article in Staff safety
Nigeria joined the rest of the world to celebrate World Patient Safety Day on 17 September 2020. This event was jointly organised this year in Nigeria by the Occupational Health and Safety Managers (OHSM), Medical and Health Workers Union of Nigeria (MHWUN), OSHAfrica, International Trade Union Congress (ITUC-Africa), Nigeria Labour Congress (NLC), Patient Safety Movement Foundation (PSMF) and the World Health Organization (WHO). -
Content ArticleThis policy paper sets out the key elements of national support available for the social care sector for winter 2020 to 2021, as well as the main actions to take for local authorities, NHS organisations, and social care providers, including in the voluntary and community sector.Working together will ensure that high-quality, safe and timely care is provided to everyone who needs it, whilst protecting people who need care, their carers and the social care workforce from COVID-19.
-
Content ArticleThis report sets out the progress and learning from the first phase of the COVID-19 pandemic in informing advice and recommendations to government and the social care sector. The Social Care Sector COVID-19 Support Taskforce was commissioned in June 2020, with this report seeing the completion of its work in August 2020. The taskforce was set up to oversee the delivery of two packages of support that the government had put in place for the care sector: the Social Care Action Plan and the Care Home Support Plan. In addition, the taskforce was asked to support the government's work on community outbreaks – areas of the country that needed particular help and intervention to deal with higher rates of infection – and advising and supporting local places to consider and respond to reducing the risk of infection in care homes and the wider social care sector. Its further remit was to provide advice on the requirements for the response to COVID-19 in the next few months, ahead of and into winter.
-
Content ArticleThe COVID-19 crisis has created a watershed moment for the NHS, demanding a reappraisal of how essential services are delivered to the public. Even prior to COVID-19, the NHS recognised a pressing need to rethink healthcare using user-centred design principles, based on populations, not organisations. With the advent of the pandemic that pressing need has become an operational imperative. Digital capability has been and will continue to be a key part of transformation, but will only work when aligned with reforms in other key enablers such as financial flow, workforce planning and regulation. Many industries have already made the shift to enabling collaboration and innovation through more agile models of delivery by embracing technologies like artificial intelligence (AI), internet of things (IoT) and/or flexible and secure forms of (multi) cloud storage. Health, on the other hand, until now has introduced new technologies with the objective of improving existing pathways and service delivery models. There is now an opportunity to reimagine healthcare, driving true transformation enabled by digital capabilities.
