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Patient-Safety-Learning

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  • First name
    Lotty
  • Last name
    Tizzard
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    United Kingdom

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  1. Content Article
    In this Guardian interview, Rob Behrens, the outgoing NHS Ombudsman for England, says that too much unsafe care is still happening in the health service and that a culture of cover up makes it hard for bereaved families to find out the truth about their loved one's death. He describes the NHS as a complex institution run by mostly excellent, committed staff that is beset by cultural issues and a focus on limiting reputational damage at the expense of transparency and fair treatment of staff who speak up.
  2. Content Article
    Serious incident management and organisational learning are international patient safety priorities. However, little is known about the quality of suicide investigations and the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. This study reviewed research in this area and found that recent literature proposes a Safety-II approach in response to the limitations of RCA.
  3. Content Article
    This Twitter thread summarises the views of Dr Ian Jackson, a retired consultant anaesthetist and former Foundation Training Programme Director, on the patient safety and training issues relating to Anaesthesia Associates (AAs). He highlights issues with the length of training AAs receive compared with anaesthetists, the difference in training individuals who have experience in healthcare and theatre roles and those who have not and the supervision model in the current AA scope of practice.
  4. Content Article
    Peripheral nerve blocks (PNB) are safe and effective alternatives or supplements to general anaesthesia. They may improve pain control both during and after surgery, thus avoiding many of the side effects of systemic opioids. PNBs may also lead to improved patient satisfaction, decreased resource utilization, and may be better for the environment by decreasing usage of aesthetic gases and other medications. With the growing use of peripheral nerve blocks in the United States, this paper examines safety issues surrounding the procedures. It examines the safety of nerve blocks as it relates to: nerve injury recognition and treatment of local anaesthetic systemic toxicity (LAST) appropriate health care professional performance of timeouts to avoid wrong-site blocks.
  5. Content Article
    In this video story, Gaylene tells the story of her hospital stay in 1987 when she was very seriously ill—so ill that her doctors thought she would die. She describes how her wishes not to have her family visit when she looked so unwell were not listened to, which resulted in a traumatic visit for Gaylene, her husband and her four children under the age of 5. She highlights the ongoing impact the event had on her family and the importance of good communication between patients and healthcare staff.
  6. Content Article
    This blog looks at evidence around the impact of universal masking in healthcare settings on infection rates. Highlighting a recent study carried out at St. George’s Hospital in London that showed universal to have a negligible benefit on infection control amongst patients, the author argues that it is time to move away from universal masking to masks being worn really carefully as part of PPE for dealing with respiratory symptoms.
  7. Content Article
    The NHS will always need whistleblowers as healthcare is complex, rapidly changing and dangerous. However, whistleblowers continue to be treated very poorly by the health service, as this Private Eye special report highlights. The report looks in detail at several whistleblowing cases and how attempts to cover up mistakes and wrongdoing have resulted in patient deaths and devastated the careers and personal lives of staff who speak up for patient safety.
  8. Content Article
    This study in Surgery aimed to evaluate the association between trauma team function and cardiac arrest in hypotensive trauma patients. Trauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centres, and 430 patients were included in the study. The results show that better team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. The authors suggest that trauma team training may improve outcomes in peri-arrest patients.
  9. Content Article
    The School And Public Health Nurses Association (SAPHNA) has coproduced this vaccination toolkit with children and young people. It aims to increase young people's awareness of what vaccines are, why they are important and what to expect from different types of vaccines.
  10. Content Article
    The combination of emerging patient safety threats and the growing amount of published patient safety research, patient safety resources and accrediting body standards makes it increasingly difficult to prioritise adopting and implementing evidence-based practices. The US Agency for Healthcare Research and Quality's (AHRQ’s) fourth iteration of Making Healthcare Safer intends to address this issue by publishing evidence-based reviews of patient safety practices and topics as they are completed. This intentional release of updated reviews will aid healthcare organisation leaders in prioritising implementation of evidence-based practices in a timelier way. The report will also help researchers identify where more research is needed and assist policymakers in understanding which patient safety practices have the supporting evidence for promotion.
  11. Content Article
    Progress on cardiovascular disease (CVD) was a significant driver of better population health and greater prosperity in the latter half of the 20th century. However, progress has recently stalled, with indications it may be in reverse. This may be due to policy choices made in the last 15 years, particularly since the global financial crisis, above and beyond the more recent impact of the Covid-19 pandemic. This report by Chris Thomas from the Institute for Public Policy Research (IPPR) shows, among other findings, that people are more likely to leave work due to a heart condition than any other health issue.
  12. Content Article
    Older people’s mental health has long been overlooked and poor mental health is often dismissed by health professionals as an ‘inevitable’ part of getting older. And despite NHS Talking Therapies having higher than average recovery rates among the over-65s, this service is less likely to be offered to older people. Commissioned by Age UK, this briefing from the Centre for Mental Health summarises evidence about the mental health of older people in England. It finds that ageist attitudes underpin a system that discriminates against older people, while fatalistic assumptions about what people can expect for their mental health in later life undermine the provision of effective support to promote wellbeing, prevent mental ill health and treat mental health difficulties. The briefing finds that while older people may possess many protective factors for good mental health, they face numerous risk factors, including poorer physical health, reduced mobility and, for some, poverty and racism. Tackling the risk factors and boosting protective factors can increase wellbeing in later life and either prevent or stop the escalation of mental health problems.
  13. Content Article
    The theme of this year’s International Long Covid Awareness Day is ‘Confront Long Covid: Recognise, prevent, act’. In this interview, we speak to retired occupational physician Dr Clare Rayner about her work in understanding Long Covid and its impact on individuals, the health service and the wider economy. She talks about recent guidance she has developed on people with Long Covid returning to work and outlines the impact Long Covid has on the workforce. She calls on healthcare leaders and the Government to invest in treatment-related research as well as highlighting the significant health risks associated with Covid reinfection.
  14. Content Article
    The total value of clinical claims associated with emergency medicine was nearly £700m in 2022/23, making them the second highest total value of claims by speciality. This podcast focuses on clinical negligence claims from the emergency department, and how insights from claims data can be used by emergency medicine teams to help improve safety. Hosted by Justine Sharpe from NHS Resolution's Safety and Learning team, the episode features guests from NHS England’s Getting It Right First Time team and the Royal College of Emergency Medicine. Topics covered include: The key themes and recommendations from NHS Resolution's 2022 ED reports, including discussion of cauda equina and aortic dissection How to use local claims data from NHSR and operational performance data from GIRFT to inform safer patient care Insights into specialty reviews and handover, communication and the importance of multidisciplinary ED teams.
  15. Content Article
    This blog identifies important features of the NHS Long Term Workforce Plan and looks at how focussing on these areas might help systems and providers develop their own plans and take agency to solve local challenges. The author, Nick Richmond, spotlights the following aspects of the plan: ‘All levers at all levels’ approach Diverse time frames for different levers The ‘train’ actions are the most significant investment in domestic supply ever The plan is integrated with service and financial planning – future demand is ‘owned’ by the government and the NHS.
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