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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The debate about fairness of artificial intelligence (AI) in health care is gaining momentum. At present, the focus of the debate is on identifying unfair outcomes resulting from biased algorithmic decision making. This article in The Lancet Digital Health looks at the ethical principles guiding outcome fairness in AI algorithms.
  2. Content Article
    This Office for National Statistics (ONS) report provides in-depth analysis of Winter Coronavirus Infection Study (Winter CIS) data looking at trends in self-reported symptoms of Covid-19 including ongoing symptoms and associated risk factors. Winter CIS was a joint study with the UK Health Security Agency (UKHSA), carried out between November 2023 and March 2024 for England and Scotland. The study was structured as a longitudinal panel survey, with each participant sent a questionnaire and asked to take a lateral flow device test every four weeks for the detection of Covid-19.
  3. News Article
    The Royal Pharmaceutical Society (RPS) has published updated professional standards to support pharmacists, pharmacy technicians and pharmacy teams in responding to patient safety incidents. Created in collaboration with the Association of Pharmacy Technicians UK (APTUK) and the Pharmacy Forum Northern Ireland (PFNI), the Patient safety professional standards: responding to patient safety incidents are designed to support pharmacy professionals to meet regulatory standards. The standards, published on 24 April 2024, reflect new legislation and updated guidance from the General Pharmaceutical Council and NHS England, replacing the previous standards published in 2016. They also provide a framework for reflecting, reporting and recording incidents, and sharing learning, taking action and reviewing and evaluating incidents as part of a patient safety culture. Read full story Source: The Pharmaceutical Journal, 24 April 2024
  4. Content Article
    Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF) aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. This video was produced by SHSCFT to help staff, service users and their families understand the importance of sharing information around their ethnicity and protected characteristics.
  5. Content Article
    These patient safety professional standards aim to support pharmacists when responding to patient safety incidents. They describe good practice and provide a broad framework for continually improving services, shaping future services and roles and delivering high-quality care across all settings and sectors. They have been developed by the Royal Pharmaceutical Society (RPS), Association of Pharmacy Technicians UK and Pharmacy Forum NI, with the support of an expert steering group and public consultation. Pharmacists, pharmacist prescribers, pharmacy technicians and the wider pharmacy team across the United Kingdom will find these standards useful. They may also be of interest to the public, to people who use pharmacy and healthcare services, other healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
  6. Event
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    The future of health and care lies at the intersection of prevention and precision. It’s a paradigm shift that requires vision, leadership, change management and the critical need to be radical. At Radical Health Festival Helsinki 2024, we’re not just thinking about the future of healthcare; we’re redefining it. Imagine a world where health is a lifelong journey, where risks are identified before they turn into crises, and care is personalised for every citizen. Is this just a pipe dream? No, it’s the radical shift we need now more than ever! This year, we deep dive into the intersection of prevention and precision. It’s a bold move and a paradigm shift requiring bold leadership. But it´s the only way forward. The 2024 programme explores the three pillars and key questions that will enable this deployment at scale: PEOPLE: Can we shift our focus from technology to people and place humans at the heart of digital transformation efforts? INNOVATION: Can we re-think innovation frameworks to accelerate the adoption and integration of cutting-edge technologies in clinical pathways? DATA: How do we turn data into insights for prevention, precision, and equity? We may not have all the answers. But Radical Health Festival Helsinki is where radical ideas take flight. Find out more about the festival
  7. News Article
    Use of antipsychotic medications in patients with dementia is linked with a much wider range of serious harms than previously thought, say UK researchers. Although there have been safety warnings on use of the antipsychotics from regulators about increased risk of stroke and death, a large study has now found increased risks for pneumonia, venous thromboembolism, heart attack, heart failure, fracture, and acute kidney injury. Reporting the findings in the BMJ, researchers from the University of Manchester said it underscores the need for increased caution when prescribing. The analysis showed that antipsychotic use was associated with increased risks for all outcomes looked at with the exception of ventricular arrhythmia. Over the first six months of treatment, it was estimated that antipsychotic use was linked with one additional case of pneumonia for every nine patients treated, and one additional heart attack for every 167 patients treated. Professor Charles Marshall, professor of clinical neurology at Queen Mary University of London, said the study findings should prompt renewed efforts to reduce the prescribing of antipsychotics to people living with dementia. "There are rare circumstances where antipsychotics are genuinely required, and the benefits outweigh these risks, but for the majority of patients with behavioural symptoms that might lead to them being prescribed anti-psychotics, we should be focussing on much safer behavioural management approaches." Read full story Source: Pulse, 24 April 2024
  8. News Article
    The Biden administration set a first-ever minimum staffing rule for nursing homes Monday, making good on the president’s promise more than two years ago to seek improvements in care for the nation’s 1.2 million nursing home residents. The final rule, proposed in September, requires a registered nurse to be on-site in every skilled nursing facility for 24 hours a day, seven days a week. It mandates enough staff to provide every resident with at least 3.48 hours of care each day. And it beefs up rules for assessing the care needs of every resident, which will boost staff numbers above the minimum to care for sicker residents. For a facility with 100 residents, it translates to a minimum of two or three registered nurses and at least 10 or 11 nurse aides per shift, as well as two additional staffers who could be nurses or aides per shift, according to the administration’s interpretation of its new formula. Set to phase in over the next few years, the mandate will replace the current vague standard that gives operators wide latitude on how to staff their facilities. While the administration has said the rule will improve care, industry lobbyists have said it’s unworkable, with staffing goals that will be impossible to achieve because of a shortage of workers. The administration received 47,000 public comments on the rule since it was proposed last September. They included observations of people lying in their own filth for hours, not being fed appropriately and being left on the floor too long after falling, Secretary of Health and Human Services Xavier Becerra said in an interview Monday. Read full story Source: Washington Post, 22 April 2024
  9. News Article
    Female survivors of breast cancer living in the most deprived areas have a 35% higher risk of developing second, unrelated cancers, compared with those from the most affluent areas, research shows. Breast cancer is the most commonly diagnosed cancer in the UK, with about 56,000 people being told they have it each year. Improved diagnosis and treatments mean that five-year survival rates are now 86% in England. People who survive breast cancer have a greater likelihood of second primary (unrelated) cancer, but until now the exact risk has not been clear. A team of researchers led by the University of Cambridge analysed NHS data from almost 600,000 patients in England and found, compared with the general female population, women who had survived breast cancer had an increased risk of developing 12 other primary cancers. Compared with the most affluent, the least well-off female survivors of breast cancer had a 166% greater chance of developing lung cancer, a 78% higher risk of stomach cancer, more than 50% increased risk of bladder and oesophagus cancers, 48% higher risk of head and neck cancer and 43% increased risk of kidney cancer. Read full story Source: Guardian, 24 April 2024
  10. News Article
    A bereaved father whose vulnerable son died after managing to escape from the Priory has called for a criminal inquiry into the mental health care group after the deaths of four more patients. Richard Caseby, who lost his son Matthew, has campaigned for three years against the privately run group after an inquest found his son’s death was contributed to by neglect. The 23-year-old was able to abscond from the hospital over a fence which had previously been identified as a risk. He was hit by a train just hours later. Now the Priory, one of the UK’s largest mental health providers, faces new scrutiny as coroners are set to examine the death of 20-year-old Amina Ismail, who died while at the Cheadle Royal Hospital in Stockport. Ms Ismail died in September 2023, a year after three other young women died at the same unit - Beth Matthews, 26, Lauren Bridges, aged 20, and 30-year-old Deseree Fitzpatrick. Mr Caseby, a former newspaper editor, told The Independent: “The Priory is a fundamentally dangerous company, one that persistently refuses to learn from its mistakes and neglect. The roll call of death and disgrace at its hospitals just gets longer.” Read full story Source: Independent, 25 April 2024
  11. Content Article
    Clive Treacey, who had a learning disability, epilepsy and complex mental health needs, died in 2017 aged 47, having spent his adult life in residential social care and inpatient settings. In 1993, he was placed by Staffordshire County Council into the David Lewis Centre in the borough of Cheshire East, where it is alleged he was sexually abused by a member of staff. Cheshire East Safeguarding Adults Board (CESAB) and Staffordshire and Stoke-on-Trent Adults Safeguarding Partnership Board (SSASPB) jointly commissioned a Discretionary Safeguarding Adults Review (D-SAR) to look at Clive's case. Authored by Professor Michael Preston-Shoot, the review relates to historical incidents of abuse and examines what is now in place to protect adults at risk since adult safeguarding became a statutory duty under the Care Act in 2014. The SAR makes 14 recommendations to the boards.
  12. Content Article
    This toolkit is a practical guide for system leaders that will help to inform future spending on health inequalities and support implementation of high-impact changes within integrated care boards (ICBs) to address health inequalities. It aims to build system leaders’ confidence in their ability to tackle inequalities in their organisations and is accompanied by a research report that looks at the approaches systems took to spending health inequalities money. It is structured in line with the four main stages of quality improvement methods:  Culture, leadership and governance Understanding the problem Developing the best solution Evaluating success
  13. Content Article
    This report is a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001). It finds that diagnosis, and in particular the occurrence of diagnostic errors, has been largely unappreciated in efforts to improve the quality and safety of healthcare. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, healthcare organisations, patients and their families, researchers and policy makers. The report's recommendations contribute to the growing momentum for change in this crucial area of healthcare quality and safety.
  14. Content Article
    Computerised provider order entry (CPOE) prompts can provide patient-specific risk estimates for multidrug-resistant organisms (MDROs). This JAMA Network study aimed to find out whether CPOE prompts could reduce empiric extended-spectrum antibiotic use in patients admitted with pneumonia. The authors found that prompts promoting standard-spectrum antibiotics for patients at low risk of infection with MDROs reduced extended-spectrum antibiotic use by 28.4%, without increasing intensive care unit transfers or length of stay for patients with pneumonia.
  15. Event
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    This virtual launch event celebrates the ARMA report Act Now: MSK Health inequalities and deprivation. • Hear about the findings of the report and what they mean for health services and healthcare professionals. • How does deprivation relate to MSK health? • What are the 5 steps to addressing health inequalities and what do they look like in practice? • What are the particular issues for children and young people? • What can you do to create change if you act now? Join the discussion with the panel: • Anthony Gilbert, Postdoctoral Clinical Research Physiotherapist, Royal National Orthopaedic Hospital NHS Trust • Shabir Aziz, Lived Experience Partner • Lesley Kay, National Clinical Director for MSK, NHS England • Jacqui Clinch, Consultant Paediatric Rheumatologist Register for the event
  16. Content Article
    Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF) aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. This video was produced by SHSCFT to guide staff in having conversations about collecting information on ethnicity from patients and carers.
  17. Content Article
    The Patient and Carer Race Equality Framework (PCREF) was a recommendation following the national Mental Health Act Review in 2018. This video by South London and Maudsley NHS Foundation Trust (SLAM) explains PCREF and how it is being applied at the Trust.
  18. Content Article
    This podcast looks at preventing respiratory syncytial virus (RSV) outbreaks within healthcare facilities and strategies to minimise transmission of RSV among healthcare workers and patients during an outbreak. 
  19. News Article
    New figures have quantified what the pandemic has meant for cancer waiting lists—and the impact is stark. Official data show that 15,971 cancer patients in the UK have had to wait more than 124 days, or four months, after diagnosis for their treatment to start since 2020 as the pandemic sends waiting lists soaring. The statistics show that the number of untreated patients has more than doubled since Covid began, with one patient waiting for more than two years, according to data released following a freedom of information request from the Liberal Democrats. This is despite an NHS target for patients to receive cancer treatments within two months of an urgent referral. Last year, 6,334 patients waited more than 124 days, compared to 2,922 in 2022, the figures show. Data was received from 69 out of 137 acute health trusts in the UK, meaning the true number of people waiting long periods for treatment is likely to be much higher. Over 1,100 cancer patients last year were left waiting more than six months to receive treatment, triple the NHS target time. Liberal Democrat Leader, Ed Davey, said: “Every single one of these figures is a tragedy. Long delays for treatment can have a devastating impact on cancer patients and their families, and in certain cases can even cost lives." Read full story Source: inews, 22 April 2024
  20. Event
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    Good health should be shared with all. It should not be damaged by social or economic disadvantage. Shared Health Foundation is inviting any GP or clinical lead who is working in the deep end of medicine to join its annual Doctors in Deprivation Training Day. The day aims to inspire, challenge, encourage and most importantly help participants find their tribe of other clinicians working in areas of deprivation. The training day will explore the challenges faced by those working in areas of deprivation and disadvantaged communities and share the hopeful work organisations in Greater Manchester and beyond are doing to reduce health inequalities and the impact of poverty on health. Attendees will: get to grips with the health inequalities that many people face, and how they can help put things right. learn about the causes and effects of health inequalities find out about the ways in which GPs and healthcare staff can do their bit to make a difference. Tickets to the training day are free of charge. Sign up for the training day
  21. Content Article
    Public confidence in the NHS is at an all time low and even when people can access the service, national surveys tell us that their experiences of NHS services are deteriorating. The authors of this blog—Patients Association Trustee Alf Collins and Health Consultant Richard Sloggett—make a simple plea: that all aspects of patient experience is taken seriously. They argue that the care backlogs and levels of unmet need require a radical re-orientation of the relationship between the Government, the health system and the public, and that this needs to involve a complete step-change in how patients are engaged in their care.
  22. Event
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    The theme for this year's The Private Healthcare Information Network (PHIN) forum underscores the pivotal role that advancements in AI, robotics, and data play in shaping the future of healthcare for the benefit of patients and everyone involved in the sector. The event is free to attend, but you need to book to guarantee your place. Register for the event
  23. Content Article
    This cohort study in JAMA Network Open aimed to assess whether therapist burnout is associated with reduced effectiveness of guideline-recommended psychotherapies for posttraumatic stress disorder (PTSD). The findings suggest that interventions to reduce therapist burnout might also result in more patients experiencing clinically meaningful improvement in PTSD symptoms from evidence-based psychotherapies.
  24. Content Article
    This report contains the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel formed under Section 103 of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA). Reporting to the US Federal Aviation Administration (FAA) and Congressional committees of jurisdiction, the Expert Panel reviewed the safety management processes and their effectiveness for each holder of an ODA for the design and production of transport aeroplanes.
  25. Content Article
    In this blog, Siva Anandaciva, Chief Policy Analyst at The King's Fund, examines NHS productivity—a top political priority. He highlights the difficulties in understanding the reasons for low productivity in the NHS after the Covid-19 pandemic and outlines the need to distinguish between productivity and delivery in order to really understand the issues.
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