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Everything posted by Patient-Safety-Learning

  1. Content Article
    This book sets out what the terms governance and leadership mean, and how thinking about them has developed over time. Using real-world examples, the authors analyse research evidence on the influence of governance and leadership on quality and safety in healthcare at different levels in the health system: macro level (what national health systems do), meso level (what organisations do) and micro level (what teams and individuals do). The authors describe behaviours that may help boards focus on improving quality and show how different leadership approaches may contribute to delivering major system change.
  2. Content Article
    The Covid-19 pandemic increased the sense of urgency to advance understanding and prevention of infectious respiratory disease transmission. There are extensive studies that demonstrate scientific understanding about the behaviour of larger (droplets) and smaller (aerosols) particles in disease transmission as well as the presence of particles in the respiratory track. Methods for respiratory protection against particles, such as N95 respirators, are available and known to be effective with tested standards for harm reduction. However, even though multiple studies also confirm their protective effect when N95 respirators are adopted in healthcare and public settings for infection prevention, overall, studies of protocols of their adoption over the last several decades have not provided a clear understanding. This preprint article demonstrates limitations in the methodology used to analyse the results of these studies. The authors show that existing results, when outcome measures are properly analysed, consistently point to the benefit of precautionary measures such as N95 respirators over medical masks, and masking over its absence.
  3. Content Article
    In this blog, Dr Nadeem Moghal looks at the recent case of a 30 year-old patient who died after a physician associate (PA) at her GP surgery failed to diagnose her with a pulmonary embolism. He outlines a recent debate about the role of PAs in general practice and why employing them has become an attractive option for GP partnerships, which run as businesses. He highlights the need for PAs to be adequately trained and supervised to ensure patient safety and argues that the role is here to stay as PAs play an important role in tackling gaps in the NHS workforce.
  4. Content Article
    The Patients Association has been working with NHS England and the Royal College of Physicians on the development of an outpatient strategy for the past year. In this series of three blogs, they discuss what they have heard from patients about the state of outpatient care and what patients would like to see change. What patients want from an outpatient strategy Kindness, reasonable adjustments and consistency needed across outpatients Personalising care and offering patients choice
  5. Content Article
    In this blog, journalist Rory Cellan-Jones reflects on some major challenges the NHS currently faces. Sharing insights from a recent meeting with medtech companies and a lecture by economist Professor Diane Coyle, he shares concerns that productivity in the health service has decreased as a result of the pandemic, and that medtech companies face barriers in selling their solutions to the NHS. He highlights a growing consensus that policymakers need to think beyond immediate firefighting and look at how to transform the NHS over the long term.
  6. Content Article
    Leadership walkarounds (LWs) have been promoted in practice as means to drive operational, cultural and safety outcomes. This systematic review in BMJ Open Quality aimed to evaluate the impact of LWs on these outcomes in the US healthcare industry. The authors found only positive association of LWs with operational and perception of cultural outcomes.
  7. Content Article
    The Government's 10-year vision set out in People at the Heart of Care, published in 2021, focuses on three objectives for people who draw on formal care and support, their families, unpaid carers and the social care workforce:   People have choice, control and support to live independent lives. People can access outstanding quality and tailored care and support. People find adult social care fair and accessible.  In April 2023, the Department of Health and Social Care (DHSC) announced that it would establish an innovation and improvement unit to develop and define clear priorities for innovation and improvement across adult social care. This document sets out the Government's priorities for innovation and scaling in care and support, including identifying, recognising and supporting unpaid carers.
  8. Content Article
    In this episode of the Medicine and the Machine podcast, Scottish GP Gavin Francis talks about the need to reconsider the importance of convalescence. He discusses the role of GPs in supporting patients through recovery after a hospital admission or period of illness and talks about a lack of awareness of the principles of convalescence amongst patients.
  9. Content Article
    Physician associates (PAs) support doctors in the diagnosis and management of patient. They are often employed in general practice as members of the multidisciplinary team, trained in the medical model. This update outlines the Royal College of General Practitioners' (RCGP's) policy position on PAs. The RCGP sees PAs as having an enabling role to play for general practice, but highlights that they must always work under the supervision of GPs and must be considered additional members of the team, rather than a substitute for GPs.
  10. News Article
    One of the biggest challenges facing clinicians who treat Long Covid is a lack of consensus when it comes to recognising and diagnosing the condition. But a new study suggests testing for certain biomarkers may identify Long Covid with accuracy approaching 80%. Effective diagnostic testing would be a game-changer in the Long Covid fight, for it’s not just the fatigue, brain fog, heart palpitations, and other persistent symptoms that affect patients. Two out of three people with Long Covid also suffer mental health challenges like depression and anxiety. Some patients say their symptoms are not taken seriously by their doctors. And as many as 12% of Long Covid patients are unemployed because of the severity of their illness and their employers may be sceptical of their condition. Researchers at Cardiff University School of Medicine in Cardiff, Wales, United Kingdom, tracked 166 patients, 79 of whom had been diagnosed with Long Covid and 87 who had not. All participants had recovered from a severe bout of acute Covid-19. In an analysis of the blood plasma of the study participants, researchers found elevated levels of certain components. Four proteins in particular—Ba, iC3b, C5a, and TCC—predicted the presence of Long Covid with 78.5% accuracy. "I was gobsmacked by the results. We’re seeing a massive dysregulation in those four biomarkers," says study author Wioleta Zelek, PhD, a research fellow at Cardiff University. "It’s a combination that we showed was predictive of Long Covid.." Read full story Source: Medscape, 29 November 2023
  11. Content Article
    Hospitalised adults whose condition deteriorates while they are on hospital wards have considerable morbidity and mortality. Early identification of patients at risk of clinical deterioration has traditionally relied on manually calculated scores, and outcomes after an automated detection of clinical deterioration have not been widely reported. The authors of this article published in The New England Journal of Medicine developed an intervention program involving remote monitoring by nurses who reviewed records of patients who had been identified as being at high risk. Results of this monitoring were then communicated to rapid-response teams at hospitals. They compared outcomes among hospitalised patients whose condition reached the alert threshold at hospitals where the system was operational, with outcomes among patients at hospitals where the system had not yet been implemented. The authors found that using an automated predictive model to identify high-risk patients, for whom interventions could then be implemented by rapid-response teams, was associated with decreased mortality. 
  12. Content Article
    This presentation was given at the WHO Global Conference: Engaging patients for patient safety that took place in September 2023. Maki Kajiwara, technical officer at the World Health Organization's (WHO's) Patient Safety Flagship and Sue Sheridan, a founding member of Patients for Patient Safety US (PFPS-US), gave the presentation to introduce the new WHO Patient Safety Storytelling toolkit. The presentation outlines the need for a storytelling toolkit and provides questions and guidance to help storytellers share their experience.
  13. Content Article
    Patient safety incidents, including medical errors and adverse events, frequently occur in intensive care units, leading to a significant psychological burden on healthcare professionals. This burden results in second victim syndrome, which impacts the psychological and psychosomatic wellbeing of these staff members. This systematic review and meta-analysis aimed to examine the occurrence of second victim syndrome among intensive care unit healthcare workers, including the types, prevalence, risk factors and recovery time associated with the condition.
  14. Content Article
    From Autumn 2023, NHS organisations in England are changing the way they investigate patient safety incidents. NHS England has introduced this new approach, which is called the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. However, discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides some basic information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident.
  15. Content Article
    The Patient Safety Incident Response Framework (PSIRF) is a new approach to responding to patient safety incidents. NHS organisations in England have been implementing the framework since September 2023 and, as part of this, each trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder, available below. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. As well as sourcing PSIRPs that are easily accessible in the public domain, we submitted a Freedom of Information (FOI) request to all NHS trusts in England in November 2023. We will continue to add links to plans as they become available. If you are aware of a PSIRP that has been published that isn't yet featured, please get in touch and we will add it to the finder.
  16. Content Article
    In May 2021, the Irish public health service was the target of a cyber-attack. The response by the health service resulted in the widespread removal of access to ICT systems. While services including radiology, diagnostics, maternity and oncology were prioritised for reinstatement, recovery efforts continued for over four months. This study describes the response of health service staff to the loss of ICT systems and the risk mitigation measures introduced to safely continue health services. It also explores the resilience displayed by frontline staff whose rapid and innovative response ensured continuity of safe patient care.
  17. Content Article
    This study in BMC Health Services Research mapped healthcare workers’ experiences with patient safety incidents during the second wave of the Covid-19 pandemic in Slovakia. The authors found that healthcare workers with patient safety incident experiences reported poor hospital management of patient safety culture. This might reflect missed the opportunities to strengthen their resilience during the Covid-19 pandemic.
  18. Content Article Comment
    Hi @FIONA ELLWOOD, if you have permissions for the PSEN, you will be able to access the notes here: https://www.pslhub.org/forums/forum/311-drop-ins-and-chats/ If you're still having problems, please email us at content@pslhub.org
  19. Content Article
    Digital health inequality, observed as differential utilisation of digital tools between population groups, has not previously been quantified in the NHS. But recent developments in universal digital health interventions, including a national smartphone app and online primary care services, allow measurement of digital inequality across a nation. This study in BMJ Health & Care Informatics aimed to measure population factors associated with digital utilisation across 6356 primary care providers serving the population of England. The authors concluded that the study results are concerning for technologically driven widening of healthcare inequalities. They highlight the need for targeted incentives to digital in order to prevent digital disparity from becoming health outcomes disparity.
  20. News Article
    A 45-year-old mother who almost died after injecting herself with a life-threatening amount of insulin she thought was Ozempic is calling on the Government and social media companies to crack down on the online counterfeit weight-loss jab trade. Michelle Sword, a receptionist from Carterton, Oxfordshire, first took Ozempic without any issues after she was prescribed it by a legitimate online pharmacy in early 2021. Ms Sword said she completed an online questionnaire and gave a false BMI that she knew would qualify her the drug. “I just told them what they wanted to hear,” she said. Ms Sword said she takes responsibility for her actions, but criticised rogue sellers for taking advantage of people with insecurities and selling a product that “can kill you”. She also wants the Government and social media companies to step in to tackle the trend. “I think the drug was in such infancy in what we knew about it that they weren’t able to “police” who got it, who took it, who sourced it. I think they [the Government] need to look at that.” Read full story (paywalled) Source: inews, 26 November 2023
  21. Content Article
    The Sentinel Stroke National Audit Programme (SSNAP) measures the quality and organisation of stroke care across England, Wales and Northern Ireland. The overall aim of SSNAP is to provide timely information to clinicians, commissioners, patients and the public on how well stroke care is being delivered. Processes of care are measured against evidence-based quality standards referring to the interventions that any patient may be expected to receive. This report presents data from more than 91,000 patients admitted to hospitals between April 2022 and March 2023 and submitted to the audit, representing over 90% of all admitted strokes in England, Wales and Northern Ireland. This data is summarised in key messages for both those who provide and those who commission stroke care in hospitals and the community, and presented in tables and charts.
  22. Content Article
    This report published by the National Audit of Inpatient Falls (NAIF) includes information on multi-factorial risk assessments and post fall management, and contains five recommendations as well as resources to support improvement.
  23. Content Article
    This report published by the National Vascular Registry (NVR) contains information on emergency (non-elective) and elective procedures for the following patient groups: patients with peripheral arterial disease (PAD) who undergo either (a) lower limb angioplasty/stent, (b) lower limb bypass surgery, or (c) lower limb amputation patients who have a repair procedure for abdominal aortic aneurysm (AAA) patients who undergo carotid endarterectomy or carotid stenting.
  24. Content Article
    This study in the American Journal of Surgery aimed to understand the impact of operating room temperature and humidity on surgical site infection (SSI). The authors found that large deviations in operating theatre temperature and humidity do not increase the risk of SSI.
  25. Content Article
    This study in the Journal of Applied Research in Intellectual Disabilities aimed to  share rich detail of the emotional and physical impact on children and young people with intellectual disabilities of attending hospital, from their own and their parent's perspective. The authors found that the multiple and compounding layers of complexity surrounding hospital care of children and young people with intellectual disabilities resulted in challenges associated with loss of familiarity and routine, undergoing procedures, managing sensory overload, managing pain and having a lack of safety awareness. They concluded that an individualised approach to care is needed to overcome these issues.
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