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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This mixed-methods study in the Journal of Multidisciplinary Healthcare examined how health staff in Indonesian hospitals perceived open disclosure of patient safety incidents (PSIs). The authors surveyed 262 health workers and interviewed 12 health workers. In the quantitative phase they found a good level of open disclosure practice, a positive attitude toward open disclosure and good disclosure according to the level of harm. However, in the qualitative phase they found that most participants were confused about the difference between incident reporting and incident disclosure. The authors concluded that a robust open disclosure system in hospitals could address several issues such as lack of knowledge, lack of policy support, lack of training and lack of policy. They also suggest that the government should develop supportive policies at the national level and organise initiatives at the hospital level in order to limit the negative implications of disclosing situations.
  2. Content Article
    The Department of Health and Social Care is seeking views and ideas on how to prevent, diagnose, treat and manage the six major groups of health conditions that most affect the population in England. These are: cancers cardiovascular disease, including stroke and diabetes chronic respiratory diseases dementia mental ill health musculoskeletal disorders The views and ideas gathered will inform the priorities and actions in the major conditions strategy. The consultation will close at 11:59pm on 27 June 2023.
  3. Content Article
    This report by The King's Fund is part of new research project that explores how NHS providers and integrated care systems (ICSs) are approaching inclusive recovery. It highlights that in 2022, people in the most deprived areas were twice as likely to be waiting more than a year for elective care compared to people in the least deprived areas. The report explores three big questions health and care leaders should be asking themselves and their teams about inequalities in their elective backlog:How are we measuring inequalities and whyDo we know why inequalities existHow will we know if things are improving?
  4. Content Article
    On paper, a GP’s working schedule can look quite inviting: consulting for three and a half hours in the morning, with a coffee break in the middle, then a gap for lunch and home visits before a similar length afternoon surgery. However, this is rarely the reality for NHS GPs. In this BMJ opinion piece, GP Helen Salisbury talks about what working life is really like for GPs and highlights the mismatch between their scheduled hours and tasks and the reality, which often involves them doing much more. She highlights how the unrealistic demands GPs face have been exacerbated by a movement of work from secondary to primary care, and argues that this is contributing to the workforce crisis that general practice faces.
  5. Content Article
    This is the first national ambulance volunteering strategy, produced by the Association of Ambulance Chief Executives. It recognises the important role volunteers play in the ambulance service and outlines a national approach to volunteering that will be adopted between January 2023 and May 2024. The strategy covers mission, vision, principles and measures of success.
  6. Content Article
    An NHS-Led Provider Collaborative is a group of providers of specialised mental health, learning disability and autism services who have agreed to work together to improve the care pathway for their local population. They will do this by taking responsibility for the budget and pathway for their given population. The Collaborative will be led by an NHS Provider who remains accountable to NHS England and NHS Improvement for the commissioning of high-quality, specialised services. These Collaboratives aim to ensure that people with specialist mental health, learning disability and autism needs experience high quality, specialist care, as close to home as appropriately possible. They seek to enable specialist care to be provided in the community to prevent people being in hospital if they don’t need to be, and to enable people to leave hospital when they are ready. This webpage explains the role of NHS-Led Provider Collaboratives and includes case studies that demonstrate how they are helping to transform specialised mental health services.
  7. Content Article
    Pharmaswiss Česka republika s.r.o. and distributor Bausch & Lomb UK Limited is recalling all unexpired batches of Emerade 500 micrograms and Emerade 300 micrograms adrenaline auto-injectors (also referred to as pens) from patients. This is due to an issue identified during an ISO 11608 Design Assessment study where some auto-injectors failed to deliver the product or activated prematurely. Specifically, the 1-metre free-fall (vertical orientation) pre-conditioning resulted in damage to internal components of the auto-injector, leading either to failure to deliver the product or premature activation. This damage was not visibly apparent following the pre-conditioning but was evident only on subsequent functional testing. It is unclear what impact this has on auto-injectors in clinical use, however as a precautionary measure and owing to the inability to identify this issue before the auto-injectors are used, the auto-injectors are being recalled. Healthcare professionals should inform patients, or carers of patients, who carry Emerade 300 or 500 microgram auto-injector pens to obtain a prescription for and be supplied with an alternative brand. They should then be informed to return their Emerade 300 or 500 microgram pens to their local pharmacy.
  8. Content Article
    The Bucharest Declaration is the outcome of a World Health Organization (WHO) high-level regional meeting on health and care workforce in Europe that took place in Bucharest 22-23 March 2023. It makes 11 statements relating to the workforce crisis facing countries across Europe about retention, recruitment and staff safety.
  9. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Stephen talks to us about his time as turnaround Chair of Mid Staffordshire NHS Foundation Trust, how NHS boards can ensure they live their values and why creating a safe space to share concerns improves patient safety.
  10. Content Article
    In healthcare, telling stories brings benefits to both storytellers and audience members, but also presents risks of harm. A reflective storytelling practice aims to honour stories and storytellers by ensuring there is time to prepare, reflect, learn, ask questions, and engage in dialogue with the storyteller to explore what went well and where there are learning and improvement opportunities. Healthcare Excellence Canada (HEC) is a pan-Canadian health organisation focused on improving the quality and safety of care in Canada. The HEC Patient Engagement and Partnerships team have co-developed these recommendations on how best to meaningfully share stories from those leading, providing and receiving care at Board meetings. This Case Study outlines the process HEC used to co-develop storytelling recommendations, focusing on a trauma-informed approach to create safe spaces for preparing, learning from and reflecting on stories, to clearly articulate their purpose, and to ensure the locus of control for storytelling rests with the storytellers.
  11. Content Article
    Attention deficit hyperactivity disorder (ADHD) is a condition that affects people's behaviour. It has a wide range of symptoms and can affect both children and adults—people with ADHD may find it hard to focus on or complete tasks, feel restless or impatient, experience impulsiveness and find it hard to organise their time and their things.[1] ADHD can have devastating mental health implications and research studies have linked ADHD to increased suicide and mortality rates. This means that being unable to access effective treatment can be a patient safety risk for people with ADHD. In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, explores the state of ADHD diagnosis and treatment in the UK. She looks at why many are concerned about the waiting times for adults and children seeking an ADHD assessment and speaks to Elsa*, who was diagnosed with ADHD in her 30s, about her experiences. *Name changed
  12. Community Post
    The impact of living with undiagnosed ADHD can be significant, but adults and children in the UK are sometimes having to wait years for an initial ADHD assessment. Have you been diagnosed with ADHD? Are you or your child on a waiting list for ADHD diagnosis or treatment? Or are you a healthcare professional that works with people with ADHD? Please share your experiences of assessment and diagnosis with us. You'll need to be a hub member to comment below, it's quick, easy and free to do. You can sign up here. You can read more about the issues related to ADHD diagnosis in this blog: Long waits for ADHD diagnosis and treatment are a patient safety issue
  13. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked nine resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices.
  14. Content Article
    The latest NHS Workforce Race Equality Standard (WRES) data shows that it is still over twenty times more likely that a White Band 5 nurse will become a Director of Nursing compared to a Band 5 BME nurse. In this letter Roger Kline, Research Fellow at Middlesex University Business School, outlines his concerns about discrimination and bullying taking place within the NHS. Addressed to Secretary of State for Health and Social Care Steve Barclay, the letter recalls the findings of the Messenger report commissioned by Mr Barclay's predecessor Sajid Javid, which found that “acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system, as evidenced by staff surveys and several publicised examples of poor practice." Referring to recent calls to reduce spending on equality, diversity and inclusion (EDI), he outlines why patient care and frontline services cannot be detached from efforts to improve EDI. He argues that research strongly suggests how staff are treated (including whether they face discrimination) impacts on patient care, staff well-being and organisational effectiveness.
  15. Content Article
    This article looks at the experience of Tammy Dobbs, who has cerebral palsy and requires extensive support from home carers to carry out daily tasks. In 2016, Tammy's care needs were reassessed by the state of Arkansas where she lives, and the hours of support she was eligible to receive were cut in half. The change in eligibility was due to a new state-approved algorithm that had calculated her support needs in a new way, in spite of the fact that there was no change to her level of need.  The situation caused Tammy much distress and resulted in drastic life changes. The article highlights the issues associated with the use of algorithms to determine need and allocate resources in health and social care. It also raises questions about what transparency means in an automated age and highlights concerns about people’s ability to contest decisions made by machines.
  16. Content Article
    The world is facing challenges emerging from multiple crises, including pandemics, wars and climate change. Against this backdrop, the Government of Japan will host the Group of Seven (G7) Summit in Hiroshima and the G7 Health Ministers' Meeting in Nagasaki, Japan, in May 2023. This article in The Lancet outlines key recommendations for G7 action to address these challenges through a human security approach and a transformation of global health architecture: Enhance resilience to public health emergencies by boosting country-led efforts to achieve universal healthcare Advance timely and equitable access to life-saving medical countermeasures as common goods Promote a multilayered approach to global health governance, including financing, that facilitates effective collaboration among state and non-state actors beyond the health sector at global and regional levels.
  17. Content Article
    Approximately 8% of US doctors experience a malpractice claim annually. Most malpractice claims are a result of adverse events, which may or may not be a result of medical errors. However, not all medicolegal cases are the result of medical errors or negligence, but rather, may be associated with the individual nature of the patient-doctor relationship. The strength of this relationship may be partially determined by a physician’s emotional intelligence (EI), or his or her ability to monitor and regulate his or her emotions as well as the emotions of others. This review evaluates the role of EI in developing the patient-physician relationship and how EI may influence patient decisions to pursue medicolegal action.
  18. Content Article
    In this letter to The Lancet, Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations argues that the need to focus on equitable rollout of vaccines in the event of a future pandemic is a key global health priority. He proposes that Governments, pharma companies and other stakeholders should focus on the challenges that led to the inequitable rollout of vaccines, which he identifies as vaccine nationalism and need for more diverse manufacturing. He highlights an industry proposal for equitable response to future pandemics supported by vaccine manufacturers and biotechnologies. the proposal involves manufacturers setting aside a percentage of pandemic tools for allocation to susceptible populations in low-income countries.
  19. Content Article
    The Covid-19 pandemic has shown the power and potential of vaccination in real time. But it has also disrupted health services and caused supply chain challenges, resulting in stagnation and backsliding of routine vaccinations. For example, global coverage of the third dose of the diphtheria–tetanus–pertussis vaccine fell from 86% in 2019 to 81% in 2021—the lowest level since 2008. 25 million children missed out on life-saving measles, diphtheria, and tetanus vaccines in 2021. This editorial in The Lancet calls for a catch-up to return to pre-pandemic vaccination levels and looks at how this can be achieved.
  20. Content Article
    This patient resource created by Prostate Cancer Research aims to equip patients and the public with information about prostate cancer. It contains information on: testing and diagnosis treatment choices living with side effects clinical trials.
  21. Content Article
    Economist Dana Peterson estimates that the economic toll of racism against Black Americans was $16 trillion over the past two decades. Discriminatory lending, wage disparities and inequities in access to higher education, among other factors, have limited the Black community’s ability to generate personal wealth and economic growth. Other minority communities have had similar experiences, and the impact goes far beyond the economy; each of these factors also takes an enormous toll on the health and wellbeing of people of colour. This is the recording of a panel discussion hosted by Harvard T.H. Chan School of Public Health, in which economic, scientific and policy experts discuss how we can build a more equitable and healthier future for everyone.
  22. Content Article
    This case study published by The Beryl Institute looks at an initiative to collect real-time feedback on patient experiences at the Stanford Health Care emergency department in California. Previously, the department had sent a survey to patients well after their visit, but the team realised that capturing this information sooner was critical. Matthew Lim, Patient Experience Manager at Stanford Health Care describes the practical and replicable steps the organisation took in implementing a QR code-based feedback system. He describes the results, lessons learned and potential future developments.
  23. Content Article
    This series of blog posts is written by a patient who experienced life-changing complications after surgery went wrong. In her posts, they explore the psychological needs of patients following healthcare harm, which are often overlooked during physical rehabilitation. "I believe that the emotional support given to the patient during those first few weeks can make a significant difference to their long term quality of life. That’s why I decided to write this blog, to give constructive feedback to help medical professionals learn from my experiences."
  24. Content Article
    Health and care workers in all parts of Europe are experiencing overwork, with high levels of burnout. This opinion piece in the BMJ looks at the issue of healthcare professionals leaving European health systems to take early retirement or work in other countries where pay and conditions are better. It highlights the causes of this exodus, including increasing patient complexity, salary erosion and work-life balance. It argues that policies should prioritise retaining existing staff, as increased training numbers offer only a partial, long term answer.to the crisis, highlighting potential approaches governments can take to retain highly qualified healthcare staff.
  25. Content Article
    Guidance needs to be applied in a careful, caring and person-centred way to ensure that patients benefit from, and are not harmed by, healthcare. In this blog, Dr Sam Finnikin, an academic GP in Sutton Coldfield, uses the story of 86 year-old Joan to illustrate the importance of shared decision-making in ensuring patients receive the most appropriate care. Joan was prescribed multiple medications by the hospital cardiology team after being diagnosed with acute coronary syndrome and a severely impaired left ventricle, but the medications made her feel very unwell and inhibited her quality of life. Joan then reached out to her GP surgery as she wanted to stop taking them, and Dr Finnikin realised that she and her family were unaware of the the reason each medication had been prescribed and the potential benefits and side effects of each one. After a long conversation about her priorities, Joan stopped the medications that were not benefitting her symptoms and died in peace and comfort at home a few weeks later. Dr Finnikin argues that shared decision-making is not an optional extra, but must be considered a vital part of healthcare, stating that "omitting shared decision making can be just as harmful to patients as being ignorant of clinical recommendations."
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