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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Before a patient undergoes a medical procedure such as surgery, they need to give their consent, having been informed about the details of the procedure and associated risks and benefits. However, in spite of the development of clear guidance on informed consent, many patients still feel nervous or unsure about asking questions and raising concerns during the consent process. Beginning with a personal account that highlights the importance of a thorough and meaningful consent process, this article in The BMJ by Tessa Richards, Associate Editor, examines the issues faced by both doctors and patients in achieving truly personalised informed consent.
  2. Content Article
    In this blog, Sarah Tilsed, Head of Patient Partnership at The Patients Association, gives an update on recent themes discussed by the Patients Association's Patient Voices Matter (PVM) panel, including complaints, counselling and the accessibility of NHS communications. PVM is a lived-experience advisory panel set up to discuss how things can be improved in the NHS for all patients. Sarah has written a range of other blog posts about PVM that can also be read on The Patients Association's website.
  3. Event
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    This Masterclass is aimed at consultants and will be led by Dr Marcy Rosenbaum, Professor of Family Medicine and Faculty Development Consultant, Office of Consultation and Research in Medical Education, University of Iowa. Marcy is an expert in the skills that make difficult healthcare conversations easier, has published widely on the topic and is world renowned in training clinicians to use these skills effectively. The Masterclass will involve skills rehearsal with simulated patients and families. It provides consultants with an opportunity to refresh their expertise an to learn about the specific skills being taught to their trainees and NCHSs in the Human Factors in Patient Safety programmes. Register for the Masterclass
  4. Content Article
    In 2020, over 2,000 people over the age of 60 fell and fractured their hip while staying in hospital in England and Wales. This graphic has been produced by the National Audit of Inpatient Falls (NAIF), which audits the delivery and quality of care for patients over 60 who fall and fracture their hip or thigh bone across England and Wales. It features the three most important findings of the 2021 NAIF Report, chosen by the patient and carer panel. The infographic covers the following questions: How can falls be prevented? What should happen after a fall? How can I help to improve care in hospital?
  5. Event
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    This Webinar hosted by Hamilton Medical, will focus on the clinical use of intelligent ventilation software. Agenda Intro from Chair Luigi Camporata Presentation from Prof. Giorgio A. Iotti : “ The birth and growth of the visionary idea” Presentation from Laura Buiteman-Kruizinga: “Lung protective ventilation in the time of COVID-19” Followed by a Q&A Register for the webinar
  6. Content Article
    This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Jono talks to us about why he is passionate about making sure patient voices are heard and valued in healthcare investigations and quality improvement. He also highlights the current workforce crisis, the need to look after NHS staff to ensure they can deliver compassionate, high quality care and the importance of being transparent with the public about the problems the NHS is currently facing.
  7. Content Article
    Painful menstruation—dysmenorrhea—interferes with the daily life of around one in five women. This blog looks at why painful periods receive so little research attention and examines the impact this has on women's lives and health. Sharing a personal story of her own painful periods, the author discusses how doctors are quick to prescribe birth control pills and antidepressants to treat painful periods, rather than investigating the problem to find out whether the cause of pain is endometriosis, a condition where endometrial tissue forms outside the uterus. It is thought that around 10% of ovulating women in the US have endometriosis and it takes an average of ten years for accurate diagnosis. The author discusses the need to raise the visibility of dysmenorrhea and endometriosis so that medical research takes it on as a serious issue.
  8. Content Article
    A Quality Account is a annual report about the quality of services offered by an NHS healthcare provider. Quality Accounts allow providers to demonstrate how they have improved their services to the communities they serve. This webpage provides information on how to put together Quality Accounts, which providers need to submit them and how to publish them.
  9. Content Article
    This action plan to implement the recommendations of the Neonatal Critical Care Transformation Review outlines how the NHS will further improve neonatal care with the support of funding set out in the NHS Long Term Plan. It includes information on capacity, staffing and support for parents.
  10. Content Article
    Accurate and timely diagnosis is a key aspect of healthcare, and misdiagnosis and delayed diagnosis can have serious consequences for patients. This eBook published by the National Academies for Science, Engineering and Medicine highlights that tackling diagnostic error in healthcare is a moral, professional, and public health duty. It makes recommendations to improve the safety of diagnostic processes, outlining the need for collaboration and a widespread commitment to change among healthcare professionals, healthcare organisations, patients and their families, researchers and policy makers.
  11. Content Article
    This webpage by the British Association of Dermatologists contains a selection of resources about skin cancer and sun safety for patients. it describes the different types of skin cancer, how to get moles checked and how to stay safe in the sun.
  12. Content Article
    Communication barriers are the number one reason Deaf people have poorer health compared to hearing people. This blog by the organisation SignHealth gives 12 tips for healthcare workers and non-clinical staff on how to communicate with Deaf people. It also describes the difficulties Deaf people face when booking appointments and describes why remote consultations are problematic for Deaf people.
  13. Content Article
    In its 2019 manifesto the government pledged to increase the full-time equivalent number of nurses working in the NHS by 50,000 by March 2024. But although data suggests that the NHS will hit that target, Ruth May, England's Chief Nursing Officer, has stated publicly that there are still substantial shortages in spite of this increase. This analysis by the King's Fund highlights that the supply of nurses to the NHS is not keeping up with demand, with vacancy levels remaining static in spite of an increase to the raw number of nurses. It also highlights wide regional variation in nurse shortages.
  14. Content Article
    This study in BMC Infectious Diseases aimed to determine whether there is an association between Covid-19 infection and acute appendicitis. The authors performed a single institution retrospective review of pre-procedure Covid-19 testing and indications for surgical intervention. They found a high prevalence of Covid-19 in both all testing and pre-procedure testing during the enrolment period and observed a high prevalence of acute appendicitis among patients identified to be Covid-positive during pre-procedure testing and without recognised symptoms of Covid-19.
  15. Content Article
    Although serious medication errors are uncommon, their effects can be devastating for patients and their loved ones. The authors of this study in the journal Patient Safety searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of serious medication errors in the emergency department from 1 January 2011 to 31 December 2020. They identified trends in the data, looking at patient sex, patient age, event harm score, event day of the week and event time of day. The authors found that: error reports more often specified that the patient was female. events were significantly more likely to happen over the weekend. most errors occurred at the prescribing stage. the most common error type was a wrong dose. They conclude that a number of patient safety strategies could reduce the risk of medication errors in the emergency department, including: stocking epinephrine autoinjectors. using clinical decision support at the ordering/prescribing stage of the process. adding an emergency medicine pharmacist to interdisciplinary emergency medicine teams.
  16. Content Article
    EZDrugID is a campaign to improve the distinctiveness of medication packaging set up by a group of healthcare workers. Inadequate standards around medication packaging mean that medications with very different actions are sometimes packaged in a very similar way causing "look-alike drugs”. This can lead to errors and serious harm to patients if the wrong drug is mistakenly used. The EZDrugID website contains information about their campaigns to maximise distinctiveness of different medications as well as a "lookalikes" gallery. See also: the hub's error traps gallery The medication safety area of the hub
  17. Event
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    On 23 June 2022, National Voices is holding an all-day conference, as we explore the topic of Integrated Care Systems (ICSs), on the eve of ICSs becoming statutory bodies that cover the entirety of England. Now is the right moment to identify the changes we want to see as a result of this fundamental shift in the way the health and care system is organised. We want to see better, more equal outcomes for people, especially those not currently well supported by existing models. We also want to see more coordinated and effective care that enables people to live well, with fewer barriers between communities and formal services. The day will consist of high profile, topical panel discussions and engaging workshops. During the conference we will have a number of expert speakers joining us, including the keynote speaker, Matthew Taylor, Chief Executive of NHS Confederation, and of course National Voices Chief Executive, Charlotte Augst. A series of workshops will cover crucial topics, including health inequalities, social prescribing and others to be confirmed. We look forward to welcoming a range of individuals and organisations to this event, which will offer an opportunity for the Voluntary, Community and Social Enterprise sector to have constructive conversations with system leaders; ensuring that people and communities are involved appropriately and that the result of the new ICSs is a positive impact on the way people experience healthcare. Register for the conference
  18. Content Article
    In this blog Patient Safety Learning considers several key patient safety issues highlighted in a recent investigation by the Healthcare Safety Investigation Branch (HSIB) into unintentional overdose of morphine sulfate oral solution. We argue that in some areas, further action is required to prevent incidents of avoidable harm recurring.
  19. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
  20. Content Article
    Women often have worse asthma than men, and female sex hormones can affect the condition. Asthma and Lung UK are conducting a survey to find out more about women's experience of asthma - women with asthma and those that care for them are invited to take the survey, which takes about five minutes to complete and is completely anonymous. Asthma and Lung UK have also published a report, Asthma is Worse for Women, outlining the need for more research into asthma and female sex hormones.
  21. Content Article
    Globally, there are 136 million women with asthma. Asthma is more common among women, women experience more severe symptoms and they are more likely to die from their asthma. Many women experience a significant worsening of symptoms around menstruation and are at risk of potentially fatal asthma attacks every month. However, there has been very little research to understand why. Asthma and Lung UK has published this report following a roundtable meeting with scientists, funders and pharmaceutical companies to discuss how to transform outcomes for women with asthma. The report covers information on sex bias in asthma and looks at recent developments in understanding about the condition, highlighting areas for further research. The report also makes the case for increasing funding to deliver better outcomes for women with asthma, strengthening leadership and infrastructure in asthma treatment, and increasing innovation in drug trials. Alongside the report, Asthma and Lung UK has made a short video where one woman talks about her experience of severe asthma, how it has affected her life and why we need more research into the link between asthma, periods and female hormones. Asthma and Lung UK has also released a survey to find out more about women's experience of living with asthma.
  22. Event
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    The NHS Communicate conference is back for a second year, offering an unparalleled opportunity for senior communicators across the health service to explore the reputational challenges facing the NHS and to share expertise and learning from healthcare and beyond. It seems like a long time since members of the public were clapping for NHS staff at the height of the pandemic. Today, the NHS finds itself under increasing operational pressure, with lengthening waiting times and an exhausted workforce with low morale. With public satisfaction at a 25-year low, and following recent tax increases to fund extra investment, public scrutiny of the NHS has rarely been greater. Building on the great success of last year’s inaugural event, NHS Communicate 2022 is a chance to explore the impacts of the pandemic on the reputation of the NHS and the role of communications in supporting and helping to build and sustain its profile and reputation. Whether it is demonstrating the value the NHS delivers to patients, or positioning the NHS as an employer of choice, NHS communications plays a vital role. Read more information and book a place
  23. Content Article
    There has been an increasing trend in commercially available diagnostic tests for food allergy and intolerance, but many of these tests lack an evidence base. In this article, Philippe Bégin from the University of Montreal describes the risks involved with using unproven diagnostic tests for food allergies and intolerances. He highlights that alongside their high cost, they may lead to false diagnoses, with associated anxiety and unnecessary strict avoidance diets. They may also lead truly allergic people to believe they are not allergic to certain foods, which could cause them to eat a food that gives them a life-threatening reaction. He also provides a list of tests that are offered to consumers, but that are unproven and should be avoided.
  24. Content Article
    Much research has been done into the causes, extent and impact of health inequalities that affect rural and coastal populations. Health services in these areas currently face serious challenges due to a combination of factors, including social deprivation, ageing populations and workforce staffing issues. In this blog, Patrick Mitchell, Director of Innovation, Digital and Transformation at Health Education England (HEE), describes a new HEE programme that aims to help tackle health inequalities in rural and coastal areas.
  25. Content Article
    SMILE (Self-Management Individualised Learning Environment) is an e-learning experience for people with rheumatoid arthritis (RA) who want to learn more about RA, its treatments and how to become good at self-managing. Each module is on a particular theme or subject and takes between 20 mins and half an hour to complete.
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