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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    SHOT is the UK’s independent, professionally-led haemovigilance scheme. It collects and analyses anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. This document contains updated information on reporting categories and what to report to the scheme.
  2. Content Article
    During the first wave of Covid-19, the drug hydroxychloroquine was used off-label despite the absence of evidence documenting its clinical benefits. Since then, a meta-analysis of randomised trials showed that the drug's use was associated with an 11% increase in the mortality rate. This study in the journal Biomedicine & Pharmacotherapy aimed to estimate the number of hydroxychloroquine-related deaths worldwide.
  3. Content Article
    'Failure to rescue' is the rate of death amongst patients with postoperative complications and has been proposed as a perioperative quality indicator. However, there may be significant variation in its definition between research studies. This study in the journal Surgery systematically reviewed all surgical literature reporting failure to rescue rates and examined variations in the definition of the ‘numerator,’ ‘denominator’ and timing of failure to rescue measurement. The authors found that failure to rescue is an important concept in the study of postoperative outcomes, but its definition is highly variable and poorly reported. They highlight that researchers should be aware of the advantages and disadvantages of different approaches to defining failure to rescue.
  4. Event
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    Join us to hear brand new results from Mölnlycke Health Care’s latest survey, conducted as part of the “In This Together” initiative recently launched in UK, providing support and information to people living with a wound and their caregivers. “The ‘In This Together’ survey explores patients perspectives on their current experiences with wound care services in England.” There are an estimated 3.8 million people in the UK with a wound being managed by the NHS, equivalent to 7% of the UK population. The impact cannot be underestimated and can be the source of great physical pain and discomfort, as well as mental distress. With significant impact on patients and NHS resources, it is clear that wound care needs focus and attention. This webinar will be the first time that the ‘In This Together’ survey results will be published, providing the most current data of how patients feel about wound care services, with responses collected between October 2023 to January 2024. This survey builds upon the work that Mölnlycke Health Care has led over the last three years to understand where wound care currently stands, and importantly what can be done to improve it. For example, the 2022 Making Wound Care Work report looked at how the emergency measures put in place during the pandemic altered the way wound care was being delivered, and the lessons that could be learned. On the back of the Making Wound Care Work report, Mölnlycke Health Care have taken the debate into the wound care media, with articles published in the British Journal of Community Nursing and Journal of Community Nursing, in order to further publicise the report findings and continue the conversation for improving services. This webinar will cover the findings of the ‘In This Together’ survey and hear the perspectives of patient and HCP representatives on the results; this is your opportunity to join the discussion. The confirmed speakers for this webinar are: (Chair) Luxmi Dhoonmoon – London North West University Healthcare Trust, Tissue Viability Nurse Consultant Rachel Power – Chief Executive, Patients Association Leanne Atkin – Vascular Nurse Consultant, Mid Yorkshire NHS Trust Ali Hedley – Medical and Professional Affairs Manager UK at Mölnlycke Health Care Register for the webinar
  5. News Article
    The European Commission is recommending measures EU countries should adopt to increase the uptake of two vaccines that prevent viral infections that can cause cancer, it said on Wednesday. The two vaccines are against the human papillomaviruses (HPV) that can cause many cancers, including cervical cancer, and against hepatitis B (HBV), which can lead to liver cancer. As part of Europe's Beating Cancer Plan, the European Union wants member countries to reach HPV vaccination of 90% for girls by 2030 and significantly increase the rate for boys. "Many Member States are well below 50% HPV vaccination coverage for girls with limited data available for boys and young adults, and there is a significant lack of data on HBV vaccination rate," the Commission statement said, adding it was as low as 1% in some countries. Read full story Source: Medscape UK, 31 January 2024
  6. Content Article
    This report sets out the findings of an Independent Review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust. The review was commissioned following reports of failings within the Trust’s services at the Edenfield Centre and the failure within the organisation to escalate concerns and mitigate patient harm.
  7. Content Article
    In this report the Parliamentary and Health Service Ombudsman (PHSO) looks at patient safety concerns relating to the care and discharge of mental health patients. Its findings are based on the analysis of more than 100 complaints that the Ombudsman has investigated between April 2020 and September 2023 where it found failings in care that involved mental health care.
  8. News Article
    The NHS is in such a dire state the next government should declare it a national emergency, experts are warning, as it emerged that record numbers of patients are being denied timely cancer treatment. It is facing an “existential threat” because of years of underinvestment, serious staff shortages and the demands of the ageing population, according to a group of leading doctors and NHS leaders. Whoever wins power after the general election will have to “relaunch” the health service and ask the public to do what they can to help save it and preserve its founding principles, they say. The call, by a commission of experts assembled by the BMJ medical journal, comes as new figures show that since 2020 more than 200,000 people in England have not received potentially life-saving surgery, chemotherapy or radiotherapy within the NHS’s supposed maximum 62-day wait. Professor Pat Price, a leading NHS oncologist who helped analyse NHS cancer care data, said that the UK was facing “the deepest cancer crisis” of her 30-year career treating cancer patients. The acute concern about the NHS’s ability to cope with the rising tide of illness deepened last night when A&E doctors claimed that a government plan launched a year ago to relieve the strain on overcrowded emergency departments had made no difference. A&E remains in “permacrisis” while care in units is “as unsafe, or more unsafe, than at this time last year”, despite Rishi Sunak hailing his “ambitious and credible plan to fix it”. Although 5,000 more hospital beds have been created, the “half-baked” plan has “made little real difference to the experience of patients and the working conditions of health care professionals”, said Dr Ian Higginson, the vice-president of the Royal College of Emergency Medicine. Read full story Source: Guardian, 31 January 2024
  9. News Article
    Mental health services are failing to keep patients safe from suicide and harm after leaving hospital, the Parliamentary and Health Service Ombudsman (PHSO) has warned. It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act. The warning comes after the Department for Health and Social Care was forced to announce a Care Quality Commission (CQC) rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year, by Valdo Calocane. Knifeman Calocane had paranoid schizophrenia and had been a regular patient of Highbury Hospital with mental health problems. In a report last week, The Independent revealed separate investigations into Highbury Hospital which have led to the suspension of more than 30 staff over allegations of falsifying records and harming patients. The latest report by the Parliamentary and Health Service Ombudsman (PHSO), following a report in 2018, looked at more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care. Lucy Schonegevel, director of policy and practice at the charity Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences. This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.” Read full story Read PHSO report Discharge from mental health care: making it safe and patient-centred (PHSO, 1 February 2024) Source: Independent (1 February 2024)
  10. News Article
    A major review into a mental health unit abuse scandal has found a catalogue of failings, including repeated missed opportunities to act on concerns, and a board “disconnected” from the realities faced by patients and staff. The independent review into failings at Greater Manchester Mental Health Foundation Trust was published today, commissioned after BBC Panorama revealed a “toxic culture of humiliation, verbal abuse and bullying” at Edenfield Centre in Prestwich in September 2022. The trust’s then chair, Rupert Nichols, resigned in November 2022, and CEO Neil Thwaite stepped down in spring last year. Review chair Professor Oliver Shanley, a former mental health trust CEO and chief nurse, describes in his report how the trust’s culture and leaders’ “insufficient curiosity” contributed to the “invisibility” of the deterioration in care quality. He says its board was focused on “expansion, reputation and meeting operational targets”. Read full story (paywalled) Read the report of the Independent Review into Greater Manchester Mental Health NHS Foundation Trust Source: HSJ, 31 January 2024
  11. Content Article
    With a number of large-scale clinical trials underway and researchers on the hunt for new therapies, Long Covid scientists are hopeful that this is the year patients will finally see improvements in treating their symptoms. This article in Medscape makes five research-based predictions that could happen in 2024. They provide promising signs of progress in treating a debilitating and frustrating disease. The predictions are: We'll gain a better understanding of each Long Covid phenotype Monoclonal antibodies may change the game Paxlovid could prove effective for Long Covid Anti-inflammatories like metformin could prove useful Serotonin levels may be keys to unlocking Long Covid
  12. Content Article
    This study in the British Journal of General Practice aimed to assess the risk of poor respiratory outcomes for people with resolved asthma compared to those with active asthma and people without asthma. The authors used three retrospective cohorts of around 16,000 patients each, in the following groups: Active asthma cohort (patients with an asthma-specific diagnostic code at any point in their GP record, and >1 asthma medication prescription). Resolved asthma cohort (patients with >1 resolved asthma code, followed from date of first resolved asthma during the study period to the earliest data of an asthma prescription, the end of the study period, date of transfer out of practice or death). Non-asthma cohort (population-based patients without active or resolved asthma or chronic obstructive pulmonary disease). The results showed that compared to the active asthma cohort, the resolved asthma cohort had fewer GP consultations for asthma exacerbations and fewer asthma hospital admissions. However, compared with non-asthma patients, resolved asthma patients had more GP consultations, greater rates of respiratory tract infections and higher rates of antibiotic use. The authors highlighted a lack of guidance around care pathways for patients with a record of resolved asthma. They concluded that patients with resolved asthma may need a more comprehensive respiratory assessment if they present with symptoms of lower respiratory tract infection, in order to assess symptom burden, airway obstruction and the potential value of inhaled treatment.
  13. Content Article
    In November 2023, the UK hosted the first global summit on artificial intelligence (AI) safety at Bletchley Park, the country house and estate in southern England that was home to the team that deciphered the Enigma code. 150 or so representatives from national governments, industry, academia and civil society attended and the focus was on frontier AI—technologies on the cutting edge and beyond. In this Lancet article, Talha Burki looks at the implications of AI for healthcare in the UK and how it may be used in medical devices and service provision. The piece highlights the risks in terms of regulation and accountability that are inherent in the use of AI.
  14. Content Article
    Sarah Rainey talks to Olivia Djouadi about her experience of type 1 diabetes with disordered eating (T1DE), which is thought to affect up to 40% of women and 15% of men with type 1 diabetes. People with T1DE, sometimes also called diabulimia, limit their insulin intake to control their weight, which can have life-threatening consequences. Olivia describes how the stress of living with type 1 contributed to her developing T1DE, and how when she finally received treatment and support in her 30s, she was able to deal with her disordered eating and see her health and wellbeing improve.
  15. Content Article
    Emergence delirium is a temporary but potentially dangerous condition that can occur when a patient awakens after a procedure. In this video, staff at the VA Pittsburgh Healthcare System (VAPHS) share how they implemented a perioperative intervention to reduce the risk of patient and staff harm.
  16. Content Article
    This article in Anaesthesia Critical Care & Pain Medicine aims to provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care. The authors aimed to formulate recommendations according to the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) methodology for four different fields:communicationorganisationworking environmenttrainingThe guidelines produced include a set of recommendations to guide human factors in critical situations.
  17. Content Article
    Doctors At Work is a series of video podcasts hosted by Dr Mat Daniel. In this episode, Dr Gordon Caldwell shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everyone to speak up. His top tips for preventing errors is to create systems, checklists and routines that ensure a focus on all aspects of care not just the obvious and urgent.
  18. Content Article
    Antibiotic resistance is an increasing problem in healthcare, especially in nursing homes where up to 75% of antibiotics are prescribed inappropriately. This series of webinars from the Pennsylvania Patient Safety Authority covers various aspects of antibiotic stewardship including: Types of antimicrobials Why antibiotic stewardship and who should be at the table Antimicrobial usage Mechanisms of antimicrobial resistance Antibiograms Antimicrobial baseline data Developing an antimicrobial stewardship plan Antimicrobial usage data
  19. Content Article
    This document outlines the concept and content of the World Health Organization (WHO) people-centred approach to addressing antimicrobial resistance (AMR) in healthcare. It aims to address the challenges and barriers people face when accessing health services to prevent, diagnose and treat drug-resistant infections. It puts people and their needs at the centre of the AMR response and guides policy-makers in taking actions to mitigate AMR.
  20. Content Article
    The first UK geriatric oncology service at a tertiary cancer centre was established at the Royal Marsden Hospital in London. Its purpose is to conduct comprehensive geriatric assessments of patients with cancer on order to make referrals to multidisciplinary care. This descriptive study aimed to track its progress. It found that the service made a median of three referrals for each patient, most commonly to physiotherapy and occupational therapy. The frequency of referrals indicates that there is a high level of unmet need in older patients with cancer.
  21. Content Article
    This resource library has been created by Health Innovation West of England to provide support materials in one location for people living with pain and professionals supporting people living with pain.
  22. Content Article
    This training tracker from the Patient Experience Library helps you find courses on patient experience and patient/public involvement hosted by a range of external organisations. Each listing contains details on how to book places and contact the course providers.
  23. Content Article
    This statement from NHS England outlines how NHS organisations should collect and present data on health inequalities and explains the powers available to them to collect such data. Integrated care boards, trusts and foundation trusts should use the statement to identify key information on health inequalities and set out how they have responded to it in annual reports. The statement has been produced according to NHS England's duty under section 13SA of the National Health Service Act 2006.
  24. Content Article
    People taking methotrexate (for inflammatory conditions such as rheumatoid arthritis) have regular blood tests to check for certain side effects. Researchers have developed a tool to predict the likelihood of them discontinuing methotrexate due to these side effects, which could in future lead to less frequent testing for most people (68%) on methotrexate. The tool uses information routinely collected by GPs. The study found that it could predict people’s risk of discontinuing methotrexate because of side effects. It was accurate for most people across different ages, inflammatory conditions, methotrexate doses and routes of administration. The researchers say the tool could in future be used by GPs to identify people who need more or less frequent blood tests. This article refers to the original research study Risk stratified monitoring for methotrexate toxicity in immune mediated inflammatory diseases: prognostic model development and validation using primary care data from the UK
  25. Event
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    This popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
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