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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. News Article
    The NHS has been advised to change the way they identify patients who are sick from coronavirus and those who test positive. Up until now, hospitals have recorded patients sick from the virus and those who tested positive together, whether they presented with symptoms or not. The new advice has been given with the hope that it will reduce the numbers of patients in hospital for the virus. Read full story. Source: The Independent, 9 June 2021
  2. News Article
    A new report published by Devon Clinical Commissioning Group, consultancy Nous reveals worrying examples of discrimination towards ethnic minority staff. It has been noted that attempts at progress and improving equality has had 'limited effectiveness' with ethnic minorities experiencing minimal resources to carry out their roles. Findings showed ethnic minorities faced barriers to appropriate care with staff experiencing "substantial inequalities". Read full story.(paywalled) Source: HSJ, 10 June 2021
  3. News Article
    New data published by NHS England has revealed the number of patients waiting at more than 18 months and 2 years. Insights show the trusts waiting times were not particularly caused by the pandemic, but rather had a backlog since before the outbreak of Covid-19. Read full story.(paywalled) Source: HSJ, 10 June 2021
  4. Content Article
    This is Patient Safety Learning’s submission to the Women’s Health Strategy: Call for evidence. In seeking to inform the development of its Women’s Health Strategy, the UK Government has requested written submissions of data, research, and other reports of relevance. In its response, Patient Safety Learning outlines the risk to patient safety of sex and gender bias. The consultation is now closed.
  5. Content Article
    In this article, Sodium Valproate: The Fetal Valproate Syndrome Tragedy, Sharon Hartles, member of the Open University’s Harm and Evidence Research Collaborative, reflects upon the use of Sodium Valporate, marketed as Epilim, to treat patients at risk of epilepsy and the subsequent harms in fetal development and birth defects that arose from its use. 
  6. News Article
    The Royal College of Nursing has warned there has been a rise in unqualified people being recruited for registered nursing roles, posing a significant risk to patient care and safety. Owing to staff shortages, employers have opted to encourage candidates without a registered nursing qualification to apply for nurse vacancies. It has been found that registered nursing positions have been opened up to allied health professionals as well as a matron role being open to those without the appropriate qualifications and experience. It has been warned that this continued practice with raise the risks to patient safety and create unnecessary vacancies elsewhere. Read full story. Source: Nursing Times, 9 June 2021
  7. News Article
    It has been recommended that GPs should see all children under five who present with respiratory symptoms in-person. Concerns have been raised that whilst in lockdown, respiratory viruses will rise when lockdown lifts due a lack of exposure owing to current safety measures. The new guidance was given to Primary Care staff via their latest bulletin advising that if children are showing respiratory symptoms, they should be tested for Covid-19 but that doctors should also make a clinical assessment in-person. Read full story. Source: BMJ, 9 June 2021
  8. News Article
    New analysis from Scotland has found there may be a possible, though small, increased risk of developing a condition called idiopathic thrombocytopenic purpura (ITP) after administration of the Oxford/AstraZeneca Vaccine. Doctors assure patients that the condition is treatable and often mild and it is more often seen in those who have pre-existing health conditions such as diabetes, heart disease or kidney disease. The condition has also been seen in patients after taking other vaccines including the flu, MMR and hepatitis B. Read full story. Source: The Guardian, 9 June 2021
  9. News Article
    News insights from a a review of NHS England data has found access inequalities across regions in England. Notably, the review found Orthopaedics patients suffered worse waiting times than others with some having to wait for more than 52 weeks before they could receive their treatment. Data analysis showed that by the end of March 2021, there were more than 400, 000 people on hospital waiting lists for more than a year. Read full story. Source: BBC News, 10 June 2021
  10. Content Article
    Mary Anne Mellor died from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent inserted four years previously.
  11. News Article
    After concerns were raised regarding safety and quality of care for women and babies at the Jessop Wing maternity unit in a Sheffield Teaching Hospital, an unannounced inspection found the unit to be 'inadequate'. Whilst the Care Quality Commission found the maternity service had some good areas which included staff feeling respected and supported, there were concerns raised regarding midwife shortages and whether the staff had the knowledge and experience to run the service appropriately. As a result of the report, several actions were taken to impose conditions on the maternity unit which included proper training of staff, improving infection control and ensuring staff were able to follow the correct safety procedures regarding urgent or serious incidents and proper storage of medicines. Read full story (paywalled) Source: HSJ, 9 June 2021
  12. News Article
    New data has found patients in ambulances experienced significant delays in hospital admissions before the pandemic began. The data revealed patients were waiting for up to an hour or more before they were given to the care of A&E staff and may have had to wait in the ambulance or A&E corridors before they could be admitted to the hospital. It has also been found that in the midst of the Covid-19 pandemic, patients were having to wait even longer before they could be admitted into hospital. A case report by West Midlands Ambulance Service detailed how a woman in her nineties experienced worsening health whilst waiting for treatment and died a short time later. Read the full story. Source: The Independent, 08 June 2021
  13. News Article
    Watchdog has warned the NHS that patients experiencing significant waiting times may be at risk amid fear patients health could worsen whilst waiting for surgery. Read full story Source: The Independent, 7 June 2021
  14. News Article
    A new report commissioned by the House of Commons finds NHS staff and social care workers are suffering from burnout at 'emergency levels'. The report has said problems with burnout among the NHS and care staff already existed but was increased due to the Covid-19 pandemic. Staff shortages have been indicated as one of the causes of burnout as the work days became longer and the pressure on staff grew. It was also found that staff felt overwhelmed after lockdown ended as patients who had not been to see their GP during lockdown were now coming in with an array of health problems. NHS and care staff felt insufficiently equipped to deal with the incoming patients due to a lack of proper staffing support in the workforce. Read the full story Read the full report here Source: BBC News, 8 June 2021
  15. Event
    until
    A multidisciplinary webinar organised by the MASIC Foundation with leading speakers, reflecting the diverse professional roles required to coordinate and deliver effective and individualised care for women experiencing Obstetric Anal Sphincter Injury (OASI). Discussion topics include: The importance of listening to women PTSD Psychosexual issues Body image and sex How a GP can help Q & A session to follow with all speakers, Professor Pauline Slade, Dr Rebecca Moore, Kate Walsh, Lucy Theo, Dr Sarah Hillman, a MASIC Ambassador and Professor Mike Keighley. Co-hosted by Dame Lesley Regan and Debra Bick OBE. For more details and interest in attending, please click here
  16. Content Article
    Workforce burnout and resilience in the NHS and social care report describes the causes and effects of burnout among staff working within the National Health Service as well as the impact of Covid-19 on burnout. 
  17. Content Article
    This narrative review in BMJ Quality & Safety argues that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error and to initiate quality improvement projects aimed at reducing the risk of error and harm. It highlights three approaches that may help with measuring the incidence of diagnostic error: Using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error Using standardised patients (secret shoppers) to study the rate of error in practice Encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process
  18. Content Article
    This guide provides guidance for hospital clinical staff and managers in the secondary care of COVID-19 patients, based on the experience of hospital trusts that performed well during the early phase of the pandemic. It summarises the challenges faced by, and responses of, several high performing trusts visited as part of the GIRFT cross-specialty COVID-19 deep dives, as well as identifying successful innovations they implemented.
  19. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
  20. Content Article
    External clinical harm reviews aim to give assurance to patients, patient groups, commissioners and the public as to whether any patients have been harmed as a result of an incident, as well as to avoid future harm to patients. This handbook by Dr Henrietta Hughes, NHS Medical Director for London North, Central and East, outlines an approach to conducting clinical external harm reviews. It identifies the factors which make external clinical harm panels successful and provides example agendas and terms of reference for the process.
  21. Content Article
    This guide for people who inject insulin or GLP-1 to treat diabetes includes information on: how to correctly inject insulin where to inject to ensure insulin and GLP-1 medication enter the body correctly how to avoid ‘Lipos’ how to store medication correctly how to dispose of needles safely.
  22. Content Article
    This checklist is for people who inject insulin or GLP-1 medication to treat their diabetes. It details the steps patients should take to ensure they inject their medication correctly and explains the impact of failing to take certain steps - such as moving injection sites and changing needles - on blood glucose control.
  23. Content Article
    This webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch  Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust
  24. Content Article
    This report by The Right Reverend James Jones KBE aims to provide an insight into what the bereaved Hillsborough families experienced in the years following the Hillsborough disaster in April 1989. It seeks to place their insight on the official public record in the hope that their suffering and experience will bring about changes to the way in which public institutions treat people who have been bereaved. It records family members' experiences of interacting with the authorities after the disaster and around the different inquests, and highlights 25 points of learning for public institutions.
  25. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
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