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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this blog, Patient Safety Partners Anne Rouse and Chris Wardley and Patient Safety Learning’s Chief Executive, Helen Hughes, examine the results of a recent survey of Patient Safety Partners (PSPs). The results reveal significant variation in how the PSP role is being implemented in NHS organisations in England and highlight frustration, barriers and successes that people in the role are experiencing.
  2. Content Article
    Most research examining the association between blood pressure and cardiovascular disease (CVD) is does not take sex into account. This research study aimed assess sex-specific associations between blood pressure and CVD mortality.by estimating sex-stratified, multivariable-adjusted incidence rate ratios (IRRs) for CVD mortality. The authors found that the association between blood pressure and CVD mortality differed by sex, with increased CVD mortality risk present at lower levels of systolic blood pressure among women, compared with men.
  3. Content Article
    Coloplast UK is a manufacturer of ostomy, continence, urology and wound care products. They commissioned the Patients Association to conduct a project to explore and recommend ways to better engage patients and carers in policymaking and the assessment of medical technologies for intimate healthcare. The Patients Association held a roundtable meeting and case study interviews with patients with intimate healthcare conditions and other stakeholders. They also conducted a survey of third-sector organisations who represent those patients and carried out desk-based research. This report summarises the findings of the project, which include that the existing mechanisms of engagement typically adopt a “patient involvement” approach where patients and carers do not have equal status as partners in the decision-making process. The report makes a number of recommendations to improve the way in which patients and their carers are engaged.
  4. Content Article
    This infographic is a visual representation of the WHO Emergency Care System Framework, designed to support policy-makers wishing to assess or strengthen national emergency care systems. It is the result of global consultations with policy-makers and emergency care providers and provides a reference framework to: characterise system capacity. set planning and funding priorities. establish monitoring and evaluation strategies.
  5. Event
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    The Patient Safety Incident Response Framework (PSIRF) is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and ensuring learning and improvement in patient safety. This national conference looks at the practicalities of implementing and using PSIRF. The day will provide an update on best practice in incident investigation under PSIRF and ensuring the focus is on a systems based approach to learning from patient safety incidents and delivering safety actions for improvement. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Book your place
  6. 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. Chidiebere is passionate about increasing representation of Black people in all forms of medical literature. In this interview, he explains how lack of representation at all levels of the healthcare system leads to disparities in healthcare experiences and outcomes. He outlines the importance of speaking openly about how racial bias affects patient safety, and argues that dispelling damaging myths about particular patient groups starts with equipping people with accurate health knowledge from a young age.
  7. Content Article
    In this blog, Louise Roe, an investigator at the Maternity and Newborn Safety Investigations (MNSI) programme, looks at how the questions you ask as a patient safety investigator can affect the quality of the information you receive from staff, as well as having an impact on how they feel about the interview. Louise lays out her journey to obtain higher-quality information from interviews while protecting staff involved in patient safety incidents. She discusses how to ask questions that uncover the 'whys' around decision making at the time of an incident. You can find the Local Rationality Questions Table here. To read the blog, click on the link below.
  8. Content Article
    Children are more than twice as likely as adults to experience a medication error at home. In this interview for the journal Patient Safety, Dr Kathleen Walsh, paediatrician at Boston Children’s Hospital, discusses why that is the case and provides some tips to keep children—and adults—safe.
  9. Content Article
    This article outlines a recent improvement put in place by a ward at Sir Robert Peel Community Hospital, part of University Hospitals of Derby and Burton NHS Foundation Trust. The team won an award for implementing learning following a patient fall to help drastically reduce the frequency of incidents and improving patient safety.
  10. Content Article
    This article looks at the judgements made by experts in the cases that are not covered by rules, focusing on the key role of stories and storytelling. Drawing on literature related to high-reliability theory, organisational learning and naturalistic decision-making, it examines how experts working in diverse critical contexts use stories to share and make sense of their experiences.
  11. 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.
  12. 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.
  13. 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.
  14. 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
  15. 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
  16. 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.
  17. 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.
  18. 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
  19. 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)
  20. 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
  21. 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
  22. 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.
  23. 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.
  24. 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.
  25. 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.
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