Patient-Safety-Learning
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In 2014 Seth Goodburn died from pancreatic cancer 33 short and heart breaking days after diagnosis. Seth's wanted to die at home however, the weight of systems and processes meant that he sadly died in an acute hospital. After Seth died his wife Lesley shared their story via a play, a film and an educational resource called Seth's Story Sharing the story has three aims to: improve and of life care. highlight the need for psychosocial support. raise awareness of pancreatic cancer signs and symptoms. Ten years later, join us at this free conference to hear the impact of sharing Seth's Story, the improvements that have been made and future plans to help others share their experiences through creative art forms. This interactive series of talks and discussions will cover: Hearing and seeing the person who has a terminal disease Role of creativity in understanding experience of care at end of life The power of sharing lived experiences through storytelling The role of the people who are important to the person receiving care and their role in care partnerships Understanding who and what is important to the person receiving care Can compassion be taught or is it an innate quality How to have compassionate kind and gentle conversations How can we support people to celebrate their life as life draws to an end How will the new integrated care systems help focus on palliative and end of life care What are the key challenges for the future of end of life care The event is hybrid, virtual and also hosted at Marie Curie London, 1 Embassy Gardens, Nine Elms, Vauxhall, SW11 7BW, with a complimentary sandwich lunch. Register for free if you wish to attend online only via MS Teams Register to attend in person More information is available on the event flyer -
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Written by ENT Surgeon David Alderson, True Cut is a new play that asks: “What happens when things go wrong in healthcare?” It brings the hidden world of the operating theatre onto the stage. When promising, young surgeon, Jo, gets out of his depth, the repercussions are profound — for everyone involved. In the papers, on TV, on social, medicine’s a pantomime: voyeuristic entertainment masquerading as news. There are really only two stories about surgeons: there’s the Hero’s Journey of unflagging compassion and selfless dedication in the face of overwhelming odds, of miracle cures wrought from challenge and graft; and then there are the evil villains for us to boo at and hiss: incompetent charlatans who should be named, shamed and punished to protect the innocent. True Cut presents a dramatic biopsy cored from the hidden heart of surgery in the real words of those who work with our warm, wet flesh: constantly striving for the perfection that their patients deserve but fated, as humans, to sometimes fall short. It’s the story of those who learn to cut—and must learn how to live with the things that they do. Following the performance there will be refreshments and the opportunity to participate in a Q&A with the creative team. AGE 18+ True Cut portrays the events surrounding a tragic mistake in clinical practice, which has profound implications for the physical and mental health of all those involved. Audience members who have experienced similar traumas may find aspects of the performance distressing. Purchase a ticket for the play -
Content ArticleWomen with learning disabilities are less likely to access cervical and breast cancer screening when compared to the general population. In this study, the Social Ecological Model (SEM) was used to examine the inequalities faced by women with learning disabilities in accessing cervical and breast cancer screening in England. The study highlighted the following barriers to access for women with learning disabilities: Women with learning disabilities may lack knowledge of cancer symptoms and cancer screening, as well as being scared about the process and getting the results. The attitudes of family and paid carers towards screening may influence women with learning disabilities' decisions as to whether screening is seen as favourable; support and training may ensure unbiased perspectives. Barriers associated with how cancer screening programmes are designed, such as postal invitations which assumes an ability to read. Screening staff need to be aware of the general needs of people with learning disabilities, such as the benefits of easy-to-read documents. Multidisciplinary working is required so reasonable adjustments can be embedded into cancer screening pathways. The authors suggest that multiple methods to reduce the inequalities faced by women with learning disabilities are needed, and that these can be achieved through reasonable adjustments. Embedding reasonable adjustments can support women with learning disabilities in making an informed decision and accessing screeni
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Project PIVOT is a new initiative led by Patients for Patient Safety US (PFPS US) that aims to advance the implementation of patient-centred patient-reported experiences (PREs) and patient-reported outcomes (PROs) to improve patient safety, diagnostic accuracy and equity in healthcare. Project PIVOT will provide an opportunity for diverse patients, communities of patients and patient organisations to collaborate with national and international experts and provide input via novel engagement methods to identify and prioritise PREs and PROs which are related to patient safety, diagnostic accuracy and equity–things that matter most to patients. Patients will also have opportunities to identify how and when they prefer to report their experiences and outcomes. Additionally, Project PIVOT will engage healthcare system leaders to identify and prioritise their PREs and PROs to explore possible synergies and integration with the PROs and PREs identified by patients. Project PIVOT is accepting applications from individuals interested in joining the project via the PFPS US website. -
Content ArticleIn this blog, Kristy Widdicombe-Dutch shares her decades-long experience of harmful healthcare that has left her with a complete loss of trust in the system. She describes how, starting in her 20s, she has experienced disbelief, gaslighting and poor care in relation to her vascular issues, which has left her with long-term physical harm and psychological trauma.
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Content ArticleSuicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, examples of optimal practice that help to keep patients safe also often important learning for organisations and healthcare professionals. This study in BMC Psychiatry aimed to explore clinicians’ views of what constitutes good practice in mental healthcare services in the context of suicide prevention. The study highlighted clinicians’ views on good practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. The authors concluded that clinicians possess important understanding of optimal practice, but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.
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Carolyn Cleveland has delivered training on empathy and compassion to healthcare organisations for many years. In this interview, she describes how she came to develop her training approach and outlines how creating a psychologically space environment for individuals to engage with the practice of empathy contributes to safer organisational cultures. -
Content ArticleThe Royal College of Nursing (RCN) is developing a professional framework for nursing which will encompass the whole nursing workforce, from the nursing support worker through to the consultant nurse. Beyond the point of registration, the work of the registered nurse increases in its complexity, and as part of this framework, the RCN has developed definitions of the levels of nursing practice beyond registration. This webpage provides definitions and standards for enhanced, advanced and consultant levels of nursing. These definitions will help those who aspire to practice at these levels, as well as giving greater clarity to employers and higher education institutions. They can be applied across all fields of nursing and in all settings.
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Content ArticleThis cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict venous thromboembolism (VTE) in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.
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EventIn this webinar, the patient campaigner Kath Sansom who will be talking to us about how the mesh scandal came about and the effect it has had on women, along with her amazing campaign work. She will be joined by two mesh injured women, Susan and Sharron, who will share their stories. Sign up for the webinar
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Content ArticleWorldwide, more than 99% of the burden of measles infections and deaths affects populations in low-income and middle-income countries. Measles accounts for 3% of the global mortality of children younger than five years, constituting 90% of deaths from measles, and rubella is the main vaccine-preventable cause of birth defects. Vaccine coverage, both through routine immunisation and supplementary immunisation activities, remains below targets for measles elimination, with considerable heterogeneity between and within countries. This Lancet article looks at how microneedle patches (MNPs) could potentially improve coverage of childhood vaccinations by providing a more thermostable, individual-dose, injection-free vaccine delivery device suitable for administration by local, non-medical personnel. MNPs could also reduce wasted vaccine doses, needle-stick injuries and breaks in the cold chain, as well as making waste management easier.
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Content ArticleThis systematic review aimed to find out the prevalence of sexual harassment, bullying, abuse, workplace discrimination and other forms of harassment among medical students, residents, fellows and attending physicians in obstetrics and gynaecology. It found that many of these behaviours were frequent among respondents of the ten studies used in the review. The findings suggest that there is high prevalence of harassment in obstetrics and gynaecology despite the field being female-dominant for the last decade.
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Content ArticlePatient-Safety-Learning posted an article in Australian Commission on Safety and Quality in Health Care
Psychotropic medicines are medications that act on the brain. They are used for mental health conditions but are sometimes also given to people because their behaviour is seen as challenging, such as people with learning disabilities or cognitive impairment. This standard produced by the Australian Commission on Safety and Quality in Healthcare provides guidance to clinicians, healthcare services, patients, families and carers on the safe and appropriate use of psychotropic medicines. It contains: Eight quality statements describing safe and appropriate care. A set of indicators to support monitoring and quality improvement. -
Content ArticlePatient-Safety-Learning posted an article in Medicines and Healthcare products Regulatory Agency (MHRA)This policy paper provides on update on the Medicines and Healthcare products Regulatory Agency's (MHRA’s) use of AI as a regulator of AI products, as a public service organisation delivering time-critical decisions and as an organisation making evidence-based decisions that impact public safety.
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Content ArticleThe Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.7 million acute care event reports dating back to 2004. This article in the journal Patient Safety analyses the patient safety event reports submitted to PA-PSRS in 2023.
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REDESIGN is a women’s health hackathon to empower women with better user experience and improve health outcomes. Hosted by the Imperial College Women’s Health Network of Excellence, in collaboration with the Imperial FemTech and Design Engineering Societies, this event promotes interdisciplinary work among students and early career professionals to solve the foremost women’s health challenges. The event will comprise various workshops, talks and networking sessions. Objectives To raise awareness of gender gaps in healthcare and the entirety of women’s health, including but also beyond the traditional focus on sexual and reproductive health. To encourage interdisciplinary collaboration among design, engineering, medical, and business students to innovate solutions to the foremost issues affecting the health of women today. To innovate the format of hackathons by promoting user-centred design in solution development, including more contexts and user experiences in the problem-solving process. Four tracks Cardiometabolic health Brain and mental health Gynaecological health Maternal health Participants The event will host up to 80 students and early career professionals, who will form teams of 4-5 people to come up with solutions to specific women’s health challenges. Judging Panel Dr Shikta Das, RWE Manager, AstraZeneca Dr Karim Sandid, Co-Founder, Chief Medical & Product Officer, Kuma Health Rebecca Leppard, Founder & CEO, Upgrading Women Marketing Sarah Fox, Senior Service Designer, TPXimpact David Robson, Lead Service Designer, TPX Impact Prize Cash prize Free coaching on marketing strategy post-event, provided by Rebecca Leppard One-year free membership to the FemHealth Insights mentoring program In addition, every participant will receive a 50% discount to the FemHealth Insights mentoring program Find out more about the hackathon -
Content ArticleImplementing a new Electronic Patient Record (EPR) is a complex process and requires meticulous planning, coordination, involving change across every aspect of a healthcare organization. However, it also presents a unique opportunity to transform patient and staff experiences and enhance productivity by eliminating time-consuming manual processes. This webinar was hosted by Deloitte and brought together some of the UK digital health industry’s most experienced leaders with significant experience in implementing electronic patient records in their own organisations. Panellists included: Dr Cormac Breen, Chief Clinical Information Officer, Guy's and St Thomas' NHS Foundation Trust Jacqui Cooper, RN Chief Nursing Information Officer, Health Innovation Manchester Professor Adrian Harris, Chief Medical Officer, Royal Devon University Healthcare NHS Foundation Trust Dr Henry Morriss, Chief Clinical Information Officer, Manchester Royal Infirmary Consultant Emergency, and Intensive Care Medicine Frances Cousins, Digital Health Lead Partner, Deloitte UK Dr Afzal Chaudhry, Executive Chief Clinical Information Officer, Epic The speakers shared insights for success across a wide variety of topics including crafting a clinical safety case, safely transferring patient data, optimising staff training, preparing for operational readiness across and within organisations and change management for a successful Go-Live.
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EventDeloitte is excited to announce a follow-up Q/A session to its successful "Safer Electronic Patient Record Implementation" webinar which took place on 18 April. Join this session to hear expert panellists, with first-hand experience in large-scale EPR implementations, answer some insightful questions. Don't miss this opportunity to deepen your understanding for a successful EPR Go-Live. Speakers: Dr Cormac Breen, Chief Clinical Information Officer, Guy's and St Thomas' NHS Foundation Trust Jacqui Cooper, RN Chief Nursing Information Officer, Health Innovation Manchester Professor Henry Morriss, Chief Clinical Information Officer, Manchester Royal Infirmary, Consultant Emergency and Intensive Care Medicine Dr Afzal Chaudhry, Executive Chief Clinical Information Officer, Epic Frances Cousins, Digital Health Lead, Deloitte UK Register for the webinar
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EventFeaturing leading legal experts and experienced clinicians this online event will provide an update on current claims processes and how to respond to claims. The conference will look at the patient perspective and explore why patients decide to litigate. There will be an extended session on mediation and ADR. The conference will also update delegates on the new Patient Safety Incident Response Framework (PSIRF) and implications for Clinical Negligence Litigation. We have a limited number of free places for this event for members of the hub. Email [email protected] if you are interested. Find out more and book a place
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IHPN & CQC will be holding their fifth annual joint Patient Safety Conference on Wednesday 15 May from 9.30am to 4.30pm in Central London. This is a popular members-only event and this year’s conference will focus on building a safety and quality culture within independent healthcare services. Speakers include: CQC’s Chief Executive, Ian Treholm Dr Henrietta Hughes OBE, Patient Safety Commissioner for England HSSIB’s Chief Executive Officer Dr Rosie Benneyworth. This year’s conference is free to members of IHPN. Please note that places will be limited to two per member organisation. If you’d like more information about the conference please contact [email protected] quoting reference ‘Reg Conf 2024’. -
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A crisis is deepening in NHS psychiatric care - but how can we turn the tide and stop a total collapse? Join The Independent’s health correspondent Rebecca Thomas and a panel of experts as they dive into the heart of the issues plaguing the NHS' mental health services. This exclusive event comes after joint Independent/Sky News investigation Patient 11 uncovered 20,000 sexual abuse, harassment and assault complaints involving both patients and staff in more than 30 NHS mental health trusts in England since 2019. Sparked by the testimony of former patient Alexis Quinn, who joins our panel, the investigation has prompted accusations by healthcare professionals that NHS psychiatric care in England is in a state of "collapse," due to "unsafe" mixed gender care spaces, inadequate safeguarding protections and bed shortages. Register for the webinar -
Content ArticleIt’s well known that diagnosis at an early stage of cancer dramatically increases chances of survival. Current NHS policy is focused on diagnosing cancer at an earlier stage and improving the speed with which patients receive a definitive diagnosis. This article from the Nuffield Trust and The Health Foundation presents graphical data illustrating that the NHS is seriously off course in achieving these aims. It examines the reasons for delays to diagnosis including difficulties patients face in getting their concerns and symptoms taken seriously, the role of deprivation in increasing diagnostic inequalities and pressures due to increasing numbers of referrals. It also looks at the role screening has to play in achieving earlier diagnosis and highlights issues with patients understanding the information they are given.
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Content ArticleThis BMJ opinion piece highlights that seeing women’s health as synonymous with sexual, reproductive and maternal health means that gaps remain in health provision to meet the wider needs of women. The Government recently outlined its 2024 priorities that build on the 2022 Women’s Health Strategy for England. The authors welcome the focus on specific areas of need, but highlight that the priorities reinforce a traditional view of women’s health and miss an opportunity to encourage policymakers, healthcare providers and the public to take a broader view. They argue that a broader approach would reduce critical gaps in the evidence base and care and treatment relating to diseases and conditions that present only in women, disproportionately in women, and differently in women.
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Content ArticleHealthcare access, quality of care received and social factors such as income, housing and food insecurity, all impact the health outcomes of US residents. Growing evidence has pointed to wellness gaps and disparities among the different racial and ethnic populations that make up the country. This research by Innerbody takes a closer look at: what groups are the most uninsured across the US healthcare quality and life expectancy across races.
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Content ArticleCo-production is a method of engaging with communities, via partnership and power-sharing between professionals and communities to co-create solutions and decisions, with the intended long-term benefit of improving healthcare delivery and outcomes. This report from NHS Providers outlines the principles of co-production and actions trusts can take to apply engagement methodologies across their organisation. It provides an overview of different forms of engagement and summarises the potential benefits to trusts, including improved patient experiences and outcomes, and the delivery of more inclusive healthcare services that better meet the needs of local communities. It also makes the connection between engagement, co-production and the broader health inequalities agenda, unlocking the potential for collaboratively developing solutions to address complex barriers to health services experienced by some communities.
