Patient-Safety-Learning
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Content Article
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A large number of people live with long-term breathlessness that has a significant impact on their daily lives. For some, breathlessness is not directly linked to an underlying, diagnosable illness, and these people can struggle to access effective treatment and support. In this interview, respiratory doctor Anna Moore explains some of the causes of breathlessness including its links to a wide range of socioeconomic factors. She outlines the person-centred, multi-disciplinary approach her team at Barts Health is taking to help people overcome breathlessness and highlights the need for more research in this area. -
Content ArticleIn this Guardian article. Palliative Care doctor Rachel Clarke examines the debate around legalising assisted dying, focusing on the need to ensure patients do not want to end their lives due to lack of adequate health and social care. She highlights the risk that if assisted dying were legalised, patients might be coerced into choosing death "not by some rightwing politician or avaricious family member, but by the woeful inadequacy of their care." She goes on to look at wider attitudes to the dying in the NHS, pointing out that hospice care is mostly funded by charities, not the NHS, and that last year in England, almost 14,000 people died in A&E while waiting more than 12 hours for a bed.
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Content ArticleThis systematic review and meta-analysis in JAMA Network Open investigated whether perioperative telemedicine can reduce the incidence of adverse events in abdominal surgery. The findings suggest that perioperative telemedicine is associated with reduced risk of readmissions and emergency department visits after abdominal surgery. However, the mechanisms of action for specific types of abdominal surgery are still largely unknown and warrant further research.
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Content Article
On Wednesday 1 May 2024, the National NatSSIPs Network hosted a webinar to discuss the NHS England consultation on the Never Events framework. The consultation is concerned with whether the existing framework is an effective mechanism to drive patient safety improvement. This blog gives an overview of the discussion at this webinar, which had over 200 participants. -
Content ArticleLocal authorities fund many of the services—such as housing, education and social care—which either support or tackle the drivers of health inequalities. The Institute of Health Equity (IHE) has looked at every local authority in England and plotted levels of health, inequalities in health and cuts in their spending power. This report provides information from 17 local authorities with statistically significant increases in inequalities in life expectancy. The report shows, since 2010, central government spending cuts to local authorities were highest in areas with lower life expectancy and more health inequalities, further harming health in these places. It also confirms widening inequalities in life expectancy between regions in England and within local authorities since 2010.
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Content ArticleIn this article, Radar Healthcare provides a summary of the main sessions, messages and themes emerging from the Care Show London and the Digital Healthcare Show 2024, which both took place in April 2024. It discusses these topics: Embracing technology in care provision Mastering CQC-ready feedback processes The importance of integration between social care and the NHS Leveraging social media AI: The challenges and opportunities Avoiding digital fatigue: Fostering patient safety In this final section, the article highlights a presentation given by Patient Safety Learning's Chief Executive Helen Hughes and Chief Digital Officer Clive Flashman about the organisation's patient safety standards. They spoke about the standards and accompanying online patient safety assessment toolkit, an easy-to-use resource designed to help organisations establish clearly defined patient safety aims and goals, support their delivery and demonstrate achievement. The article also highlights the contribution of the hub to improving patient safety, saying, "Patient Safety Learning's platform is recognised for its excellence in sharing knowledge on patient safety. It provides a comprehensive suite of tools, resources, case studies, and best practices to support those striving to improve patient care."
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Content ArticleThis study in JAMA Network Open aimed to determine whether magnetic seizure therapy (MST) has comparable efficacy to modified electroconvulsive therapy (ECT) for bipolar mania. The results suggest that MST is associated with a high response rate and fewer cognitive impairments in bipolar mania and that it might be an alternative therapy for the treatment of bipolar mania.
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Content Article
Little Voices is a project run by Walsall Healthcare NHS Trust to amplify the voices of children who were patients at the Trust. Little Voices helped inform and support the Trust's ambition to deliver care in a setting that is child-friendly and equitable for all children. Getting input directly from children of a young age enhanced the Trust's understanding of what accessing care is really like for a child, seen through their eyes and not those of a parent or carer. Specific improvements are being implemented in the areas of hand hygiene, mealtimes that matter, play that is engaging and reducing fear and anxiety. -
Content ArticleThis narrative review aimed to investigate adverse events in trauma resuscitation, evaluate contributing factors and assess methods, such as trauma video review (TVR), to mitigate adverse events. The authors found that, when integrated with standardised tools, TVR shows promise for identifying adverse events. They suggest that future research should prioritise linking trauma team performance to patient outcomes and developing sustainable TVR programs to enhance patient safety.
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Content ArticleThis article tells the story of 61 year-old Susannah Constantine who was diagnosed with a rare neurological condition after her MRI was not looked at by her GP surgery for over a year. Susannah decided to have a private MRI when doctors couldn't diagnose why she’d been suffering from tinnitus and pins and needles in the fingers of her left hand. The results were sent to her GP, and Susannah heard no more, so struggled on for another year—she gradually became weaker and her muscles atrophied. She called her GP surgery to check if the MRI held any clues and learnt no one there had ever looked at the results—they had just been sat there for a year. She was told she needed to see a neurosurgeon immediately and was diagnosed with arteriovenous malformation (AVM), a rare neurological condition that disrupts the flow of blood and oxygen to the brain. If not spotted and treated in good time there is a one in three chance of suffering a brain haemorrhage, paralysis or stroke.
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Content ArticleThis Washington Post article looks at the lack of error and accident reporting in the US reproductive health and fertility industry. Unlike any other area of healthcare, no outside authority or agency regulates Never Events that happen at fertility providers. The authors highlight a case that allowed a glimpse into the industry, when legal action was taken against a San Francisco fertility centre where a storage tank imploded, damaging or destroying 4,000 human eggs and embryos. A jury later found that a manufacturing defect was largely to blame for the disaster but also implicated the actions taken by staff at the centre. The authors also highlight that patients are often asked to sign nondisclosure agreements as part of a legal settlement, which further restricts transparency when something goes wrong.
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EventThe second Healthcare Fatigue Forum is being held on Tuesday 5th November 2024 at the Hyatt in Birmingham. Registration will open soon. This event will cover topics including the current state of fatigue risk management in the NHS, relevant and ongoing research, countermeasures and tools to mitigate fatigue. Attendees are invited to submit posters of research that is, or has, been undertaken in the field of fatigue management in health and social care workers.
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Content ArticleThe health needs of the population are changing as it ages. Health services, particularly in secondary care, have traditionally been designed to deal with patients with a single disease, but for a growing number this is no longer a suitable model of care. Primary care has been at the vanguard of delivering more person centred and whole-person care, but many of the existing policy measures and incentives within it are outdated and aimed at managing single diseases. This report by Future Health sets out a series of recommendations for developing the Major Conditions Strategy to encompass a wider range of long-term and multiple conditions, putting patients rather than specific conditions at the centre. It also provides new data on the rising challenge of long-term conditions and in particular multiple long-term conditions.
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Content ArticleIn this HSJ blog, Ken Jarrold highlights three key things he learned during his ten years as chair of NHS trusts: Focus on the people that matter—service users and frontline staff Keep an appropriate level of contact and relationship with the chief executive Live the values of the trust. He emphasises chairs keeping their focus on the people they serve and ensuring they feel at home interacting with staff and service users, as well as other leaders. He also states his hope that the Leadership Competency Framework for conducting annual appraisals of NHS chairs published by NHS England in February 2024, if applied appropriately, will result in improvements in how chairs serve their organisations.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)Fatigue is a perpetual risk in safety-critical industries. If that risk is not managed appropriately, it can result in a significant reduction in human performance, with associated impacts on safety. This paper from the Chartered Institute of Ergonomics & Human Factors (CIEHF) aims to present a roadmap for improving fatigue risk management in health and social care to improve patient safety and individual health workers' health and wellbeing. It makes a case for UK health and social care national bodies and organisations managing fatigue as a systemic risk. See also: CIEHF: Fatigue risk management in health and social care webinar recording
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Content Article
A growing number of patients with eating disorders are reporting having treatment withdrawn by services, often without notice and without their consent. We spoke to eating disorder campaigner Hope Virgo about how pressures on services, enduring stigma around eating disorders and dangerous new narratives are leading to the practice of treatment withdrawal. Hope explains how this is affecting vulnerable patients and highlights that as the number of people developing eating disorders increases, the risks to patient safety will only get worse. -
Content ArticleThis presentation looks in detail at Never Events, which it defines as serious, largely preventable patient safety incidents that should not occur if relevant preventative measures have been put in place. It sets out their history and development in the NHS in England, outlines different types of Never Events and considers how they can be tackled and prevented.
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Content ArticleThis article reflects on the death of Wayne Jowett and the impact this had on how the NHS approaches patient safety. Wayne died after the cytotoxic drug vincristine, intended for intravenous injection, was instead injected into his spine. The circumstances around his death informed the subsequent development of Serious Reportable Events in the NHS, and later the Never Events Framework.
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Content ArticleThis framework establishes a standardised approach to the annual appraisal of chairs, including ICB, NHS trust and foundation trust chairs. The appraisal should be a valuable and valued undertaking that provides an honest and objective assessment of a chair’s impact and effectiveness, while enabling potential support and development needs to be recognised and fully considered. The framework is aligned with the NHS Leadership Competency Framework and informed by multi-source feedback. It establishes a standard process, consisting of four key stages, to be applied to the annual appraisal of chairs.
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Content ArticleDisordered eating can affect anyone, but it can be confusing to understand and recognise it in our own personal experiences. This guide, published by East London NHS Foundation Trust, is a snapshot of how adults in East London have navigated those experiences of uncertainty while seeking support for disordered eating. For many of the contributors, preconceptions about what an eating disorder is (or isn’t) have previously acted as a barrier to seeking or receiving support. It also contains advice on how to seek support for disordered eating.
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Content ArticleNever Events are serious, largely preventable patient safety incidents that should not happen if the available preventative measures have been implemented by the healthcare provider. This document sets out the NHS approach to Never events and includes a list of recognised Never Events in 2012/13.
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Content ArticleThis video provides an introduction to Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF). The PCREF aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment.
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Content Article
On 17 and 18 April 2024, government ministers, high-level representatives and health experts from all over the world gathered in Santiago, Chile for the Sixth Global Ministerial Summit on Patient Safety. In this long-read article, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the key themes and issues discussed at the event. -
Content ArticleThis study in the American Journal of Surgery looked at whether language barriers have the potential to influence acute stroke outcomes. The authors examined postoperative stroke outcomes among non-English primary language speakers and found that there were no differences in length-of-stay or secondary outcomes, but there were higher odds of feeding tube placement.
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Content ArticleThe debate about fairness of artificial intelligence (AI) in health care is gaining momentum. At present, the focus of the debate is on identifying unfair outcomes resulting from biased algorithmic decision making. This article in The Lancet Digital Health looks at the ethical principles guiding outcome fairness in AI algorithms.
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