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Content Articlee-Bug, operated by the UK Health Security Agency, is a health education programme that aims to promote positive behaviour change among children and young people to support infection prevention and control efforts, and to respond to the global threat of antimicrobial resistance. e-Bug provides free resources for educators, community leaders, parents, and caregivers to educate children and young people and ensure they are able to play their role in preventing infection outbreaks and using antimicrobials appropriately.
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Content ArticleIncivility in the workplace, school and political system in the United States has permeated mass and social media in recent years and has also been recognized as a detrimental factor in medical education. This scoping review in BMC Medical Education identified research on incivility involving medical students, residents, fellows and faculty in North America to describe multiple aspects of incivility in medical education settings published since 2000. The results of the review highlight that incivility is likely to be under-reported across the continuum of medical education and also confirmed incidences of incivility involving nursing personnel and patients that haven't been emphasised in previous reviews.
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Content ArticlePatient experience is deteriorating across the NHS, so hearing from users should be of the utmost importance as the NHS looks to improve, yet too often those leading work on patient experience feel that it is not prioritised. The King’s Fund has been working with the Heads of Patient Experience (HOPE) network to design and develop projects to better understand how people and communities are experiencing health and care services. This article outlines learning and recommendations from this work.
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Content ArticlePeople with learning disabilities are more likely to be taking multiple medicines, but labels are not designed with them in mind. This article in the Pharmaceutical Journal looks at a project run by a team at Leeds and York Partnership NHS Foundation Trust in 2021, which came from a person with learning disabilities requesting medicine labelling with “the name of the tablets in big letters so I know what tablets I’m taking."
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Content ArticleThe story behind Martha’s rule is depressingly familiar. A parent raising significant concerns about their daughter’s ongoing care only to be ignored with tragic consequences. Unfortunately, this feels like the latest in a long line of incidents where the NHS has failed to heed warnings from patients and their families about the quality of their care. This article by Dan Wellings looks at recent collaborative work by The King's Fund and the Heads of Patient Experience (HOPE) network to understand why the NHS is still too often not listening to people who use its services. He highlights that progress made since the early 2000s in improving how the health service listens to patients has stalled, with the proportion of patients feeling involved in decisions about their care or treatment falling in recent years. He also outlines how organisational cultures that focus disproportionately on the positive miss opportunities to hear and respond to stories that demonstrate serious patient safety and experience issues.
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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. Gordon talks to us about how bureaucracy in the health service can compromise patient safety, the vital importance of agreed quality standards and what hillwalking has taught him about healthcare safety. -
Content ArticleBetween 2009 and 2010, 48 year-old David Richards was admitted to intensive care during the ‘swine flu pandemic’. He spent six weeks in an intensive care unit (ICU), first on mechanical ventilation and later receiving extra-corporeal membrane oxygenation (ECMO) treatment. He recovered and became a survivor of severe acute respiratory distress syndrome (ARDS). During his 50 days in intensive care, David's former partner Rose kept an ‘ICU diary’. Rose recorded clinical updates as well as conversations with relatives and staff who were by David's bedside. In this article, David describes how important this diary has been to him understanding and processing his experience. It forms a record not just of procedures, treatments and clinical signs but of how he reacted, how he appeared to feel and how he tried to communicate during a time that were permeated by delirium.
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Content ArticleIn this article, Stephen Shorrock, Chartered Ergonomist and human factors specialist, shares some some insights on the concept of ‘human error and the idea of ‘honest mistakes’. He outlines the problem with thinking of errors as ‘causing’ unwanted events such as accidents, arguing that this approach ignores all of the other relevant ‘causes’, especially in high-hazard, safety-critical systems,
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Content ArticleThis article in the British Journal of Anaesthesia argues that the criminalisation of medical accidents leaves clinicians scared to report systemic causes and contributors to bad outcomes, removing a foundational pillar of patient safety. Looking at the case of RaDonda Vaught, a nurse who was found guilty of criminally negligent homicide for a fatal medication accident, the authors highlight the need to move away from seeing adverse incidents in healthcare as being easily avoided through greater attention, trying harder or adherence to rules. They call on healthcare organisations to learn from the case and argue that healthcare systems need to be collaboratively redesigned with a systems perspective.
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Content ArticleTo improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesising information from a patient's history and physical examination or from a handoff, performing tests or procedures, administering medications and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results, but sometimes this work does not unfold in the way that was anticipated. This article, originally published in Pennsylvania Patient Safety Advisory, argues that efforts to improve healthcare work will not succeed without recognising that there is a difference between a theoretical construct of "work-as-imagined" and the reality of "work-as-done".
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Content Article
WHO: World AMR Awareness Week 2023
Patient-Safety-Learning posted an article in WHO
Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites no longer respond to antimicrobial agents. As a result of drug resistance, antibiotics and other antimicrobial agents become ineffective and infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness and death. The World AMR Awareness Week (WAAW) is a global campaign to raise awareness and understanding of AMR and promote best practices among One Health stakeholders to reduce the emergence and spread of drug-resistant infections. WAAW is celebrated from 18-24 November every year. The World Health Organization (WHO) explains what antimicrobial resistance is and provides resources for organisations wanting to take part in WAAW 2023, on their campaign webpage. -
EventuntilOn the NHS75 anniversary, NHSE announced that paediatrics will be the next priority pathway for the rollout of virtual wards. With over 350,000 children in the queue for treatment, capacity pressures continue to mount for paediatric teams. The stage is set for paediatric virtual wards to address these pressures head-on, and emerging evidence is promising. Pilot sites have demonstrated paediatric virtual wards can: Reduce a child’s length of stay in hospital by an average of 3 days Decrease hospital readmission by 38% for children with chronic conditions. So what is needed to build paediatric virtual wards that work for both children and their caregivers? This webinar will dive into the nuanced approach required when caring for children at home, bringing in insights and learnings from leading UK paediatric clinicians and experts working in the field. In this webinar you will learn: The need for a fresh approach: the huge potential for paediatric virtual wards to reduce pressure in paediatric departments and why these pathways require teams to think differently Lessons from the front-line: the key take-aways from one of the first NHS sites to trial paediatric virtual wards How to build a successful paediatric virtual ward: what is needed to set up a paediatric virtual ward pathway and team for success Speakers: Zoe Tribble, Children's Nurse Jim McDonald, Black Country ICB Juliana Faleti, Paediatric Nurse Register for the webinar
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EventuntilOn the back of the National Point of Care Testing guidance issued in May by the IBMS, RCPath and ACB. This webinar will explore the use case of rapid diagnostic testing to Care, Monitor and Protect. The purpose of a POCT service is to enable the delivery of high quality, accessible diagnostics at the point of need for clinical services, improving clinical outcomes and enhancing the patients’ healthcare experience. The aim should be to ensure that POCT services nationally utilise (and inform) advances in technology to innovate the way in which patients can access diagnostics and clinical services. Technology plays an important part of the patient pathway and in 2022 The World Health Organisation (WHO) published The Target Product Profile (TPP) for readers of rapid diagnostic tests detailing the preferred product characteristics and target regimen profiles. The webinar will provide a guide for commissioners, NHS settings and community pharmacies delivering NHS services. The NHS Long Term Plan highlights the importance of patients receiving care closer to home, shifting from a traditional model of hospital-based services towards a more adaptive community-based approach. Learn about Previous case studies of how Testing to Care, Monitor and Protect has been robustly rolled out across the NHS. Issues faced and how they were overcome. Impact of digital readers when combined with high-quality lateral flow tests in a clinical setting How The Target Product Profile (TPP) for readers of rapid diagnostic tests was developed according to a process based on the WHO Target Product Profiles, Preferred Product Characteristics, and Target Regimen Profiles. Speakers Dr George Newham PhD, Research and Development Manager, SureScreen Diagnostics Dr Rahul Batra, Clinical Innovations and Disruptive Technologies Lead in the Centre for Clinical Infection and Diagnostics Research at Guy’s and St Thomas’ Hospital Julie Hart, NHS Pathway Transformation and Market Access Expert: Diagnostics and Artificial Intelligence Dr Andrew Botham, Chief Scientific Officer - TestCard Register for the webinar
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Content ArticleThis blog by the British Society for Rheumatology (BSR) shares highlights of the evidence given to a House of Lord's inquiry into homecare medicines services' governance and accountability. The witness sessions heard evidence on levers for accountability, performance and safety, e-prescribing and workforce. The blog looks at challenges faced by providers, the need for improved regulation and accountability and lack of data and KPIs. It also describes a desktop investigation being undertaken by NHS England to understand the range of arrangements that are in place and how homecare medicines services are held to account.
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Content Article
D-coded diabetes
Patient-Safety-Learning posted an article in Diabetes
D-coded diabetes is a tool that aims to simplify complex research studies about diabetes making the science accessible to everyone living with the condition. It uses simple language and images to explain the methodology and results of studies and trials. D-coded diabetes was created by The Diabesties Foundation, a nonprofit organisation aimed at delivering impact by revolutionising advocacy, education and support for people living with Type 1 Diabetes. -
Content Article Comment
Camden Hospital: The Safety Huddle: Preventing repeat falls and near miss falls (October 2015)
Patient-Safety-Learning commented on Claire Cox's article in Implementation of improvements
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Hi @kam kam, thanks for letting us know. We will try and find this resource in another location, and if we can't, will take this Learn article down. In the meantime, you might be interested in some of our other resources relating to falls prevention: https://www.pslhub.org/tags/Falls/- Posted
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Content Article
UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video, founder of UKCVFamily Charlet Crichton talks to us about the side effects she experienced after having the AstraZeneca Covid vaccine. She outlines why she established the group and describes the support it offers to patients. She outlines some of the issues people face when trying to access diagnosis and treatment, and discusses the limitations of the MHRA's Yellow Card scheme in collecting data about adverse reactions. She also describes how healthcare professionals can support people with adverse reactions by taking their concerns seriously and investigating symptoms thoroughly. -
Content ArticleGood patient communication is key, particularly when a patient is waiting for planned care or treatment. From referral by a primary care clinician through to discharge from secondary care, clear, accessible communication is vital throughout. This guide from NHS England sets out key communication principles to help providers deliver personalised, patient-centred communications. It includes considerations for communicating to patients about new models of care as well as helpful information and resources. It covers key aspects of patient communication while waiting for care including personalisation, using clear language, shared decision making, managing delays and cancellations and offering interim health information.
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Content ArticleThe Health Equity Network (HEN) aims to build momentum for health equity across the UK. It provides an opportunity for organisations, community and voluntary groups and individuals to share their work on health equity and to engage across the country with others with the same interests. This is the report of HEN's first annual conference held on 5 October in Birmingham. The report includes links to videos of key speakers from the conference and bullet points detailing their input. It also includes brief summaries of the breakout sessions and a summary of feedback from attendees.
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Content ArticleThese charts have been collaboratively developed by clinical teams across England to standardise how the deterioration of children in hospital is tracked. There are four charts for children of different ages, designed to be used on general children’s wards. PEWS observation and escalation chart: 0 to 11 months PEWS observation and escalation chart: 1-4 years PEWS observation and escalation chart: 5-12 years PEWS observation and escalation chart: ≥13 years
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News ArticlePregnant women are being forced to wait days longer than expected for “urgent” inductions of labour as NHS staff shortages and a lack of beds lead to severe delays. New mothers told i the delays, which the health watchdog has found can last up to five days, increased the anxiety they felt during labour. One first-time mother, who wanted to remain anonymous, said that her ordeal has put her off having any more children. The woman, who gave birth to a son in August, said she was “pushed” to book an induction when her waters broke and her baby was almost two weeks overdue. Despite being told by multiple healthcare professionals she needed to “give birth within 24 hours” due to a risk of infection, she did not end up delivering her baby for another 49 hours – without being induced. A birthing expert told i she has “never seen a crisis in maternity” like it during her almost 10 years working in the sector. It comes after it was revealed that the Care Quality Commission (CQC) watchdog has issued warnings to seven hospitals due to delays to the induction of labour since last year. Read full story (paywalled) Source: inews, 5 November 2023
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Event
NHS England - PSIRF embedding webinar 1
Patient-Safety-Learning posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Paul Chandler, Head of Patient Safety & Quality Assurance, Patient Safety Specialist, PSIRF Lead, Royal Hospital for Neuro-disability Lesley McKay, Associate Chief Nurse for Infection Prevention and Control, Warrington and Halton Teaching Hospitals NHS Foundation Trust Register for the webinar -
Content ArticleThis article by the charity DiaTribe looks at the impact of armed conflict and displacement on people living with diabetes. Referencing the situation facing people with diabetes in Gaza, it highlights the safety risks including lack of access to healthcare professionals, insulin and other medications and reliable food sources. As well as signposting to other resources for people living with non-communicable diseases (NCDs) in conflict zones, the article provides advice for patients on being prepared for unexpected disasters, including ensuring they have a good knowledge of self-management, know how to safely store insulin and have a diabetes identification card. It also outlines what healthcare workers, governments and aid organisations can do to support people with diabetes living in or having fled conflict zones.
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Content ArticleDuring the pandemic, approximately 4.1 million people across the UK were identified as clinically extremely vulnerable (CEV) to Covid-19, and asked to shield for their own protection. This decision, made in the light of an unprecedented pandemic, would separate those with autoimmune inflammatory conditions, such as rheumatoid arthritis, from the rest of society for their own protection. This report by the charity Versus Arthritis presents qualitative research led by Dr Charlotte Sharp, a consultant rheumatologist, Lynn Laidlaw who has an autoimmune rheumatic disease and had to shield, and patient contributor Joyce Fox from the Centre for Epidemiology at the University of Manchester. It highlights the stories of people who lived through shielding and details the impact on their daily lives, their physical and mental wellbeing, their work, and their relationships with their families and the rest of society.
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Content ArticleIn this video, the Long Covid Groups' KC Anthony Metzer questions Professor Kamlesh Khunti to find out if he agrees that Long Covid should be cited as a reason not to allow Covid-19 to spread unchecked via non-pharmaceutical interventions (NPIs). Professor Khunti is a member of SAGE and former Chair of the National Long Covid Research Working Group.
