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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This study in the Journal of Applied Research in Intellectual Disabilities aimed to  share rich detail of the emotional and physical impact on children and young people with intellectual disabilities of attending hospital, from their own and their parent's perspective. The authors found that the multiple and compounding layers of complexity surrounding hospital care of children and young people with intellectual disabilities resulted in challenges associated with loss of familiarity and routine, undergoing procedures, managing sensory overload, managing pain and having a lack of safety awareness. They concluded that an individualised approach to care is needed to overcome these issues.
  2. Content Article
    The harsh reality of surgery often involves grappling with the distressing and emotionally taxing aspects of human suffering that many people outside of healthcare never witness. When complications occur, surgeons feel the weight of their responsibility and are often alone to ruminate with negative thoughts of self-doubt, sometimes leading to anxiety and depression. This article in The American Journal of Surgery examines existing literature on Second Victim Syndrome (SVS) specifically focusing on prevalence among surgeons and factors related to different responses. The authors identify women and junior surgeons at particularly high risk of SVS and peer support as a preferred method of coping but an overall lack of institutional support highlighting the need for ongoing, open conversations about the topic of surgeon well-being.
  3. News Article
    A 10-year-old boy with severe asthma died as a result of multiple failings by healthcare professionals amounting to neglect, a coroner has concluded. William Gray, from Southend, died on 29 May 2021 from a cardiac arrest caused by respiratory arrest, resulting from acute and severe asthma that was “chronically very under controlled”. His death has led to calls to improve asthma treatment for children nationwide. The court heard that William’s death was a “tragedy foretold” having previously suffered a nearly fatal asthma attack on 27 October, 2020, which he survived. The coroner said that William’s death was avoidable, his symptoms were treatable, and he should not have needed to use 16 reliever inhalers over 17 months, but instead his condition should have been treated with preventer medications and should have been controlled. Julie Struthers, a solicitor at Leigh Day who represented the family, said, “In an inquest involving concerns with medical treatment it is rare for a coroner to find neglect, and even rarer for a coroner to find Article 2, a person’s right to life, to be engaged. This reflects the real tragedy of what happened to William, the substantial number of failures by multiple healthcare professionals in his care, and the importance of improving asthma treatment for children nationwide.” Read full story (paywalled) Source: inews, 22 November 2023
  4. Content Article
    In this opinion piece for the BMJ, Partha Kar looks at the current debate surrounding the role of medical associate professionals (MAPs) in the NHS. He highlights the concerns raised by many that MAPs are “doctors on the cheap” and outlines the reasons for friction between junior doctors and MAPs, which include the issues of pay, training and regulation. He also outlines issues facing locally employed doctors (LEDs), international medical graduates (IMGs) and specialist, associate specialists (SASs) including lack of access to training, supervision and career progression. He makes five suggestions to improve the situation and calls for a pause to consider how these different roles can interact and work together, for the good of both staff and the health service.
  5. Content Article
    This report by the Royal College of Emergency Medicine presents insights about Emergency Department (ED) crowding in England. It highlights that overcrowding is a major threat to public health and outlines the reasons for overcrowding - primarily increasing patient demand coupled with high hospital bed occupancy, which has resulted in exit block.
  6. Content Article
    TrialResults.com present the results of completed clinical trials in an easy to understand format. The site allows you to search for clinical trials related to different areas and conditions, and filter results by country and sponsor. You can they view and download a Plain English summary of each trial. It was set up by TrialAssure, a global company committed to clinical trial and human health data transparency for the entire pharmaceutical industry.
  7. Content Article
    Professor Jane Somerville, emeritus professor of cardiology at Imperial College, talks about the issues facing doctors who raise concerns about patient safety issues in the NHS. She shares her views on the risks facing doctors who speak up and the ways that healthcare managers treat whistle blowers. She also highlights issues in the employment tribunal system and outlines the need to regulate NHS managers. In the video, Jane mentions the employment tribunal of Dr Martyn Pitman. Since this interview was recorded, Dr Pitman lost the case he brought for retaliatory victimisation.
  8. Content Article
    The scale of the health inequalities challenge can often feel daunting and overwhelming for system leaders, but tackling health inequalities is one of the four statutory purposes of integrated care systems (ICSs) to support communities to live long, healthy lives. This article outlines a project the NHS Confederation has launched to support healthcare leaders adopt best practice to address this issue.
  9. Content Article
    The UK’s healthcare systems are experiencing a prolonged period of high pressure, with industrial action, backlogs in elective care persisting, and a shortage of doctors that ongoing high vacancy rates evidence. This report by the GMC analyses trends in the medical workforce across the UK. It uses a variety of sources to provide insights for policymakers and workforce planners, as well as offering deeper analysis on specific themes.
  10. Event
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    In this first webinar of the Changes in Primary Care series, Dr Claire Fuller, Medical Director of Primary Care at NHS England will discuss the new reception team alongside frontline general practice staff. Register for the webinar
  11. Content Article
    e-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.
  12. Content Article
    Incivility 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.
  13. Content Article
    Patient 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.
  14. Content Article
    People 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."
  15. Content Article
    The 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.
  16. 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.
  17. Content Article
    Between 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.
  18. Content Article
    In 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,
  19. Content Article
    This 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.
  20. Content Article
    To 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".
  21. Content Article
    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.
  22. Event
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    On 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
  23. Event
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    On 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
  24. Content Article
    This 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.
  25. Content Article
    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.
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