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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In England and Wales, law requires that coroners issue a Prevention of Future Death (PFD) report when they believe that action should be taken to prevent future deaths. Prevention of Future Death reports therefore provide an opportunity to learn and prevent harm. This study in the Journal of Patient Safety and Risk Management thematically analyses PFD reports received by the National Institute for Health and Care Excellence (NICE) along with the organisation's response. The study provides insight into the PFD report practices of a national guidance producing and standard setting body in the UK, as well as supporting system-level understanding of current practices in relation to PFD reports. However, the authors note that there are no means to assess if the Chief Coroner's Office and the wider safety system considered NICE's responses adequate or whether the actions taken were effective. 
  2. Content Article
    Medicines talk is a website hosting a collection of stories to inspire new avenues for discussion between healthcare professionals and their patients about their medicines and care. Story 1: Life is meant for laughing Story 2: What is it all for? Story 3: 'Keeping going': Are my medicines a help or a hindrance? Story 4: I look after myself Story 5: Is there anything we can stop today? Story 6: A glimpse of the future? Story 7: Polluting the planet The stories were co-authored by Professor Deborah Swinglehurst and Dr Nina Fudge, based on research conducted between 2016 and 2021 at Queen Mary University of London (QMUL). The researchers studied 24 people aged 65 or older who had been prescribed ten or more different items of regular medication, through home visits, interviews and attending appointments for up to two years. They also observed and spoke with health professionals in three general practices and four community pharmacies.
  3. 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. Jenny talks about the challenge of keeping up with and prioritising new guidance and the need to streamline recommendations to ensure they are implemented efficiently. She also discusses the importance of getting the basics, like staffing levels, right and how sea swimming has influenced how she sees patient safety.
  4. Content Article
    This report documents a meeting held in September 2022 that explored how Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys shed light on disparities in patient experience and how improved measurement can advance healthcare equity in the US. Over 600 CAHPS survey users, researchers, healthcare organisation leaders, patient advocates, policymakers, Federal partners and the CAHPS Consortium attended.
  5. Content Article
    This research report by the Energy Institute is intended for senior management and specialists charged with designing and implementing indicators for major accident hazards safety, or responsible for operating such systems. The report provides an introduction to the Health and Safety Executive (HSE) human factors key topics, and proposes ways in which these might be measured. It also sets out a process for identifying relevant PIs. The research report incorporates findings related to current thinking on safety PIs, in particular for human factors, how organisations currently monitor human factors in practice, and what processes are used to ensure appropriate indicators are selected.
  6. Content Article
    The Strengthening Medication Safety in Long-Term Care initiative, funded by the Ontario Ministry of Long-Term Care was established in partnership with the Institute for Safe Medication Practices (ISMP) Canada to address the medication safety-related recommendations in Justice Gillese’s Long-Term Care Homes Public Inquiry Report. The three-year initiative is designed to improve medication management processes, including those intended to deter and detect intentional and unintentional harm in long-term care homes across the province of Ontario. This bulletin provides an overview of the initiative and highlights selected examples of improvement projects completed in the first phase.
  7. Content Article
    This guide is a self assessment tool to enable Primary Care to become dementia friendly. It includes a checklist for GP practices to help people with dementia and their carers access high quality care and support. People with dementia, carers and staff in GP practices have worked together to co-design and develop this guide. It outlines the benefits for general practice in becoming dementia friendly and includes checklists covering: General practice systems General practice culture Patient diagnosis, care and support Physical environment This guide is adapted from the Alzheimer’s Society’s Guide to Making General Practice Dementia Friendly.
  8. Content Article
    Solving Together is a partnership that enables people with different ideas and views to put forward solutions and experiences. From Monday 9 October to Friday 3 November 2023, Solving Together is hosting a series of conversations on Children and Young People’s Mental Health that aim to get ideas on how access and waiting times for community services could be improved. The conversation topics are: Reducing inequalities in access, experience and outcomes Prevention and early intervention Experience of services Transfer of care and wider support
  9. Content Article
    The risks in perioperative care are well known. However, for patients having surgery in some African countries, the dangers are far more apparent. Staff are few and far between and many have not been able to access rationale for their practice or receive adequate training over the years. Friends of African Nursing (FoAN) is a small UK-based charity that has been providing education in several African countries to address this issue. More than 3,000 nurses and other healthcare workers have been trained face to face—and many more on-line—in patient safety, staff safety and infection prevention. FoAN's Chair of Trustees Kate Woodhead describes the challenges facing nurses working in perioperative care in many African countries.
  10. Content Article
    Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.
  11. Content Article
    This document from the Patient Experience Library aims to map the evidence base for patient experience in digital healthcare. We shine a spotlight on areas of saturation, we expose the gaps and we make suggestions for how research funders and national NHS bodies could steer the research to get better value and better learning.
  12. Content Article
    Inconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. The Safer Tracheostomy Care in Adults bundle was a programme of 18 interventions implemented across 20 hospitals in England between August 2016 and January 2018. These interventions were designed to improve the quality and safety of care for patients who have had tracheostomies. This evaluation report outlines why the interventions were needed and assesses their impact, including an estimated reduction in total hospital length of stay per tracheostomy admission of 33.02 days, corresponding to a potential reduction of over £27,000 per admission.
  13. Content Article
    This bulletin from the Canadian Institute for Health Information (CIHI) describes two new in-hospital infections indicators for Clostridium difficile (C. difficile) and Methicillin-Resistant Staphylococcus aureus (MRSA). It includes a table listing CIHI’s selected patient safety performance indicators and definitions.
  14. Content Article
    The ICS Delivery Forum is a series of regional conferences hosted by Public Policy Projects. Each event convenes local ICS leadership, key health and care experts and other stakeholders including industry leaders. A series of panel discussions and case study presentations are given throughout the day. This document summarises the key insights from the Leeds ICS Delivery Forum event held in Leeds on 28 June 2023. The document placed these discussions into the broader context of health and care transformation, both at a local and national level. As such, wider sources and research are used to expand upon the key points.
  15. News Article
    A 25-year-old who died from a heart haemorrhage after being diagnosed with a panic attack had been seen by a non-medical school trained physician associate (PA) but not a doctor, it has emerged. Ben Peters, 25, attended the emergency department at Manchester Royal Infirmary on the morning of 11 Nov 2022 with chest pain, arm ache, a sore throat and shortness of breath. While waiting, he endured a “severe episode of vomiting”. Peters was diagnosed with a panic attack and gastric inflammation by the PA and sent home with two medications, after a supervising consultant, who the coroner found never reviewed the patient in person, agreed with the diagnosis. Less than 24 hours later, Peters died from a rare complication of the heart that had resulted in a tear of the heart’s major artery, known as aortic dissection, and led to a fatal haemorrhage. The Aortic Dissection Charitable Trust (TADCT) says around 2,000 people in Britain die from the condition each year, which can be “reliably diagnosed or excluded” using a CT scan, but “misdiagnosis affects one-third of patients”. A prevention of future deaths notice issued by Chris Morris, the area coroner for Greater Manchester South, written to Manchester University Foundation Trust, said: “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined or reviewed in person by a doctor." Read full story Source: The Telegraph, 21 October 2023
  16. News Article
    An ambulance spent 28 hours outside a hospital after an "extraordinary incident" was declared due to delays. The Welsh Ambulance Service said 16 ambulances had waited outside the emergency department at Morriston Hospital, Swansea, at one time. It said multiple sites across Wales were affected, "specifically" in the Swansea Bay health board area. Lee Brooks, director of operations, told BBC Radio Wales Breakfast the situation was "heart-breaking". The service said people should only call 999 if their emergency was "life or limb threatening". Judith Bryce, assistant director of operations at the Welsh Ambulance Service, said on Sunday the service was experiencing "patient handover delays outside of emergency departments. This is taking its toll on our ability to respond within the community." Read full story Source: BBC News, 23 October 2023
  17. News Article
    The Health Services Safety Investigation Branch has been accused of taking “divisive potshots” at NHS finance directors. Speaking at an event to mark the watchdog becoming an independent body, HSSIB chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa… Often you see the finance director and safety lead don’t work effectively together and we need to change that.” Dr Benneyworth said progress on safety would not be made unless it was tackled “in the same breath” as operational and financial matters. In response, the Healthcare Financial Management Association said Ms Bennyworth’s views had “incensed” its members. Commenting below the story, HFMA chief executive Mark Knight said: “I have been contacted by a number of finance directors who are incensed by the comments in this article. To gain a fuller picture of the views of the newly created HSSIB we will be asking for a meeting with Dr Benneyworth and [HSSIB chair Ted] Baker. The HFMA would like to understand the evidence on which the assertions in the article are based, which are completely at odds with how I know the vast majority of finance directors and their teams behave.” Read full story (paywalled) Source: HSJ, 23 October 2023
  18. News Article
    The drive to cut NHS waiting lists are becoming ‘disproportionately reliant’ on the private sector, experts have warned, as new data suggests rapid growth in the elective activity carried out by non-NHS providers. Internal figures for activity commissioned by integrated care boards and NHS England, seen by HSJ, suggests the value-weighted activity carried out by private providers has increased by around 30 per cent on pre-covid levels. The value-weighted elective activity carried out by NHS providers rose by just three per cent over the same three-month period, from April to June 2023. The figures relate to activity measured under the “elective recovery fund”, which accounts for the bulk of elective activity. NHSE said it was right to make use of “all available capacity” to treat long-waiters. However, experts said the NHS would struggle to bring down waiting lists without significantly increasing the amount of elective work it did. Waiting list analyst Rob Findlay said independent sector outsourcing was “not genuine backlog clearance, but a way of plugging some of the recurring shortfall in core NHS capacity.” Read full story (paywalled) Source: HSJ, 23 October 2023
  19. News Article
    The Gaza Strip’s health-care system stands on the brink of collapse as bombings damage hospitals and ambulances and as generators run out of fuel, highlighting how quality medical care is a casualty of war. Dire scenarios await Gaza’s medical professionals. They face dwindling basic resources such as power, water and anesthesia, compelling doctors to confront wrenching decisions on whose lives to save. The growing humanitarian crisis is plunging health-care workers into the critical emergency planning that follows both human-made and natural disasters — assessing staffing and other resources, managing existing health needs on top of gruesome new ones, and looking out for their own welfare. “When we are in a disaster setting or conflict, we usually have more patients than resources. We have to be very creative to be able to provide the best care for the most number of people,” said Lindsey Ryan Martin, who is director of global disaster response and humanitarian action at Massachusetts General Hospital in Boston and has been monitoring the situation in Gaza. The health-care crisis extends beyond Tuesday’s deadly blast at al-Ahli Hospital in Gaza City. Aid organizations say the war continues to imperil an already beleaguered health-care system. Gaza’s Health Ministry said five hospitals were out of service as of Thursday and an additional 14 health facilities have closed because they lack fuel and electricity. Read full story Source: The Washington Post, 19 October 2023
  20. Content Article
    Research clearly demonstrates that from conception onwards, rapid brain development influences the cognitive, emotional and social development of babies and young children. Pre-conception to five years is an important time in a child’s life and critical for brain and psychological development, the formation of enduring relationship patterns, and emotional, social and cognitive functioning – all of which are foundations for healthy development, but which can also confer protection against mental health conditions. The establishment of sensitive, attuned and responsive relationships is essential for positive mental health and wellbeing and underpins interventions to address problems in social and emotional development, poor mental health and mental health conditions in under 5s. This report by the Royal College of Psychiatrists (RCPsych) aims to outline the importance of mental health in babies and young children under 5 to policy makers, commissioner and healthcare practitioners.
  21. News Article
    More support is needed to prevent babies and young children developing mental health problems in later life, leading doctors say. Their report shows there is growing evidence that intervening very early on - from conception to the age of five - may help stop conditions arising or worsening. The Royal College of Psychiatrists is calling for more specialist services. The government says the mental health of children and parents is paramount. Officials say they are investing more in expanding NHS services, alongside funding programmes designed to support children and caregivers. NHS data shows about 5% of two to four-year-olds struggle with anxiety, behavioural disorders and neurodevelopmental conditions including ADHD. The Royal College of Psychiatrists' report suggests half of mental health conditions arise by the age of 14, and many start to develop in the first years of life, making early action "vital". Dr Trudi Seneviratne, from the Royal College of Psychiatrists (RCPsych), said the majority of under-fives with mental health conditions were not receiving the level of support needed "to help them become productive, functioning adults and reach their full potential. The period from conception to five is essential in securing the healthy development of children into adulthood. Unfortunately, these years are often not given the importance they should be, and many people are unaware of what signs they should be looking out for. Parents, carers and society as a whole have a critical role to play. This includes securing positive relationships and a nurturing environment that supports the building blocks of a child's social, emotional and cognitive development." Read the RCPsych report Infant and early childhood mental health: the case for action Read full story Source: BBC News, 21 October 2023
  22. News Article
    A mother of two prescribed antidepressants after complaining of fatigue was devastated when she learned she had stage four bowel cancer and had just nine months to live. Helen Canning complained of anaemia and low energy for more than a year, but as a 37-year-old with two children under the age of five, her symptoms were put down to prolonged postnatal depression and work stress. “At the end of the school day, I’d sit at my desk and lose half an hour of my time just sitting and staring,” the A-level science teacher from Suffolk said. “I was so tired. Then I would get even more stressed because I was getting behind on my work.” She went to the GP because she was concerned about her symptoms. Despite being told her iron was low, she said she was never offered a blood test to investigate this further. As well as prescribing antidepressants, the GP referred her to a gynaecologist for an ultrasound scan on her left side in December 2020, but the scan did not detect anything. But less than a year later in August 2021, she was diagnosed with bowel cancer after she was rushed into A&E with a “crippling, stabbing pain” and violent vomiting, the night before her ninth wedding anniversary. She was told she had advanced colorectal cancer, a primary tumour in the right side of her colon, with secondary growths on her ovaries, liver, and peritoneum. Though Mrs Canning was given only nine months to live after her diagnosis, the mother of two leaned on her family for strength as she started chemotherapy. It has now been over two years and she continues to fight. Now she is determined to raise awareness of the common signs and symptoms of bowel cancer, and urges people to “know their own ‘normal’ and not be afraid to keep pushing for further testing and answers when doctors don’t”. Read full story Source: Independent, 22 October 2023
  23. News Article
    Eighteen more hospitals in England contain potentially crumbling concrete, bring the total affected to 42, the Department of Health has confirmed. The reinforced autoclaved aerated concrete (Raac) has also been found in 214 schools and colleges in England as well as thousands of other buildings. NHS Providers, which represents hospitals, said the concrete "puts patients and staff at risk". Full structural surveys are taking place at all newly confirmed sites. The government said it was committed to eradicating Raac from NHS buildings completely by 2035. Seven of the worst-affected hospitals will be replaced by 2030 as part of the programme to build 40 new hospitals in England, it added. Sir Julian Hartley, chief executive of NHS Providers, said there had been fears that more of the material would be found following surveys of NHS buildings. "Trusts are doing everything they can, at huge cost, to keep patients safe where this concrete is found," he said. Read full story Source: BBC News, 21 October 2023
  24. Content Article
    World Patients Alliance is the umbrella organisation of patients and patients’ organisations around the globe. They seek to ensure that all patients have access to safe, high quality, and affordable healthcare everywhere in the world. These videos produced by World Patients Alliance provide information for patients on the following topics: How do you talk to your healthcare provider? An introduction to medication safety How many medications are too many?
  25. Content Article
    This report by the Nuffield Trust looks at workforce training issues in England, arguing that the domestic training pipeline for clinical careers has been unfit for purpose for many years. It presents research that highlights leaks across the training pathway, from students dropping out of university, to graduates pursuing careers outside the profession they trained in and outside public services. Alongside high numbers of doctors, nurses and other clinicians leaving the NHS early in their careers, this is contributing to publicly funded health and social care services being understaffed and under strain. It is also failing to deliver value for money for the huge taxpayer investment in education and training.
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