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Patient-Safety-Learning

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  1. Content Article Comment
    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/
  2. 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.
  3. Content Article
    Good 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.
  4. Content Article
    The 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.
  5. Content Article
    These 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
  6. News Article
    Pregnant 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
  7. Event
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    The 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
  8. Content Article
    During 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.
  9. Content Article
    In 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.
  10. 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. 
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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
  18. 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.
  19. 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’.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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
  25. 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
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