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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Bowtie is a visual tool which effectively depicts risk, providing an opportunity to identify and assess the key safety barriers either in place or the ones lacking, between a safety event and an unsafe outcome. This guidance from the UK Civil Aviation Authority outlines how the bowtie model works and how to use it.
  2. Event
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    This session is aimed at understanding what causes burnout, the impact and how to prevent/overcome it. Listening to stories from 2 Doctors and understanding the emotions, impact and consequence of burnout can help others look out for the signs and try to prevent it. Through talking and opening up, we hope to raise the awareness of burnout. It is real, can cause trauma and is linked to our wellbeing needs in the workplace. Guest speakers are: Dr Jess Morgan, Paediatrician Dr Chris Healey, Gastroenterologist Please join this session to learn from each other, listen and talk about wellbeing needs in the workplace. This is an open session to everyone, it will be healthcare based but is transferable. It is a free space and a social movement that has one agenda: To help staff flourish in the workplace. Sign up for the session. Joining instructions for this virtual event will be emailed directly to you closer to the date The basic needs at work campaign is based on research and simple QI methodology to address basic needs. It doesn't need to be complicated, but it does need to stick! The Basic Needs at Work resources can be found here
  3. Event
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    The Improvement Culture Club has 4 pillars that underpin it: 1. Creativity 2. Kindness 3. Empowerment 4.Knowledge This session will explore how can we "think" without limits, explore the art of possibilities and stop doing the same thing again and again?. Creativity breaks down boundaries, connects with your imagination and transcends traditional thinking. The first session looks at creativity in healthcare. It will cover: What is creative thinking? How to be a creative thinker and the mindset What are the barriers to being creative in healthcare What are benefits of creative thinking in healthcare This will be an interactive session with opportunities for you to share ideas, learning and suggestions. It is open to everyone. The Improvement culture club is aiming to understand the conditions and approaches needed to really shift organisational culture to be "ready" to support staff to carry out improvement. Staff are busy, tired and burnt-out, finding the motivation and time to carry out improvement requires a shift in approach. The Event is hosted with the Q Community. Please note, MSTeams link to the event will be shared with you closer to the date. Sign up for the webinar
  4. Content Article
    In this opinion piece, BMJ journalist Clare Dyer examines how the healthcare system is grappling with the question of how Lucy Letby was allowed to get away with killing babies in plain sight for so long. She looks at culture and governance issues that meant that concerns raised by consultants were not appropriately acted on.
  5. Content Article
    On 4 September 2023, England’s health and social care secretary Steve Barclay announced that the government was considering introducing 'Martha’s rule', requiring NHS hospitals to give quick access to a second clinical opinion in urgent cases. In this article, Clare Dyer of the BMJ looks at how the introduction of a formal system to allow patients or families the right to demand an urgent second opinion will affect doctors.
  6. Content Article
    This editorial in the HSJ outlines the financial issues facing Integrated Care Systems (ICS) in England, drawing attention to deficits reported in Greater Manchester, West Yorkshire and East London. HSJ Deputy Editor Dave West highlights that neither the Government nor the opposition are keen to signal new funding adequate to deal with these funding gaps.
  7. 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 key insights from the Manchester ICS Delivery Forum event held on 25 May 2023. The document places these discussions into the broader context of health and care transformation, both at a local and national level, so wider sources and research are used to expand upon the key points. It looks at the following aspects of integration in Manchester: Community engagement Working with VCSE organisations Governance
  8. Content Article
    This is the tenth MBRRACE-UK annual report and details the care of 572 women who died during pregnancy, or up to one year after pregnancy between 2019 and 2021 in the UK. The report also includes confidential enquiries into the care of women who died between 2019-2021 in the UK and Ireland from haemorrhage, amniotic fluid embolism, anaesthetic causes, sepsis, general medical and surgical disorders, epilepsy and stroke. By global standards, giving birth in the UK is safe, but the data reported this year should be taken as a warning signal concerning the state of maternity services and the consequences of increasing inequalities and social complexities. While Covid-19 is a significant feature of the deaths reported this year, the pandemic must not distract from wider trends. The Government’s ambition in England was to reduce maternal mortality by 50% between 2010-2025. This target is unlikely to be met. Since 2009-11, maternal mortality has increased by 15%. Crucially, the figures detailed in this report are from before the cost-of-living crisis of 2022-23. When the deaths due to Covid-19 are excluded, maternal death rates are very similar to those in 2016. There is concern that we risk losing the gains made in previous decades. Downloads Lay summary Full report Infographics Themed Surveillance Report Themed Maternal Morbidity Report Themed Maternal Mortality Report
  9. Content Article
    Monitoring and responding to deterioration in social care settings is critical to providing safe, effective and responsive care. Front-line staff are pivotal for highlighting change to wider teams and managing low to medium risk individuals in their place of residence. However, there is a core set of principles that most systems use which may not be used by non-clinical staff in residential settings. This case study explores an intervention to empower non-clinical staff to take observations. The Whzan blue box contains a digital tablet and equipment to take temperature, pulse, oxygen saturation levels and blood pressure measurements. Staff were trained and supported on site to use the system and set up a digital platform to share measurements with wider teams. Staff fed back that they felt empowered and able to better engage in conversation with health care professionals, highlighting the importance of having a common language. This case study was submitted to the Care Quality Commission (CQC) by North East and North Cumbria ICB.
  10. Content Article
    HPV is a common infection that is spread by skin-to-skin contact, including sexual contact, which can lead to the development of cancers affecting both women and men, including cancers of the cervix, vulva, vagina, penis, anus, and oral cavity. In England, young people aged 12 to 13 years are offered immunisation against HPV as part of the NHS vaccination programme. Research has shown that in England cervical cancer has almost been eliminated among young women who were offered the HPV vaccine. However, research by the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol has identified sustained inequalities in uptake by area and minority ethnic groups. It has also identified unmet information needs among young people in schools where vaccination uptake is low, with implications for obtaining consent and vaccination uptake. This web page contains a number of information videos to address information needs about HPV among young people. They were coproduced with young people from disadvantaged backgrounds and diverse ethnic groups.
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    The Maternity Consortium is hosting a free virtual event sharing examples of good practice from Local Maternity and Neonatal Systems (LMNS) working in partnership with Voluntary Community and Social Enterprise (VCSE) organisations and Maternity and Neonatal Voices Partnerships (MNVPs) to implement their equity and equality plans. The event will also include a national update on the equity and equality plans from NHS England and an opportunity to network with colleagues in breakout rooms. Who should attend? The event is open to anyone working in the maternity and neonatal space, including in LMNSs, Trusts, regions, specialist perinatal/maternal mental health services, the VCSE sector, local authorities, MNVPs, service user voice representative roles, other frontline services, and academia. Agenda Introduction from the Maternity Consortium Presentation from NHS England Presentation from North East and North Cumbria LMNS Presentation from Suffolk and North East Essex LMNS Breakout rooms About the Maternity Consortium Tommy’s and Sands are co-leading the Maternity Consortium as members of the VCSE Health and Wellbeing Alliance. The Maternity Consortium includes: National Maternity Voices, Pregnancy and Baby Charities Network, Five X More, Muslim Women’s Network UK and LGBT Mummies. The Maternity Consortium's aim is to use our collective expertise to join up national and local voices behind a common agenda: to reduce health inequalities for families throughout the whole pregnancy journey from pre-conception and through the first year of a baby’s life. Contact: Celeste Pergolizzi, Maternity Consortium Coordinator and Engagement Lead, celeste.pergolizzi@sands.org.uk Sign up for the event
  12. Content Article
    Orchard Care Homes had noticed high numbers of antipsychotic medicines being prescribed to people living with dementia. There appeared to be little consideration of why these people were distressed and communicating this through behaviour. Orchard staff were convinced pain was a key factor in these distress responses—they were not necessarily because the person had a diagnosis of dementia. Orchard adopted PainChek, a digital pain assessment tool, in 2021 to support their dementia promise framework. They worked with the PainChek team and ran a pilot with the app. They were one of the first care providers to use this solution in the UK. It was originally launched it in one of their specialist dementia care communities, but is now in all 23 Orchard homes. Since the rollout of the app, there has been an increase in available pain relief and a decrease in conflict-related safeguarding referrals. There is increased time available for colleagues and a reduction in polypharmacy. There has been a 10% decrease in antipsychotic medicine use across all 23 homes, promoting a greater quality of life. People now have effective pain management plans. Orchard have also been able to ensure distress plans are in place which firstly considers if pain is the cause of distress. This case study was submitted to the Care Quality Commission's (CQC's) Capturing innovation to accelerate improvement project by Orchard Care Homes.
  13. Content Article
    World Hospice and Palliative Care Day takes place on 14 October 2023.  Patient safety in hospice and palliative care involves ensuring that every patient is able to access the services, support and pain relief that they need when they reach the end of life. It is also vital that families and carers are given relevant and timely support and information by healthcare services during their loved one’s hospice or palliative care, and following their death.
  14. Content Article
    Healthcare services regularly receive patient feedback, most of which is positive. Empirical studies suggest that health services can use positive feedback to create patient benefit. This study in Plos One aimed to map all available empirical evidence for how positive patient feedback creates change in healthcare settings. The researchers included 68 papers describing research conducted across six continents, with qualitative (n = 51), quantitative (n = 10), and mixed (n = 7) methods. Only two studies were interventional. Most outcomes described were desirable. These were categorised as: short-term emotional change for healthcare workers (including feeling motivated and improved psychological wellbeing) work-home interactional change for healthcare workers (such as improved home-life relationships) work-related change for healthcare workers (such as improved performance and staff retention). Some undesirable outcomes were described, including envy when not receiving positive feedback. The impact of feedback may be moderated by characteristics of particular healthcare roles, such as night shift workers having less interaction time with patients. The researchers called for further interventional research to assess the effectiveness and cost-effectiveness of receiving positive feedback in creating specific forms of change such as increases in staff retention. They also suggest that healthcare managers may wish to use positive feedback more regularly, and to address barriers to staff receiving feedback.
  15. Content Article
    Sometimes groups of patients who may not engage easily with healthcare services are labelled 'hard to reach'. This graphic by artist Sonia Sparkles highlights that there are barriers in healthcare that can prevent different groups accessing services—ranging from physical access needs to lack of cultural appreciation. These barriers are often created by healthcare staff and organisations who, when designing services, fail to consider the diverse nature of the population their services are for. A wide range of graphics relating to patient safety, healthcare and quality improvement is available on the Sonia Sparkles website.
  16. Content Article
    In this article for the Journal of Patient Safety, Alan Card from the Department of Pediatrics at the University of California, argues that the purpose of patient safety work is to reduce avoidable patient harm, and this requires us to slay dragons—to eliminate or at least mitigate risks to patients. He expresses the view that current practice focuses almost exclusively on investigating dragons—tracking reports on the number and type of dragons that appear, how many villagers they eat and where, whether they live in caves or forests and so on. He argues that while information about risks is useful to the extent that it informs effective action, it does nothing to make patients safer by itself: "We cannot investigate a dragon to death. No more can we risk assess our way to safer care."
  17. Content Article
    In this interview, Derek Feeley, IHI President Emeritus and Senior Fellow shares the work of the Health Improvement Alliance Europe (HIAE) workgroup related to curiosity. He outlines five simple rules linked to complexity theory, which states that if you are trying to make sense of a complex situation, you should create simple, order-generating rules. The five simple rules are: Ask rather than tell. Listen to understand rather than to respond. Hear every voice rather than only those easiest to hear.  Prioritise problem framing rather than problem solving. Treat vulnerability as a strength rather than a weakness.
  18. Content Article
    The Worldwide Hospice and Palliative Care Alliance (WHPCA) is an international non-governmental organisation focusing exclusively on hospice and palliative care development worldwide. With over 100 members worldwide, it's mission is to bring together the global palliative care community to improve well-being and reduce unnecessary suffering for those in need of palliative care in collaboration with the regional and national hospice and palliative care organisations and other partners. The WHPCA website hosts a wide variety of resources relating to hospice and palliative care including: Advocacy resources Building Integrated Palliative Care Programs and Services Country reports and needs assessments Covid-19 Resources Disease specific plans and guidance Fundraising resources Global Atlas of Palliative Care at the End of Life Laws, regulations and national strategies Media resources National association strategic plans Palliative Care Toolkits and Training Manual Standards, clinical guidelines and protocols UN guidelines, documents and strategies on palliative care Universal Health Coverage Resources WHPCA position statements WHPCA publications and reports
  19. Content Article
    Lewis Chilcott was 23 years old when he died at Royal Sussex County Hospital in Brighton. In this blog, his father Simon describes what happened to Lewis and how his family was treated by the hospital following Lewis’s death. Simon continues to call for greater transparency in the investigation process and improvements to the way hospitals engage with bereaved families.
  20. Content Article
    For many years the NHS has talked about the need to shift to a more personalised approach to health and care—where people have choice and control over the way their care is planned and delivered, based on “what matters” to them and their individual strengths, needs and preferences. In this HSJ article, Ben Wilson, product solution director at Orion Health, discusses the progress, benefits and future possibilities for an integrated, patient-centric healthcare system.
  21. Content Article
    The Covid-19 pandemic had an adverse impact on the detection and management of cardiovascular disease (CVD) risk factors including hypertension. In June 2022, nearly two million fewer people with hypertension were recorded as being treated to target, compared with the previous year. As a result, NHS England commissioned the AHSN Network to deliver a new national Blood Pressure Optimisation (BPO) programme building on its portfolio of work around cardiovascular disease. This report lays out: evidence about the impact of the BPO programme how it has been received by frontline staff how it has been implemented nationally.
  22. 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. Ashley talks to us about the need to professionalise patient safety roles while also upskilling frontline healthcare staff to improve patient safety, describing the role that professional coaching can play. He also discusses the challenges we face in understanding how AI affects decision making in healthcare and how it could contribute to patient safety incidents.
  23. Content Article
    This joint manifesto has been produced by the charities Sue Ryder, Marie Curie, Together for Short Lives, National Bereavement Alliance and Hospice UK. Ahead of the next General Election, they are calling upon all political parties and candidates to commit to policies that ensure everyone affected by dying, death and bereavement receives the best possible care and support, both now and in the future. The manifesto calls for the new Government to: Deliver a new funding solution for hospices and palliative and end of life care to end the postcode lottery in access Introduce a national delivery plan for palliative and end of life are in every nation to support delivery of local services Guarantee that palliative and end of life care services meet each individual’s needs, including those of people dying at home Act to ensure that nobody dies in poverty and tackle inequalities in palliative and end of life care Improve support for families and carers of people with a terminal illness
  24. Content Article
    Doctors are dying by suicide at higher rates than the general population—somewhere between 300 to 400 physicians a year in the US take their own lives. This article in The Guardian looks at why so many surgeons are dying to suicide and what can be done to stop the trend. It examines how the culture of working long hours and the expectation to be 'superhuman' leads surgeons to suppress their symptoms and avoid seeking help for mental health issues. The article also tells the story of US surgeon and President of the Association of Academic Surgery Carrie Cunningham, who has lived with depression, anxiety and a substance abuse disorder for many years.
  25. Content Article
    This infographic by artist Sonia Sparkles highlights ways to prevent patient falls in hospital. A wide range of graphics relating to patient safety, healthcare and quality improvement is available on the Sonia Sparkles website.
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