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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Hampshire and Isle of Wight Integrated Care System (ICS) has achieved great results in supporting access to the NHS Diabetes Prevention Programme. This case study outlines the approach taken by the ICS to improve access, what the outcomes were and key lessons learned.
  2. Content Article
    Coroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending ‘Reports to Prevent Future Deaths’ (PFDs) to interested persons. This systematic review in Pharmaceutical Medicine aimed to establish whether Coroners’ concerns about medications are widely recognised. The authors found that PFDs related to medicines are not widely referred to in medical journals or UK national newspapers. By contrast, the Australian and New Zealand National Coronial Information System has contributed cases to 206 publications cited in PubMed, of which 139 are related to medicines. The research suggests that information from English and Welsh Coroners’ PFDs is under-recognised, even though it should inform public health. The results of inquiries by Coroners and medical examiners worldwide into potentially preventable deaths involving medicines should be used to strengthen the safety of medicines.
  3. Event
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    The Cancer Care Conference will be a culmination of Public Policy Projects' year-long programme to develop the Cancer Care Delivery Plan, and will feature a broad range of high-level speakers who are key players in cancer care policy and delivery. This full-day in-person conference in London will give you a unique opportunity to take part in conversations that will shape a broad range of healthcare policy that aims to improve delivery of cancer care. The Conference will also feature delegates from NHS England, NHS trusts, cancer specialists, academics, patient advocacy groups and leading industry partners, providing a space to network and develop relations that can enable substantive improvements in cancer care. Key topics Improving prevention, screening and treatment practices Addressing inequalities in access and outcomes Delivering personalised care and precision medicine Effectively utilising technology and data to improve care Addressing workforce and resource challenges Register for the conference
  4. Content Article
    This article looks at why health journalists should be more thorough in their approach to covering news relating to diagnostic errors. Leading researchers suggest that health care providers have done little to address the problem of diagnostic errors since a seminal report was released by the Institute of Medicine in 2015 describing the widespread harms from missed and delayed diagnoses. The article looks at the issues relating to diagnosis and highlights the importance of journalists reporting on solutions as well as stories of harm. It also focuses on how health journalism can play a key role in holding healthcare organisations to account.
  5. Content Article
    When many people think about NHS services they often think about clinical staff, such as doctors or nurses, and how they deliver care and interact with patients and families. However, in the context of patient safety, there is often more to see ‘behind-the-scenes’ in non-patient facing services. These services may be less visible, but they play a vital part in ensuring patient safety. Understanding the importance of these services, and how they are crucial to the ability of the NHS to operate effectively, is often underestimated. In this blog for the Healthcare Safety Investigation Branch (HSIB), National Investigators Russ Evans and Craig Hadley highlight how 'behind-the-scenes' services are crucial to help the NHS operate effectively and safely.
  6. Content Article
    This report by the Royal College of Midwives (RCM) highlights the impact of midwifery staffing shortages on women. It looks at historical failures to invest appropriately in maternity services and talks about a mounting maternity crisis, drawing attention to Care Quality Commission inspections of maternity services that are identifying concerns around safety directly linked to staffing shortages. According to the report’s findings, if the number of NHS midwives in England had risen at the same pace as the overall health service workforce since the last general election, there would be no midwife shortage; there would be 3,100 more midwives in the NHS, rather than having a shortfall of 2,500 full-time midwives. The RCM published the results of a survey last month which showed that midwives give 100,000 hours of free labour to the NHS per week to ensure safe care for women. It also showed that staffing levels were repeatedly cited as cause for concern around the safety of care, and that midwives and maternity support workers are exhausted and burnt out.
  7. Event
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    The NHS long term plan (LTP) builds on the commitments for mental health services set out in the five-year forward view for mental health (FYFVMH), emphasising collaboration and the use of digital innovations to deliver more personalised and streamlined care. The mental health implementation plan 2019/20-2023/24 provides a framework to support the delivery of these commitments locally, and sets out a combination of fixed, flexible and targeted approaches, with core national targets supported by flexibility for local systems to agree how best to deliver services. To support the ambitions within the Plan, the NHS has made a renewed commitment that funding for mental health services will grow faster than the overall NHS budget, creating a new ringfenced local investment fund worth at least £2.3 billion a year by 2023/24. In 2022 the Government issued a call for evidence to inform a new, 10-year cross-government Mental health and wellbeing plan. In January 2023 the Government announced it will publish a Major Conditions Strategy that will include mental health. The Government has said a joined up strategy will ensure that mental health conditions are considered alongside physical health conditions. The GovConnect Mental Health annual conference is committed to providing learning and solutions which improve mental health and wellbeing outcomes, particularly for people who experience worse outcomes than the general population. This is a key part of our Governments commitment to ‘level up’, and address unequal outcomes and life chances across the country. The government has committed to develop a new cross-government, 10-year plan for mental health and wellbeing for England to support this objective. Mental Health 2023 – Delivering Collaborative Whole Pathways of Care. Will give attendees the opportunity to engage with key personnel from delivery partners and national stakeholder organisations, providing an assessment of FYFVMH transition to LTP planning and delivery progress, addressing the 13 core areas of mental health services provision set out in the implementation plan, including child and adolescent mental health, maternal mental health services, the mental health of older people, and care for people with serious mental illness. Along with learning and interactive debate on: How can we improve the quality and effectiveness of treatment for mental health conditions? How can we all support people living with mental health conditions to live well? How can we improve the quality and effectiveness of treatment for mental health conditions? How can we all improve support for people in crisis? How can we all intervene earlier when people need support with their mental health? We invite all organisations and individuals from all NHS settings, Local authorities, independent and VCSE sectors and private providers to join us at the Royal Society of Medicine, London. Register for the conference
  8. Content Article
    The UK government’s long-awaited NHS workforce plan for England outlines a vision to increase the number of nursing staff in England over the next 15 years, with a promise of 170,000 more nurses by 2036/37. This article from the Royal College of Nursing (RCN) outlines how the detail of the plan will affect nurses. It argues that the plan fails to acknowledge the financial investment needed if its objectives are to be fulfilled, and expresses the RCN's concern that it does not address financial support for student nurses.
  9. Content Article
    In this blog post, Kath Sansom, founder of the Sling the Mesh campaign, looks at the issue of payments being made to doctors and lobby groups by pharma and medical tech companies. She argues that these payments are a patient safety concern as it can lead to doctors displaying bias in advising treatments, with benefits being overstated and risks downplayed. This is especially concerning when industry money is given to consultants or researchers trialling new treatments. Kath highlights an investigation carried out by the Observer into the issue and explains why Sling the Mesh have lobbied the UK Government for a UK Sunshine style payment act, which would allow the public to look up the names of doctors, surgeons and researchers to see if they have taken money from industry.
  10. Content Article
    Co-production is a way of working that involves those who use health and care services, carers and communities, in equal partnership. It engages groups of people at the earliest stages of service design, development and evaluation. Co-production acknowledges that people with lived experience of a particular condition are often best placed to advise on what support and services will make a positive difference to their lives. In this blog post, Helen Lee from NHS England's Experience of Care Co-production Programme talks about work her team has been doing to put co-production at the centre of quality improvement, including the launch of a new suite of materials. These resources aim to encourage professionals and leaders to expect to hear a range of experiences and be curious and open minded to these views.
  11. Content Article
    The aim of the NHS Safety Thermometer is to provide a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free care’. Data is collected by Trusts on pressure ulcers, falls, urinary tract infections (UTI), and Venous Thromboembolism (VTE) assessments, prophylaxis and treatment. The North East Quality Observatory Service (NEQOS) Safety Thermometer Tool allows trusts to compare themselves against their peers (for improvement purposes) as well as to undertake internal comparisons across different service areas within the Trust. Produced quarterly, the tool uses National Safety Thermometer data published by NHS Digital and presents this by Trust across the North East & North Cumbria (NENC) area, providing comparisons between peers as well as with the national average, with breakdowns by service areas for detailed analysis.
  12. Content Article
    Understanding of the significance of psychological safety has grown over recent years as we see the implications of people not speaking out—a culture that forces people to conceal rather than reveal. Concealing observations, ideas and thoughts can lead to major events that are harmful to organisations as much as individuals. Sometimes, individuals feel it is imperative to speak out somewhere, which leads to whistleblowing. This article looks at how to identify whether a workplace has a psychologically safe culture and how to transform cultures where staff don't feel able to speak up. It describes The Wellbeing and Performance Agenda, which contains six elements for building psychological safety: Transforming managers into leaders Psychological responsibility Sharing responsibility for the future success of the organisation Adaptive and positive culture Intelligent management Safe and resilient individuals
  13. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Martin talks to us about the role of Professional Nurse Advocates (PNAs) in improving patient safety through restorative clinical supervision for nurses. He also talks about the need to recognise the close relationship between staff safety and patient safety, and the impact that long waiting lists and limited NHS capacity are currently having.
  14. Content Article
    This toolkit summarises good practice for Integrated Care Boards (ICBs) and primary care commissioners and providers regarding the provision of primary care services for people seeking asylum who are living in initial and contingency accommodation. It aims to ensure equality in access to services and improved long-term health outcomes for residents in Home Office accommodation, minimising health inequalities and encouraging collaborative working with accommodation providers and other local stakeholders.
  15. Content Article
    The major conditions strategy is a national framework being developed by the Department of Health and Social Care (DHSC) and the Office for Health Improvement and Disparities (OHID). It will focus on six major groups of conditions: cancers cardiovascular diseases, including stroke and diabetes chronic respiratory diseases dementia mental ill health musculoskeletal disorders This briefing by NHS Confederation examines how the upcoming major conditions strategy can set the conditions to prevent, treat and manage multimorbidity in England.
  16. Event
    This joint conference hosted by The Mental Health – Time for Action Foundation and Safely Held Spaces is aimed at stimulating discussion and promoting change in the way mental health services view the role of the family in the therapeutic process. Going beyond the “carer-patient” model, the conference brings into focus the broader perspective that mental health is not just an individual concern but involves the whole family system. Recognising the importance of the family system’s wellbeing promotes a more holistic approach to mental health. Our objective is to foster an environment for learning and discussion about the latest evidence-based practices across the NHS and third sector organisations. The conference will encompass a series of talks, workshops, and interactive panel discussions. You will have the opportunity to engage with a network of families experiencing mental distress, paving the way for collaborative efforts.
  17. Content Article
    In this video, Chief Digital Officer Clive Flashman talks about the hub as a patient safety innovation as part of Patient Safety Learning's entry to the Digital Health Hub Foundation Digital Health Awards 2023.
  18. Content Article
    The NHS Long Term Workforce Plan 2023 is crucial to the long term sustainability of the health service. The National Centre for Rural Health and Care is concerned that the plan has not been 'rural proofed' and makes very few references to rural issues. They are preparing a response and are looking for views about the plan through this survey. The closing date for responses is 4 August 2023.
  19. Content Article
    Investigations suggest that, in some fields, at least one-quarter of clinical trials might be problematic or even entirely made up. This article in Nature looks at the findings of researchers who have been studying clinical trials and calling for greater regulatory scrutiny. It particularly examines the work of John Carlisle, NHS anaesthetist and editor at the journal Anaesthesia, who scrutinised over 500 studies with randomised controlled trials, over a period of three years. Carlisle found that 26% of the papers had problems that were so widespread that the trial was impossible to trust, either because the authors were incompetent or because they had faked the data. He called these ‘zombie’ trials because they had the semblance of real research, but closer scrutiny showed they were masquerading as reliable information.
  20. Content Article
    In 2020, the Independent Medicines and Medical Devices Safety Review (IMMDS), chaired by Baroness Cumberlege, highlighted the avoidable harm caused by both pelvic and sodium valproate. It also set out the devastating impact on people’s lives when patients’ voices go unheard. The Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner (PSC) to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. The work will focus on what a suitable redress scheme for those affected should look like, to meet the needs of those affected. The PSC will publish a public report of this work. Once the project is complete, the Government will consider the report and set out next steps. The project will engage with patients through: meeting patients and their representative organisations. an online survey to gather views, which will be launched in due course.
  21. Content Article
    In this video, Chris tells his story of how he dealt with a traumatic childhood and subsequent diagnosis of schizophrenia. He talks about the medication and therapy that have helped him. Warning: The film does contain references to distressing themes.
  22. Community Post
    Thanks so much for sharing your experience with us. I'm so sorry that you are still having jaw issues and have been unable to get the support you need from your orthodontist, and hope you are able to get some answers soon
  23. Community Post
    Thank you for sharing your experience, and for raising some important questions around informed consent and the use of cosmetic procedures in children. Was your experience in the UK, and if so, was it a private or NHS orthodontist you saw?
  24. Content Article
    The New Zealand Ministry of Health has released its first Women’s Health Strategy, which sets the direction for improving the health and wellbeing of women over the next 10 years. It outlines long-term priorities which will guide health system progress towards equity and healthy futures for women.  The vision of the strategy is pae ora (healthy futures) for women. All women will: live longer in good health have improved wellbeing and quality of life be part of healthy, and resilient whānau and communities, within healthy environments that sustain their health and wellbeing.  A key priority is equitable health outcomes for wāhine Māori, a commitment under Te Tiriti o Waitangi (The Treaty of Waitangi). The strategy also aims to help achieve equity of health outcomes between men and women, and between all groups of women.
  25. Content Article
    The UK Covid-19 Inquiry is the independent public inquiry set up to examine the UK’s response to and impact of the Covid-19 pandemic, and learn lessons for the future. In order to fully understand the impact of the pandemic on the UK population, the Inquiry is inviting the public to share their experiences of the pandemic by launching Every Story Matters. It will inform the Inquiry’s work by gathering pandemic experiences which can be brought together and represent the whole of the UK, including those seldom heard. The output of Every Story Matters will be a unique, comprehensive account of the UK population’s experiences of the pandemic, to be submitted to the Inquiry’s legal process as evidence. This toolkit contains information and creative assets that can be used to encourage participation in Every Story Matters. Every Story Matters aims to provide inclusive methods for people to talk about their experience of the pandemic, so anyone that wants to share their story feels heard, valued, and can contribute to the Inquiry.
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