Patient-Safety-Learning
PSL ModeratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleFood allergy affects around 7-8% of children worldwide, or about two children in an average-sized classroom. As children spend at least 20% of their waking hours in school, it is not surprising that data show that 18% of food allergy reactions and 25% of first-time anaphylactic reactions occur at school. This report by the Benedict Blythe Foundations looks at the prevalence and seriousness of allergies in school-aged children, and the devastating consequences when things go wrong at school.
-
Content ArticleThis webpage explains the approach of the Parliamentary and Health Service Ombudsman (PHSO) to financial remedy relating to complaints against organisations. Where someone believes they have experienced an injustice or hardship because an organisation has not acted properly, or has given a poor service and not put things right, PHSO makes recommendations on the amount of compensation based on its severity of injustice scale. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts the PHSO would usually recommend in those circumstances.
-
Content ArticleIn this report, Professor Brian Edwards summarises contributions given to the UK Covid-19 Inquiry by various politicians and senior civil servants, relating to how prepared the UK and Scottish Governments were for the Covid-19 pandemic. It contains reflections on the contributions of: Nicola Sturgeon (First Minister of Scotland during the pandemic) Matt Hancock (Secretary of State for Health and Social Care during the pandemic) Jenny Harries (Chief Executive of the UK Health Security Agency) Emma Reed (civil servant, DHSC)
-
Content ArticleWidening health inequities are leading to decreasing trust in institutions, reinforcing social fractures and leaving excluded communities further behind. Narrowing the health gap made worse by the pandemic is not only a matter of social justice, but essential to build trust, social cohesion and economic resilience. This report by the World Health Organization (WHO) explores the interrelationships between health, the economy and social capital. It examines how governments can work to build social cohesion and invest in people’s health to improve resilience and promote an equitable recovery. It outlines five solutions to reach those who are affected the most by health inequalities: those who live precarious, marginalised lives.
-
Content ArticleThere are an estimated 363,000 adults experiencing multiple disadvantage in England—they may be experiencing a combination of homelessness, substance misuse, mental health issues, domestic abuse and contact with the criminal justice system. The Changing Futures programme works in partnership in local areas and across government to test innovative approaches and drive lasting change across the whole system, in order to provide better outcomes for adults experiencing multiple disadvantage. This prospectus provides information for partnerships interested in submitting an expressions of interest to be part of the Changing Futures programme.
-
Content ArticleThe Digital Medicines Transformation Portfolio aims to use digital technologies to make prescribing, dispensing and administering medicines everywhere in Wales, easier, safer and more efficient for patients and professionals. It brings together the programmes and projects that will deliver a fully digital prescribing approach in all care settings in Wales. This video outlines the different elements of the portfolio that will be introduced across primary and secondary care, including the Shared Medicines Record, which will store information about a patient's medications all in one place.
-
Content ArticleGenerative AI is being heralded in the medical field for its potential to ease the burden of medical documentation by generating visit notes, treatment codes and medical summaries. Doctors and patients might also turn to generative AI to answer medical questions about symptoms, treatment recommendations or potential diagnoses. This article in JAMA Network looks at the liability implications of using AI to generate health information, highlighting that no court in the US has yet considered the question of liability for medical injuries caused by relying on AI-generated information.
-
Content ArticleIn this article, The King's Fund Chief Executive Richard Murray argues that if the NHS Workforce Plan manages to do the things it says it will do, the NHS could start to overcome the repeated workforce crises that have periodically plagued it over the past 75 years. He highlights that the plan sets out forecasts of future supply and demand for staff, with explanations of how these figures were derived, and that the `action’ it sets out encompasses everyone working in health including those in government.
-
Content ArticleAs the NHS turns 75, the Chief Executives of The Health Foundation, Nuffield Trust and The King’s Fund have written to the leaders of the three largest political parties in England, calling on them to make the upcoming general election a decisive break point by ending years of short termism in NHS policy-making. The joint letter highlights four key areas where long-term policies coupled with considered investment would help chart a path back to a stronger health service: Invest in the physical resources the NHS needs to do its job including equipment, beds, buildings and new technology. Deliver long overdue reform of adult social care Commit to a cross-government strategy over the course of the next parliament to improve the underlying social and economic conditions that shape the health of the nation Build on the recently published NHS long term workforce plan with sustained commitment to providing the resources it needs to succeed
-
Content ArticleNHS Resolution has launched its first eLearning module that focuses on learning from the significant avoidable harm that can occur during antenatal and postnatal care and is seen in the cases notified to its Early Notification Scheme. This free resource is designed to support clinicians working in maternity services. The module uses three illustrative case stories to immerse learners into the antenatal, intrapartum and postnatal care provided to mothers and the neonatal care provided to their babies. It aims to deepen learners' understanding of NHS Resolution’s role within the healthcare system, develop their understanding of the law of negligence as applied to clinical claims and explore how clinical decisions and actions can lead to avoidable harm. The module takes approximately two-and-a-half hours to complete and can be used as evidence of CPD hours undertaken for revalidation.
-
Content ArticleThis study looked at nursing within the UK and The Netherlands' health sectors, which are both highly regulated with policies to increase inclusiveness. It aimed to investigate the interplay between employment conditions and policy measures at sectoral level, in order to identify how these both facilitate and limit employment participation for disabled workers.
-
Content ArticleThe Safe Care at Home Review is an important reminder that people with care and support needs may experience abuse and neglect, sometimes under the guise of ‘care’. Older people, or people with disabilities, may be particularly vulnerable to harm because of their dependence on others and the complexity of their care needs. They might rely on other people for physical, mental or financial support, and may face difficulties recognising or reporting harm. The review draws on a range of evidence, including the Home Office funded Vulnerability Knowledge and Practice Programme, which has highlighted that one in six domestic homicides involved people who were cared for by, or caring for, the suspect.
-
Content ArticleGloucestershire Hospitals NHS Foundation Trust introduced a policy for reviewing deaths in 2017 based on the structured judgement review (SJR) methodology, which identified triggers for which deaths to review. To support implementation, the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource. This webpage and poster describe the quality improvement process and how these issues were overcome.
-
Content ArticleThis policy explains how the Structured Judgement Review (SJR) process is implemented within Maidstone and Tunbridge Wells NHS Trust. The policy advises staff on how to undertake a mortality case record review, which documentation to use, in which circumstances an SJR is required and how the new process relates to previous systems and processes. The policy also explains how the process links to revised mortality reporting, escalation of concerns and dissemination of learning. It covers all inpatients and Emergency Department patients who die whilst in the Trust’s care, and patients who die within 30 days of discharge.
-
Community PostWe want to hear from patients with experience of NHS and/or private orthodontists and dentists in any healthcare setting, including community practices and hospitals. Did the orthodontist/dentist give you the treatment and support you needed? If you had ongoing problems, how did the orthodontist/dentist and other healthcare professionals respond? Have you tried to make a complaint? You can read one patient's experience in this opinion piece: “I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment
- Posted
- 11 replies
-
1
-
-
Content ArticleThis easy-read guidance outlines what the Care Quality Commission (CQC) expects good care to look like for autistic people and people with a learning disability. It explains how the CQC aims to help health and adult social care services develop and run services that are right for the people they serve.
-
Content ArticleInvolvement activities enable people to influence and improve policies and services that affect their lives through activities such as focus groups, patient involvement forums and research studies. My Involvement Profile is a tool for lived experience experts to record and share their access needs when taking part in involvement activities in health and social care. My Involvement Profile has two parts: A personal information form to record your contact details and other experience you have A form to record your access and support requirements.
-
Content ArticleUS endocrinologist Richard Plotzker shares a recent experience of buying over-the-counter medication from a grocery store. When he opened the outer packaging, the blister packs were empty apart from one pill in each being resealed by scotch tape. Richard called the manufacturer and returned the medication for investigation. He describes how the incident highlights the need to be vigilant about any unusual appearance in the packaging of medication.
-
Content ArticleThis national data collection project has been commissioned by NHS England (NHSE) and is run by the NHS Benchmarking Network (NHSBN). The aim of the project is to understand the extent to which organisations are complying with the NHSE Learning Disability Improvement Standards, and to identify improvement opportunities. Compliance with these standards requires organisations to assure themselves that they have the necessary structures, processes, workforce and skills to deliver the outcomes that people with learning disabilities and their families and carers, expect and deserve. This project aims to collect data from a number of perspectives to understand the overall quality of care across Learning Disability services. Read summary reports from previous years of the NHS England Learning Disability Improvement Standards project.
-
Content ArticleWhat exactly is machine learning and how is it being used in healthcare? Are machines always better than a person? How do we know? In this interview, Patient Safety managing editor, Caitlyn Allen asks these questions of artificial intelligence healthcare researcher Dr Avishek Choudhury.
-
Content ArticleThis opinion piece in the Journal of Eating Disorders looks at the use of the diagnosis 'terminal anorexia' and its impact on people with anorexia nervosa, their families and the healthcare professionals working with them. Alykhan Asaria offers a lived-experience perspective on how the term may cause distress and harm to patients, feeding the narrative power of an individual's eating disorder. The article also talks about how the term can remove hope from patients, families and clinicians, and how it might set a dangerous precedent in paving the way for people with other mental health conditions to be labelled 'terminal'.
-
Content ArticleSince retiring from his role in public health, Dr Bill Kirkup has focused on independent investigations into public service failures, including maternity services at Morecambe Bay and East Kent. In this podcast, Bill talks to Parliamentary and Health Service Ombudsman Rob Behrens about his career, what he's learnt during his investigations and how we can make more progress in improving patient safety.
-
Content ArticlePrimary care services are the front door to the NHS - they are the first port of call when we feel unwell and the main coordinator of care when we are living with health conditions. The primary care team have an important role in making people feel welcomed, listened to and taken seriously. Yet we often hear examples about people who have not had their communication needs met within primary care. This includes people with sensory impairments, people with learning disabilities, autistic people, people living with dementia, people who don’t speak English fluently, people with low or no literacy, people who are digitally excluded, people living nomadically, people experiencing homelessness and many others. This report sets out the key issues faced by people with specific communication needs within primary care and what they feel would make the biggest difference, as well as key actions primary care leaders and teams can take to support inclusive communication.
-
Content ArticleAs a doctor, receiving a letter from the GMC confirming that a complaint has been raised against you by a patient, and the GMC are now investigating that complaint, can be a frightening experience. This blog by solicitor Nicola Wheater, looks at how communication failings can lead to GMC complaints and describes what to expect from the process. She also highlights support available for doctors facing a GMC complaint.
-
Content ArticleThis report by Healthcare Inspectorate Wales (HIW) relates to vascular services provided by Betsi Cadwaladr University Health Board following the de-escalation of these services as a Service Requiring Significant Improvement (SRSI). The review outlines that while progress has been made against all nine recommendations made by the Royal College of Surgeons, the health board still has improvements to make.
