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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this blog, Clare Crowley and Nick Woodier, National Investigators at the Healthcare Safety Investigation Branch (HSIB) look at the simple but often overlooked measures that NHS staff and organisations can take to improve the design and display of information in the workplace. They refer to a recent HSIB investigation that highlighted how the choice of information to display, and the visibility and accuracy of that information, can influence how NHS staff access and use it.
  2. Content Article
    This article forms a section of A guide to good governance in the NHS, published by NHS Providers. Mary Dixon-Woods and Graham Martin contrast problem-sensing with comfort-seeking, confront structural complacency and a lack of eagerness to use hard and soft intelligence, and discuss the crucial importance of openness.
  3. Content Article
    Wales has a long history and tradition of upholding universal policies, welfare, sustainability and rights-based approaches to population wellbeing. However, the trends in reducing the health gap are mixed, the rate of improvement is slower than anticipated, and new groups are emerging with disproportionately higher risk of poor health and premature death and disease.  The Welsh Health Equity Solutions Platform has been designed as a resource to find data and solutions relating to health equity. It includes an interactive data dashboard, policy and healthy equity frameworks and international case studies. It aims to support and accelerate healthy prosperous lives for all in Wales.
  4. Content Article
    In this blog, Kath Sansom, founder of campaign group Sling the Mesh, outlines her concerns about three new mesh products for muscle and tendon injuries that have been given near automatic approval by the US Food and Drug Administration (FDA). She highlights that although the manufacturers claim the products have caused no sensitivity issues and no adverse responses in animals, there is no data on the potential long term impact of the mesh devices. Highlighting the knowledge that we now have about the potential for surgical mesh to cause severe injury and side-effects, Kath raises concerns about the lack of regulatory rigour and the potential for these degradable devices to cause fibromyalgia and other systemic issues. Read more about the approval of products for shoulder soft tissue repair
  5. Event
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    In a networked world, passionate and relatable voices are the ones that help ideas to travel furthest and fastest. Individual influencers are rapidly reshaping public health conversations–not only in terms of who is listened to, but also in terms of the issues discussed. With half the world’s population actively using social media and 41% of Brits using social channels for news (Ofcom, 2022), identifying the most effective ambassadors, advocates and platforms is essential. In this session, speakers from YouTube Health and MHP Group will be joined by an ABPI Code expert and leading content creator and doctor. This expert panel will offer unique perspectives from across channel, content creation and compliance spheres. They will share real-world examples of how to use video to drive engagement and provide insight into supercharging your next campaign. The event will explore: The growing role of video to deliver information in the health space How to identify the right messengers and platforms to create impactful health content that drives change The different methods for reaching your target audience, including how to leverage content creators How to create and deliver content that adheres to the pharmaceutical industry regulations and compliance And more! The panel will also share useful tips and ideas to create impactful video content. Sign up for the event
  6. Content Article
    This video made by Health Education England and the Restraint Reduction Network looks at the impact of inappropriately used restraint practices in mental health and learning disability services. Three people with lived experience of restraint discuss the impact it has had on their lives and why they are campaigning for change.
  7. Content Article
    This year marks the NHS's 75th anniversary, and is an important moment to look back at where the service has come from, consider where it stands today and to look forward to how it needs to change to meet future needs. This report from the NHS Assembly draws on the feedback of thousands of people who have contributed to a rapid process of engagement with patients, staff and partners. It aims to help the NHS, nationally and locally, plan how to respond to long term opportunities and challenges. It sets out what is most valuable about the NHS, what most needs to change, and what is needed for the NHS to continue fulfilling its fundamental mission in a new context.
  8. Content Article
    Postpartum hypertensive disorders pose a serious health risk to new mothers; nearly 75 percent of maternal deaths associated with hypertensive disorders occur in the postpartum period. For the past decade, the obstetrics department at the Hospital of the University of Pennsylvania (HUP) has tried to lower these risks by checking patients’ blood pressure after they are released from the hospital. Their initial efforts to have patients return to the office for an in-person blood pressure check shortly after discharge yielded disappointing results, so the team revamped their approach and ultimately developed an extremely successful program called Heart Safe Motherhood. The programme started when the team at HUP gave a small group of women a blood pressure cuff each. They told them they would receive text messages after discharge instructing them to take their blood pressure at 8am, and that they would need to send in the reading. At 1pm, they would get another text requesting that they send their blood pressure again. This article describes how Heart Safe Motherhood evolved to improve the likelihood of mothers submitting their readings, and how the programme was scaled up to five hospitals in the group. It looks at how the approach has helped tackled health inequalities and improved the safety of postpartum mothers.
  9. Content Article
    An evidence review into the scale of the prescribed drug dependence and withdrawal problem in England published by Public Health England (PHE) in 2019 called for support for patients experiencing withdrawal symptoms, including a national 24 hour helpline and associated website. These calls have since been echoed in a recent BBC Panorama episode and other media accounts, but despite the evidence reviews, media interest and public awareness, nothing has changed.  This open letter to the Government published in the BMJ calls for specialist NHS services to support patients harmed by taking prescription medications. Signed by healthcare professionals, it highlights that there are still almost no NHS services to support patients who have been harmed by taking medicines as prescribed by their doctor, such as antidepressants and benzodiazepines. The signatories believe that the NHS has a clinical and moral obligation to help those who have been harmed by taking their medication as prescribed, and are urgently calling upon the UK Government to fund and implement withdrawal support services.
  10. Content Article
    This report summarises the key insights from the Birmingham ICS Delivery Forum event, held in Birmingham in April 2023. It places the discussions that took place into the broader context of health and care transformation, both at a local and national level, and uses wider sources and research to expand upon the key points.
  11. Content Article
    NHS services have been under increasing pressure in recent years, particularly since the start of the Covid-19 pandemic. We have previously reported on the NHS’s efforts to tackle the backlogs in elective care and its progress with improving mental health services in England. This report gives an overview of NHS services that may be used when people need rapid access to urgent, emergency or other non-routine health services, and whether such services are meeting the performance standards the NHS has told patients they have a right to expect. It covers: general practice community pharmacy 111 calls ambulance services (including 999 calls) urgent treatment centres accident and emergency (A&E) departments.
  12. Content Article
    Over time and across the world, the need to be transparent with patients and families when care has not gone well is now recognised as a key element of high-quality, safe and patient-centred healthcare. However, a significant gap still persists and some organisations have yet to welcome a transparent and accountable approach, while others fail to turn these principles into reliable actions. This editorial in BMJ Quality & Safety highlights the vulnerable position patient and families are in after error disclosure and looks at how data on processes around error disclosure are key to improvement. The authors call for healthcare organisations to redouble their engagement with patients and families who have been harmed by their healthcare and use the principles of accountability, compassion and transparency to drive their response.
  13. Content Article
    This report assesses why NHS hospitals are failing to deliver higher activity despite higher spending on the service and higher levels of staffing over the last couple of years. It argues that politicians need to urgently focus on capital investment, staff retention and boosting management capacity, and sets out key questions for policy makers to address if they want to solve the NHS crisis. The NHS has been on a longer-term negative trajectory: most of the challenges identified in the report existed before the pandemic and have been exacerbated since.
  14. Content Article
    The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the US. In addition to over 4.5 million acute care reports, the PA-PSRS database contains more than 396,000 long-term care healthcare-associated infection (HAI) reports. This study in Patient Safety aimed to look at trends in HAIs in long term care using data from the PA-PSRS database. The study found that there was an increase in the total number and rate of infections reported to PA-PSRS in 2022. 
  15. Content Article
    Doctors are taught from medical school about the benefits of IUDs, and often encourage patients that they are a good contraceptive option. However, recent media attention on the pain that some women suffer when having their IUDs fitted has started conversations about the need for cervical blocks and more honest counselling of women about the procedure. Rebekah Fenton, adolescent medicine fellow at Lurie Children's Hospital of Chicago, joins us to talk about how she counsels her patients, and why the most important thing is to make sure women are in charge of their reproductive healthcare decisions.
  16. 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. Dan talks to us about how his experiences as a paediatrician and military doctor have influenced his view of patient safety. He also describes the increasing complexity in healthcare systems and highlights the need for the Government to commit policy and resources to building and sustaining the NHS workforce.
  17. Content Article
    Over the two decades before the pandemic, the number of NHS patients admitted to hospital increased year-on-year, despite a reduction in the number of hospital beds. Since the Covid-19 pandemic, fewer patients have been admitted to NHS hospitals and length of stay has risen, raising questions about NHS productivity, quality of care and the prospects of meeting ambitions to recover services. This report by the Health Foundation analyses data around hospital admissions and suggests reasons for these trends.
  18. Content Article
    This strategy sets out how the Care Quality Commission (CQC) will listen, inform and involve people and work in partnership with organisations that represent people. The new strategy will run to 2026 and has four objectives: Build a trusted feedback service where people’s experiences drive improvements in care Create a trusted, accessible public information service designed around people’s expectations and needs Develop an inclusive approach to proactively involving people who use services, their family, carers and organisations that represent or act on their behalf in shaping our plans, policies and products Work in partnership with organisations that represent or act on behalf of people who use services to improve care
  19. Content Article
    Community public access defibrillators (CPADs) contain an automated electronic device (AED) that, in the event of a sudden out of hospital cardiac arrest, can provide lifesaving treatment by delivering an electric shock to the heart. CPADs can be found in public areas such as disused telephone boxes or community centres, and often the defibrillators are locked and a special code is needed to open the unit. In this blog, Sharon Perkins, HSIB Maternity Investigator, looks at the issues surrounding the accessibility of CPADs. During the course of a maternity investigation, the HSIB team became aware of instances where access to CPADs had been restricted by their location and lack of registration.
  20. Content Article
    In this blog, Sophie Jarvis, NIHR Public Partnerships Manager, Una Rennard, a public contributor, and Bryher Bowness, a PhD Student at King’s College London, highlight the role of people who care for friends and family in health and social care research, and why they should be involved.
  21. Content Article
    Personalised Care will benefit up to 2.5 million people by 2024. It aims to give people the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life. Personalised care is based on ‘what matters’ to people and their individual strengths and needs. This webpage by NHS England contains information about the following aspects of personalised care: Patient choice Shared decision making Patient activation and supported self-management Social Prescribing and community based support Personalised care and support planning Personal health budgets
  22. Content Article
    This report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
  23. Content Article
    The NHS in England’s annual budget is £161 billion. Yet across the sector there is huge cause for concern, including the still-growing backlog, workforce issues, the state of the estate and the relentless demand on primary care. In this blog, ex-NHS strategic health authority chief executive Mike Farrar and Health Policy Insight editor Andy Cowper look at how these issues can be tackled to provide an NHS that meets the needs of the population. They cover the following subjects: Politics, policy and prevention System working and pivoting to prevention - how to shift resources Building a compelling case for change Moving towards less top-down-ism Being clear about what an ICS is for Culture change and mindsets shifts Resourcing change
  24. Content Article
    Are whistleblower reward programmes a charter for malicious complaints, as some claim, or are they a genuine incentive providing a safety net against retaliation? How successful are these programmes in recovering fraud and other proceeds of crime and serious organised crime? This paper aims to answer these questions—it was produced by WhistleblowersUK in collaboration with US lawyers who contributed to the development and improvement of US reward programmes. It aims to address questions about the legislation around US reward programmes, dispel some of the myths and look at some of the objections attributed to British attitudes about rewarding whistleblowers.
  25. Content Article
    Technology holds promise for the future of healthcare. It can prevent illness, enable early diagnosis, empower health management and support general wellbeing. But how might people use technology to have more control over their health and wellbeing? And do they want to? This report explores the role of technology in managing, improving and supporting health and wellbeing. The NHS Confederation, in partnership with Google Health, commissioned Ipsos to explore people’s behaviours, attitudes and beliefs about responsibility and control when it comes to their health, the role that health technologies play in this and their expectations about the future of healthcare. A survey of more than 1,000 adults in the UK – a third of whom live with one or more long-term conditions (LTCs) – and interviews with individuals with LTCs and who have frequent interaction with the health system, forms the centrepiece of this report.
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