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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This stocktake by NHS Confederation highlights insights from medicines optimisation forums on the experience of ICS medicines optimisation so far: the opportunities that exist, the barriers experienced, the support that is needed, and what the vision for medicines optimisation could achieve.
  2. Content Article
    In 2022, an illustration of a Black foetus in the womb by Nigerian medical illustrator and medical student Chidiebere Ibe, went viral. The image sparked an important conversation around representation in medical imagery and the impact this has on health outcomes for patients who are Black, Indigenous and people of colour (BIPOC). Research showed that only 5% of medical images show dark skin and only 8% of medical illustrators identified as BIPOC. A collaboration between Chidiebere Ibe, Deloitte and Johnson & Johnson, Illustrate Change aims to build the world's largest library of BIPOC medical illustrations for use in medical education and training. So far, the library contains images relevant to the following specialties: Dermatology Eye disease General health Haematology Maternal health Oncology Orthopaedics
  3. Content Article
    Academic Health Science Networks (AHSNs) host England’s fifteen Patient Safety Collaboratives. They are experts in supporting quality improvement projects using methodology from the Institute of Healthcare Improvement model for improvement. This resource pack by The AHSN Network provides an overview of the different ways Patient Safety Collaboratives can support safety improvement projects and includes case studies and resources.
  4. Content Article
    This standard has been produced by NHS England to promote consistent delivery and quality of specialist orthodontic care provision to patients in England. It aims to ensure that resources invested by the NHS in specialist care are used in the most effective way, provide the best possible quality and quantity of care for patients and meet need rather than serve demand. The standard includes the following information: What is orthodontics? Complexity assessment Illustrative patient journey Assessing need Understanding current provision Model of care Clinical standard National key performance indicators Quality and outcome measures
  5. Content Article
    The widespread adoption of effective hybrid closed loop systems would benefit people living with type 1 diabetes by improving the amount of time spent within target blood glucose range. Hybrid closed loop systems (also known as 'artificial pancreas' typically utilise simple control algorithms to select the best insulin dose for maintaining blood glucose levels within a healthy range. Online reinforcement learning has been utilised as a method for further enhancing glucose control in these devices. Previous approaches have been shown to reduce patient risk and improve time spent in the target range when compared to classical control algorithms, but are prone to instability in the learning process, often resulting in the selection of unsafe actions. This study in the Journal of Biomedical Informatics presents an evaluation of offline reinforcement learning for developing effective dosing policies without the need for potentially dangerous patient interaction during training.
  6. Content Article
    This is the 15th annual clinical radiology census report by The Royal College of Radiologists. The census received a 100% response rate, meaning this report presents a comprehensive picture of the clinical radiology workforce in the UK as it stood in October 2022. Key findings The workforce is not keeping pace with demand for services. In 2022, the clinical radiology workforce grew by just 3%. In comparison, demand for diagnostic activity is rising by over 5% annually, and by around 4% for interventional radiology services.  The UK now has a 29% shortfall of clinical radiologists, which will rise to 40% in five years without action. By 2027, an additional 3,365 clinical radiologists will be needed to keep up with demand for services.   This will have an inevitable impact on the quality-of-care consultants are able to provide. Only 24% of clinical directors believe they had sufficient radiologists to deliver safe and effective patient care.   Interventional radiologists are still limited with the care they can provide. Nearly half (48%) of trusts and health boards have inadequate IR services, and only 1/3 (34%) of clinical directors felt they had enough interventional radiologists to deliver safe and effective patient care.   Stress and burnout are increasingly common among healthcare professionals, risking an exodus of experienced staff. 100% of clinical directors (CDs) are concerned about staff morale and burnout in their department. 76% of consultants (WTE) who left in 2022 were under 60.  We are seeing increasing trends that the workforce is simply not able to manage the increase in demand for services. 99% of departments were unable to manage their reporting demand without incurring additional costs.   Across the UK, health systems spent £223 million on managing excess reporting demand in 2022, equivalent to 2,309 full-time consultant positions.
  7. Content Article
    In this interview, we speak to sociologist Dr Marieke Bigg about why she decided to write her debut non-fiction This won’t hurt: How medicine fails women. Marieke discusses how societal ideas about the female body have restricted the healthcare system’s approach to women’s health and describes the impact this has had on health outcomes. She also highlights areas where the health system is reframing its approach by listening to the needs of women and describes how simple changes, such as allowing women to carry out their own cervical screening at home, can make a big difference.
  8. Content Article
    The language used by healthcare professionals can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it day-to-day. At its best, good use of language; verbal, written and non-verbal (body language) which is more inclusive and values based, can lower anxiety, build confidence, educate and help to improve self-care. On the other hand, poor communication can be stigmatising, hurtful and undermining of self-care and have a detrimental effect on clinical outcomes.  Language Matters Diabetes is a global movement that aims to improve the way in which healthcare professionals and wider society talks about and to people with diabetes. These three pocket guides for different groups aim to address use of language about diabetes and people with diabetes in order to improve experiences of care and tackle stigma. Language Matters pocket guide: Healthcare professionals Language Matters pocket guide: Parents and families Language Matters pocket guide: Media and social media
  9. Content Article
    In December 2022, Public Policy Projects brought together oncology experts and key stakeholders for a roundtable to discuss how effective partnership working in healthcare environments can reduce health inequalities in breast cancer outcomes. The objective of the roundtable was to create a series of actionable insights and recommendations for health providers to create a more resilient health and care system and, ultimately, improve breast cancer outcomes in the UK. This document is a summary of the key outcomes, insights and recommendations that were generated from the roundtable. It is not an exhaustive report of facilitating and enabling partnerships to tackle health inequalities, but rather a particular view from a group of key sector stakeholders.
  10. Event
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    Taking place as part of Clinical Audit Awareness Week, this webinar will feature Vin Diwakar, Medical Director for Secondary Care and Transformation, discussing the bigger picture around taking action on clinical audit and how the newly launched NHS Impact can support improvements based on findings and recommendations. We will also hear from Michael Sykes, Senior Research Fellow at Northumbria University and Quality Improvement Lead for the National Diabetes Audit on how supporting the quality improvement capabilities of national audit recipients, and creating the opportunity for them to collaborate, may improve outcomes. There will be an opportunity for group discussions and insights. Register for the webinar
  11. Content Article
    Despite their widespread use, the impact of commissioners’ policies for body mass index (BMI) for access to elective surgery is not clear. Policy use varies by locality, and there are concerns that these policies may worsen health inequalities. This study in BMC Medicine aimed to assess the impact of policies for BMI on access to hip replacement surgery in England. The authors used National Joint Registry data for 480,364 patients who had primary hip replacement surgery in England between January 2009 and December 2019. They found that rates of surgery fell after localities introduced policies restricting access to surgery based on BMI, whereas rates rose in localities with no policy. Localities with BMI policies have higher proportions of independently funded surgery and more affluent patients receiving surgery, indicating increasing health inequalities, and policies enforcing extra waiting time before surgery were associated with worsening mean pre-operative symptom scores and rising obesity. The authors recommend that BMI policies involving extra waiting time or mandatory BMI thresholds are no longer used to reduce access to hip replacement surgery.
  12. Content Article
    Gaslighting at work can take many forms and is often subtle, causing the victim to question their perception. This blog gives some examples of gaslighting at work and suggests ways to deal with it if you believe you are experiencing gaslighting from a colleague.
  13. Content Article
    NHS England has collated this set of resources about understanding complexity. Understanding complexity video by NHS Horizons Understanding and Working with Complexity blog by Andrew Singfield Spread and Complexity in the NHS blog by Diane Ketley Looking at Spread – Three Helpful Lenses blog by Diane Ketley Spreading and scaling up innovation and improvement paper by Trisha Greenhalgh Changing how we think about healthcare improvement paper and audio recording by Jeremy Braithwaite ‘Adaptive Spaces’ for an emerging future blog by Q community What is Adaptive space? A Brief Introduction video by Gareth Evans Adaptive Space in Action video by Matthew Mezey Adaptive space – Overview of the work of Mary Uhl-Bien video by Diane Ketley How ‘Adaptive Spaces’ enable innovation in healthcare and beyond webinar with Mary Uhl-Bien How to master the art of creating ‘Adaptive Spaces webinar with Mary Uhl-Bien Mary Uhl-Bien in Conversation: COVID-19, complexity leadership and spread of innovation video recording with Mary Uhl-Bien Adaptive spaces, networks…. and a challenge called spread blog by Diane Ketley Complexity leadership theory: Shifting from Human Capital to Social Capital paper by M Arena and Mary Uhl-Bien How to Catalyse Innovation in Your Organisation paper by M Arena et al Navigate Complexity: Three Habits of Mind blog by Sonja Blignaut Three habits of mind video by Jennifer Garvey Berger and Keith Johnston Cynefin framework introduction video and book chapter by Jennifer Garvey Berger and D Snowden Stacey framework blog and video recording by R Stacey
  14. Content Article
    Community pharmacies are offering an increased range of services to support care for people in the community. It is therefore essential that they are able to record and share vital information about a person’s care with GP practices and other services. Using digital standards, we can ensure that care professionals and citizens have timely access to relevant information, leading to better, safer and more personalised care in the community. This Community Pharmacy Standard developed by the Professional Record Standards Body (PRSB) defines the information that should be recorded in the community pharmacy and sent to the person’s GP, for all the services covered by the English Community Pharmacy Contractual Framework.
  15. Content Article
    It is hard to separate litigation from the debate surrounding patient safety and the quality of healthcare. When we talk about developing an NHS patient safety culture, issues such as litigation and clinical negligence costs always seem to feature somewhere in discussions. In this article in the British Journal of Nursing by John Tingle, Lecturer in Law at Birmingham Law School, outlines approaches to improving patient safety in the NHS and examines the extent to which these have been driven by the desire to reduce litigation.
  16. Content Article
    Age-Friendly Health Systems (AFHS) is an initiative that aims to follow evidence-based practices while minimising harm in older patients. The evidence-based elements of high-quality care are known as the 4Ms: What Matters Medication Mentation Mobility During the early days of the Covid-19 pandemic, a team from the Oregon Health & Science University (OHSU) decided to examine the equity of their care for older adults. The resulting study published about the age-friendly work at OHSU is the first to include data about health equity as part of AFHS outcomes and illustrates the importance of creating equitable care at clinical and institutional policy levels. This blog looks at the process the team went through to assess and collect data about age-related equity.
  17. Content Article
    Race and ethnicity have been associated with poor pregnancy outcomes in many countries. In the UK, the rates of baby death and stillbirth among Black and Asian mothers are double those for White women. Most studies examine trends for individual countries. This large database study explored how race and ethnicity is linked to pregnancy outcomes in wealthy countries. Key findings Black women consistently had worse outcomes than White women across the globe.  Hispanic women were three times more likely to experience baby death compared with White women.  South Asian women had an increased risk of early birth and having a baby with an unexpectedly low weight (small for the length of pregnancy) compared with White women.  Racial disparities in some outcomes were found in all regions. The researchers call for a global, joined-up approach to tackling disparities. Breaking down barriers to care for ethnic minorities, particularly Black women, could help. More research is needed to understand why outcomes are for worse for ethnic minorities. The researchers recommend routine collection of data on race and ethnicity. The link below takes you to the Plain English summary of the research, you can also view the full research study.
  18. Content Article
    This study aimed to operationalise and use the World Health Organization's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths.
  19. Community Post
    @BDF @Jo Griffin @Greenfingers @Stefanie If any of you would be interested in sharing your perspectives as a parent in a blog about these issues, please do get in touch with us at content@patientsafetylearning.org. We can offer editorial support and blogs can be anonymous
  20. Content Article
    The Child Health Clinical Outcome Review Programme has produced this review of the barriers and facilitators in transitioning children and young people with complex chronic health conditions into adult health services. Based on data on children and young people with one of 12 complex conditions identified from a sample period between 1st October 2019 and 31st March 2021, the report concludes that there is no clear pathway for the transition from healthcare services for children and young people to adult healthcare services. The report finds that the process of transition and subsequent transfer is often fragmented, both within and across specialties, and that adult services often sit only with primary care. It argues that developmentally appropriate healthcare should be everyone’s responsibility, with adequate resources needed to allow this to happen. The Inbetweeners also calls for services to: involve young people and parent/carers in transition planning and transition to adult services improve communication and coordination between all specialties be organised to enable young people to transfer to adult services effectively, and provide strong leadership at Board and specialty level at all stages of transition and transfer. The report’s recommendations highlight areas that are suitable for regular local clinical audit and quality improvement initiatives by those providing care to this group of patients. It suggests that the results of such work should be presented at quality or governance meetings, and action plans to improve care should be shared with executive boards.
  21. Content Article
    HQIP hosts a Service User Network (SUN) for people who are interested in contributing to improving the quality of healthcare services. Anyone with lived experience as a patient or carer is invited to join. The SUN was established in 2009 and has had over 40 patient and carer advocates working in an advisory capacity to HQIP. There is no commitment once you sign up and all opportunities will be shared via a newsletter, To register your interest, complete this form. HQIP will then send you regular updates about projects that you could contribute to.
  22. Content Article
    There has been growing concern about doctors’ conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study in the Journal of the Royal Society of Medicine mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement. The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.
  23. Content Article
    In this blog, Paul Whiteing, Chief Executive of Action Against Medical Accidents (AvMA), highlights how proposed changes to the UK legal system will affect people who have been harmed by healthcare and their families' access to justice. He describes the negative impact of legislation that would make claims less than £100,000 subject to a fixed cost regime. Paul writes, "The consequence of a fixed cost regime is that where the patient wins their case against the healthcare provider, the costs awarded will be capped at the rates set by Parliament." Related reading Read our Patient Safety Spotlight interview with Paul.
  24. Content Article
    The National Vascular Registry (NVR) has published a report on the impact of the Covid-19 pandemic on vascular surgery in the UK, presenting key findings from NVR data throughout 2020 and 2021. NVR previously reported on data as at 25 September 2020, which showed that Covid-19 infection in patients undergoing vascular surgical procedures significantly increased the risk of respiratory complications and mortality. Here, they update this analysis, using data through to the end of 2021, and explore whether the Covid-19 vaccination programme provided protection to patients against this life-threatening complication. One finding is that, between March 2020 and Dec 2021, confirmed postoperative Covid-19 diagnoses were most common among non-elective procedures, ranging from 18.4% (non-elective AAA repair) to 27.5% (major lower limb amputation). For elective procedures, the reported rates of confirmed postoperative Covid-19 diagnoses were lower, ranging from 1.6% (elective AAA repair) to 4.1% (lower-limb bypass). Other key findings include: There was only a modest rise during the first Covid-19 wave (Mar-Jun 2020) with a larger rise during the second wave (Nov 2020-Feb 2021) There was a different pattern for respiratory complications after surgery, with higher rates observed in both wave 1 and wave 2 The period from March to December 2021 was associated with rates of respiratory complications and in-hospital postoperative mortality returning to levels observed pre-pandemic in 2019 Overall, the report concludes that the vaccination programme had a modest benefit to patients in reducing the risk of respiratory complications, and therefore carries a public health message relevant for both national and international audiences.
  25. Content Article
    In this blog, Becki Meakin, Involvement Manager with Shaping Our Lives, a non-profit making user-led organisation that enables individuals to have a stronger voice, writes about why all patients should think about speaking up about their health experiences. She talks about the difference sharing your story can make, and how to get started.
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