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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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
  7. 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?
  8. 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.
  9. 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.
  10. Content Article
    Food 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.
  11. Content Article
    This 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.
  12. Content Article
    In 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)
  13. Content Article
    Widening 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.
  14. Content Article
    There 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.
  15. Content Article
    The 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.
  16. Content Article
    Generative 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.
  17. Content Article
    In 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.
  18. Content Article
    As 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
  19. Content Article
    NHS 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.
  20. Content Article
    This 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.
  21. Content Article
    The 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.
  22. Content Article
    Gloucestershire 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.
  23. Content Article
    This 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.
  24. Community Post
    We 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
  25. Content Article
    This 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.
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