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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Involvement 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.
  2. Content Article
    US 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.
  3. Content Article
    This 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.
  4. Content Article
    What 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.
  5. Content Article
    This 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'.
  6. Content Article
    Since 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.
  7. Content Article
    Primary 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. 
  8. Content Article
    As 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.
  9. Content Article
    This 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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
  14. Event
    until
    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
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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. 
  24. 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.
  25. 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.
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