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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Pharmaswiss Česka republika s.r.o. and distributor Bausch & Lomb UK Limited is recalling all unexpired batches of Emerade 500 micrograms and Emerade 300 micrograms adrenaline auto-injectors (also referred to as pens) from patients. This is due to an issue identified during an ISO 11608 Design Assessment study where some auto-injectors failed to deliver the product or activated prematurely. Specifically, the 1-metre free-fall (vertical orientation) pre-conditioning resulted in damage to internal components of the auto-injector, leading either to failure to deliver the product or premature activation. This damage was not visibly apparent following the pre-conditioning but was evident only on subsequent functional testing. It is unclear what impact this has on auto-injectors in clinical use, however as a precautionary measure and owing to the inability to identify this issue before the auto-injectors are used, the auto-injectors are being recalled. Healthcare professionals should inform patients, or carers of patients, who carry Emerade 300 or 500 microgram auto-injector pens to obtain a prescription for and be supplied with an alternative brand. They should then be informed to return their Emerade 300 or 500 microgram pens to their local pharmacy.
  2. Content Article
    The Bucharest Declaration is the outcome of a World Health Organization (WHO) high-level regional meeting on health and care workforce in Europe that took place in Bucharest 22-23 March 2023. It makes 11 statements relating to the workforce crisis facing countries across Europe about retention, recruitment and staff safety.
  3. 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. Stephen talks to us about his time as turnaround Chair of Mid Staffordshire NHS Foundation Trust, how NHS boards can ensure they live their values and why creating a safe space to share concerns improves patient safety.
  4. Content Article
    In healthcare, telling stories brings benefits to both storytellers and audience members, but also presents risks of harm. A reflective storytelling practice aims to honour stories and storytellers by ensuring there is time to prepare, reflect, learn, ask questions, and engage in dialogue with the storyteller to explore what went well and where there are learning and improvement opportunities. Healthcare Excellence Canada (HEC) is a pan-Canadian health organisation focused on improving the quality and safety of care in Canada. The HEC Patient Engagement and Partnerships team have co-developed these recommendations on how best to meaningfully share stories from those leading, providing and receiving care at Board meetings. This Case Study outlines the process HEC used to co-develop storytelling recommendations, focusing on a trauma-informed approach to create safe spaces for preparing, learning from and reflecting on stories, to clearly articulate their purpose, and to ensure the locus of control for storytelling rests with the storytellers.
  5. Content Article
    Attention deficit hyperactivity disorder (ADHD) is a condition that affects people's behaviour. It has a wide range of symptoms and can affect both children and adults—people with ADHD may find it hard to focus on or complete tasks, feel restless or impatient, experience impulsiveness and find it hard to organise their time and their things.[1] ADHD can have devastating mental health implications and research studies have linked ADHD to increased suicide and mortality rates. This means that being unable to access effective treatment can be a patient safety risk for people with ADHD. In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, explores the state of ADHD diagnosis and treatment in the UK. She looks at why many are concerned about the waiting times for adults and children seeking an ADHD assessment and speaks to Elsa*, who was diagnosed with ADHD in her 30s, about her experiences. *Name changed
  6. Community Post
    The impact of living with undiagnosed ADHD can be significant, but adults and children in the UK are sometimes having to wait years for an initial ADHD assessment. Have you been diagnosed with ADHD? Are you or your child on a waiting list for ADHD diagnosis or treatment? Or are you a healthcare professional that works with people with ADHD? Please share your experiences of assessment and diagnosis with us. You'll need to be a hub member to comment below, it's quick, easy and free to do. You can sign up here. You can read more about the issues related to ADHD diagnosis in this blog: Long waits for ADHD diagnosis and treatment are a patient safety issue
  7. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked nine resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices.
  8. Content Article
    The latest NHS Workforce Race Equality Standard (WRES) data shows that it is still over twenty times more likely that a White Band 5 nurse will become a Director of Nursing compared to a Band 5 BME nurse. In this letter Roger Kline, Research Fellow at Middlesex University Business School, outlines his concerns about discrimination and bullying taking place within the NHS. Addressed to Secretary of State for Health and Social Care Steve Barclay, the letter recalls the findings of the Messenger report commissioned by Mr Barclay's predecessor Sajid Javid, which found that “acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system, as evidenced by staff surveys and several publicised examples of poor practice." Referring to recent calls to reduce spending on equality, diversity and inclusion (EDI), he outlines why patient care and frontline services cannot be detached from efforts to improve EDI. He argues that research strongly suggests how staff are treated (including whether they face discrimination) impacts on patient care, staff well-being and organisational effectiveness.
  9. Content Article
    This article looks at the experience of Tammy Dobbs, who has cerebral palsy and requires extensive support from home carers to carry out daily tasks. In 2016, Tammy's care needs were reassessed by the state of Arkansas where she lives, and the hours of support she was eligible to receive were cut in half. The change in eligibility was due to a new state-approved algorithm that had calculated her support needs in a new way, in spite of the fact that there was no change to her level of need.  The situation caused Tammy much distress and resulted in drastic life changes. The article highlights the issues associated with the use of algorithms to determine need and allocate resources in health and social care. It also raises questions about what transparency means in an automated age and highlights concerns about people’s ability to contest decisions made by machines.
  10. Content Article
    The world is facing challenges emerging from multiple crises, including pandemics, wars and climate change. Against this backdrop, the Government of Japan will host the Group of Seven (G7) Summit in Hiroshima and the G7 Health Ministers' Meeting in Nagasaki, Japan, in May 2023. This article in The Lancet outlines key recommendations for G7 action to address these challenges through a human security approach and a transformation of global health architecture: Enhance resilience to public health emergencies by boosting country-led efforts to achieve universal healthcare Advance timely and equitable access to life-saving medical countermeasures as common goods Promote a multilayered approach to global health governance, including financing, that facilitates effective collaboration among state and non-state actors beyond the health sector at global and regional levels.
  11. Content Article
    Approximately 8% of US doctors experience a malpractice claim annually. Most malpractice claims are a result of adverse events, which may or may not be a result of medical errors. However, not all medicolegal cases are the result of medical errors or negligence, but rather, may be associated with the individual nature of the patient-doctor relationship. The strength of this relationship may be partially determined by a physician’s emotional intelligence (EI), or his or her ability to monitor and regulate his or her emotions as well as the emotions of others. This review evaluates the role of EI in developing the patient-physician relationship and how EI may influence patient decisions to pursue medicolegal action.
  12. Content Article
    In this letter to The Lancet, Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations argues that the need to focus on equitable rollout of vaccines in the event of a future pandemic is a key global health priority. He proposes that Governments, pharma companies and other stakeholders should focus on the challenges that led to the inequitable rollout of vaccines, which he identifies as vaccine nationalism and need for more diverse manufacturing. He highlights an industry proposal for equitable response to future pandemics supported by vaccine manufacturers and biotechnologies. the proposal involves manufacturers setting aside a percentage of pandemic tools for allocation to susceptible populations in low-income countries.
  13. Content Article
    The Covid-19 pandemic has shown the power and potential of vaccination in real time. But it has also disrupted health services and caused supply chain challenges, resulting in stagnation and backsliding of routine vaccinations. For example, global coverage of the third dose of the diphtheria–tetanus–pertussis vaccine fell from 86% in 2019 to 81% in 2021—the lowest level since 2008. 25 million children missed out on life-saving measles, diphtheria, and tetanus vaccines in 2021. This editorial in The Lancet calls for a catch-up to return to pre-pandemic vaccination levels and looks at how this can be achieved.
  14. Content Article
    This patient resource created by Prostate Cancer Research aims to equip patients and the public with information about prostate cancer. It contains information on: testing and diagnosis treatment choices living with side effects clinical trials.
  15. Content Article
    Economist Dana Peterson estimates that the economic toll of racism against Black Americans was $16 trillion over the past two decades. Discriminatory lending, wage disparities and inequities in access to higher education, among other factors, have limited the Black community’s ability to generate personal wealth and economic growth. Other minority communities have had similar experiences, and the impact goes far beyond the economy; each of these factors also takes an enormous toll on the health and wellbeing of people of colour. This is the recording of a panel discussion hosted by Harvard T.H. Chan School of Public Health, in which economic, scientific and policy experts discuss how we can build a more equitable and healthier future for everyone.
  16. Content Article
    This case study published by The Beryl Institute looks at an initiative to collect real-time feedback on patient experiences at the Stanford Health Care emergency department in California. Previously, the department had sent a survey to patients well after their visit, but the team realised that capturing this information sooner was critical. Matthew Lim, Patient Experience Manager at Stanford Health Care describes the practical and replicable steps the organisation took in implementing a QR code-based feedback system. He describes the results, lessons learned and potential future developments.
  17. Content Article
    This series of blog posts is written by a patient who experienced life-changing complications after surgery went wrong. In her posts, they explore the psychological needs of patients following healthcare harm, which are often overlooked during physical rehabilitation. "I believe that the emotional support given to the patient during those first few weeks can make a significant difference to their long term quality of life. That’s why I decided to write this blog, to give constructive feedback to help medical professionals learn from my experiences."
  18. Content Article
    Health and care workers in all parts of Europe are experiencing overwork, with high levels of burnout. This opinion piece in the BMJ looks at the issue of healthcare professionals leaving European health systems to take early retirement or work in other countries where pay and conditions are better. It highlights the causes of this exodus, including increasing patient complexity, salary erosion and work-life balance. It argues that policies should prioritise retaining existing staff, as increased training numbers offer only a partial, long term answer.to the crisis, highlighting potential approaches governments can take to retain highly qualified healthcare staff.
  19. Content Article
    Guidance needs to be applied in a careful, caring and person-centred way to ensure that patients benefit from, and are not harmed by, healthcare. In this blog, Dr Sam Finnikin, an academic GP in Sutton Coldfield, uses the story of 86 year-old Joan to illustrate the importance of shared decision-making in ensuring patients receive the most appropriate care. Joan was prescribed multiple medications by the hospital cardiology team after being diagnosed with acute coronary syndrome and a severely impaired left ventricle, but the medications made her feel very unwell and inhibited her quality of life. Joan then reached out to her GP surgery as she wanted to stop taking them, and Dr Finnikin realised that she and her family were unaware of the the reason each medication had been prescribed and the potential benefits and side effects of each one. After a long conversation about her priorities, Joan stopped the medications that were not benefitting her symptoms and died in peace and comfort at home a few weeks later. Dr Finnikin argues that shared decision-making is not an optional extra, but must be considered a vital part of healthcare, stating that "omitting shared decision making can be just as harmful to patients as being ignorant of clinical recommendations."
  20. Content Article
    For decades the NHS has collected routine data on millions of patients. In a world where big data has increasing value, the UK has an opportunity to truly leverage its health data assets to benefit people in the UK and across the world—both through better health and through the generation of more research and development and economic growth. This report by the Institute of Global Health Innovation at Imperial College London provides a broad overview of the UK’s health data policy landscape. It identifies strategic and technical recommendations to move towards a health data policy ecosystem that allows clinical, societal or financial value to be more readily extracted from patient data.
  21. Content Article
    This blog on the Sling the Mesh website provides an overview of research by Professor Carl Heneghan, Director of the Centre for Evidence-Based Medicine at Oxford University, into regulatory issues relating to pelvic mesh. It outlines issues uncovered by Professor Heneghan and his colleagues, including the fact that clinical trial data was not required in the regulation of mesh and that early evidence of complications was ignored in the approval of subsequent devices.
  22. Content Article
    A group of patients and families with experience of end-of-life care worked with researchers from the Nuffield Trust to review findings from its research investigating the effect of the pandemic on people who were receiving end-of-life care at home. This web page summarises the research findings from the perspective of patients and family.
  23. Content Article
    Hospital command and control centres (CCCs) are central locations within a hospital where staff can coordinate and manage the response to emergencies, disasters and other critical events. They are also often used to track and monitor the location and status of hospital staff and resources, such as beds, equipment and supplies, in order to ensure that they are used efficiently and effectively. This blog by Sukhmeet Panesar, Chief Health Officer at Monstar Labs, acts as an introduction to CCCs in healthcare. It includes information on the different types of CCC, the benefits of CCCs and the challenges they may face.
  24. Content Article
    Good hand hygiene in healthcare is essential to reduce the spread of healthcare associated infections (HAIs), which are the most frequent adverse event in healthcare globally. Although progress has been made in improving hand hygiene, there is still a pressing need to give healthcare professionals around the world the necessary knowledge and facilities to achieve effective infection control. The latest World Health Organization (WHO) data shows that globally, half of healthcare facilities do not have basic hand hygiene services, one in five facilities have no water services and one in ten have no sanitation services.
  25. Content Article
    Breaks from operational duty are an important factor in the management of fatigue. But as highly committed and professional operational staff often perform several secondary tasks and activities—inside or outside the ops room—breaks can become a victim. This blog by Chartered Ergonomist and Human Factors Specialist Stephen Shorrock offers some general guidelines about what kinds of tasks add to stress and fatigue and should be avoided during rest breaks. He places break activities into three categories which place different demands on the individual: red, amber and green activities. He also highlights that when it comes to breaks from operational duty, changes in activity are the key to reducing fatigue-related risks.
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