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Content ArticleThis BMJ article by journalist Andrew Kersley reports on a meeting of 157 medical experts and academics held at the Royal Society of Medicine on poverty and the cost-of-living crisis, which took place in May 2023. One academic at the event warned that the long term effect of ongoing economic inequality on life expectancy was worse than six unmitigated covid pandemics. The three solutions proposed at the meeting that received the most support were: a national strategy to tackle poverty the nationwide delivery of “more affordable, quality, secure social and rental housing” urgently increasing the rate of Universal Credit as well as removing the restrictions related to total benefits and multiple children.
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Content ArticleIn Australia, as in many other countries, the harms caused by transvaginal mesh surgery have prompted individual and collective attempts to achieve redress. Media outlets covered aspects of the rise of mesh surgery as a procedure, the experience of mesh-affected women and the formal inquiries and legal actions that followed, The authors of this article in the journal Health Expectations conducted a media analysis of the ten most read Australian newspapers and online news media platforms, focusing on how mesh and the interaction of stakeholders in mesh stories were presented to the Australian public. They found that mass media reporting, combined with medicolegal action and an Australian Senate Inquiry, appears to have provided women with greater epistemic justice, with powerful actors considering their stories. They argue that although medical reporting is not recognised in the hierarchy of evidence embedded in the medical knowledge system, in this case, media reporting has contributed to shaping medical knowledge in significant ways.
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Content Article
An understanding of the social sciences within infection prevention and control (IPC) is important for those working in health and social care. This new book positions the specialty of IPC as more than a technical discipline concerned with microbes. It is about people and their behaviour in context and the book therefore explores a number of relevant social sciences and their relationship to IPC across different contexts and cultures. IPC is relevant to every person who works in, and accesses health care and it remains a global challenge. Exploring novel approaches and perspectives that expand our collective horizons in an ever changing and evolving IPC landscape therefore makes sense. -
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. Maureen discusses the important role of professional standards in building a patient safety infrastructure, the need to reframe safety as a positive idea and her experience of implementing learning processes during her time as a GP. -
Content ArticleDehydration can be a significant risk to people taking certain medicines. These Sick Day Rules cards aid patients in understanding the medicines they should stop taking temporarily during illness which can result in dehydration, such as vomiting, diarrhoea and fever. They are intended for use as a tool to support conversations between healthcare professionals and patients about their medicines and dehydration.
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Content ArticleWhen people don't feel their actions will make a difference because of the vast scale of a problem, they are less likely to act, and this has implications for attempts to improve patient safety and reduce avoidable harm. In this article, Brian Resnick, science and health editor at Vox, interviews psychologist Paul Slovic, who has been researching human responses to risk and compassion since the 1970s. They discuss the psychological impact of large numbers of people on our ability and willingness to respond compassionately and to act on that compassion. They look at Slovic's research into the concepts of psychic numbing and the prominence effect, focusing on the global refugee crisis and why individuals and governments fail to act in the face of immense suffering.
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Content ArticleThis study in the Journal of Patient Safety outlines the development of the Leapfrog composite patient safety score. The researchers aimed to develop a composite patient safety score that provides patients, healthcare providers and healthcare purchasers with a standardised method to evaluate patient safety in general acute care hospitals in the United States. The study concluded that the composite score reflects the best available evidence regarding a hospital’s efforts and outcomes in patient safety.
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Content ArticleThis study in the Journal of Patient Safety and Risk Management aimed to assess the patient safety situation in Ghana across the World Health Organization's (WHO’s) 12 action areas of patient safety. The authors used interviews and observation including a WHO adapted questionnaire across 16 selected hospitals, including two teaching hospitals selected from the northern and southern parts of the Ghana. The key strength identified in the patient safety situational analysis was knowledge and learning in patient safety, while patient safety surveillance was the weakest action area identified. There were also weaknesses in areas such as national patient policy, healthcare associated infections, surgical safety, patient safety partnerships and patient safety funding.
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Content Article
The Community Health and Wellbeing Worker (CHWW) model was devised in Brazil in the 1990s, where it is called the Family Health Strategy. There are over 250,000 CHWWs in Brazil, described as ‘the ears and eyes of the GP in the community’. They are full time members of the local primary care team and focus on a defined location, usually 200 households, keeping in regular contact with the residents. By visiting households at least once a month, the delivery of primary care becomes truly local and embedded into everyday life. This article describes a pilot of a CHWW model by the NIHR Applied Research Collaboration Northwest London. It discusses how the project was established and includes case studies from the pilot. -
Content ArticleIn this blog, After Action Review (AAR) specialist Judy Walker shares an account of a successful AAR that took place amongst a surgical team. The AAR was called after a near-miss where the anaesthetist was prevented from injecting spinal block medication into the wrong side of a patient's spine by an operating department practitioner (ODP). The story demonstrates the benefits of AAR, including accelerated learning, a no-blame approach, flattening staff hierarchy and a significant reduction in the time it takes to investigate an incident.
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Content Article
D1abasics campaign resources (UHS, May 2023)
Patient-Safety-Learning posted an article in Diabetes
People with diabetes account for one in three hospital inpatients, and this is projected to increase to one in five in the next few years. Often, people are in hospital for reasons other than their diabetes, so it is important that staff across all specialties understand the basics of diabetes care in order to ensure patient safety. D1abasics is an innovative project that aims to equip all healthcare professionals to support the basic diabetes healthcare needs of their patients. Developed by the diabetes team at University Hospital Southampton with funding and support from the charity Diabetes UK, the campaign includes resources such as posters, lanyards and prompt cards. The diabetes team is supporting learning across the hospital by making visits to all wards and specialties to promote D1abasics. You can download the D1abasics poster below. -
Content Article
The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
Content ArticleThis mixed-methods study in the Journal of Multidisciplinary Healthcare examined how health staff in Indonesian hospitals perceived open disclosure of patient safety incidents (PSIs). The authors surveyed 262 health workers and interviewed 12 health workers. In the quantitative phase they found a good level of open disclosure practice, a positive attitude toward open disclosure and good disclosure according to the level of harm. However, in the qualitative phase they found that most participants were confused about the difference between incident reporting and incident disclosure. The authors concluded that a robust open disclosure system in hospitals could address several issues such as lack of knowledge, lack of policy support, lack of training and lack of policy. They also suggest that the government should develop supportive policies at the national level and organise initiatives at the hospital level in order to limit the negative implications of disclosing situations.
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Content ArticleThe Department of Health and Social Care is seeking views and ideas on how to prevent, diagnose, treat and manage the six major groups of health conditions that most affect the population in England. These are: cancers cardiovascular disease, including stroke and diabetes chronic respiratory diseases dementia mental ill health musculoskeletal disorders The views and ideas gathered will inform the priorities and actions in the major conditions strategy. The consultation will close at 11:59pm on 27 June 2023.
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Content ArticleThis report by The King's Fund is part of new research project that explores how NHS providers and integrated care systems (ICSs) are approaching inclusive recovery. It highlights that in 2022, people in the most deprived areas were twice as likely to be waiting more than a year for elective care compared to people in the least deprived areas. The report explores three big questions health and care leaders should be asking themselves and their teams about inequalities in their elective backlog:How are we measuring inequalities and whyDo we know why inequalities existHow will we know if things are improving?
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Content ArticleOn paper, a GP’s working schedule can look quite inviting: consulting for three and a half hours in the morning, with a coffee break in the middle, then a gap for lunch and home visits before a similar length afternoon surgery. However, this is rarely the reality for NHS GPs. In this BMJ opinion piece, GP Helen Salisbury talks about what working life is really like for GPs and highlights the mismatch between their scheduled hours and tasks and the reality, which often involves them doing much more. She highlights how the unrealistic demands GPs face have been exacerbated by a movement of work from secondary to primary care, and argues that this is contributing to the workforce crisis that general practice faces.
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Content ArticleThis is the first national ambulance volunteering strategy, produced by the Association of Ambulance Chief Executives. It recognises the important role volunteers play in the ambulance service and outlines a national approach to volunteering that will be adopted between January 2023 and May 2024. The strategy covers mission, vision, principles and measures of success.
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Content ArticleAn NHS-Led Provider Collaborative is a group of providers of specialised mental health, learning disability and autism services who have agreed to work together to improve the care pathway for their local population. They will do this by taking responsibility for the budget and pathway for their given population. The Collaborative will be led by an NHS Provider who remains accountable to NHS England and NHS Improvement for the commissioning of high-quality, specialised services. These Collaboratives aim to ensure that people with specialist mental health, learning disability and autism needs experience high quality, specialist care, as close to home as appropriately possible. They seek to enable specialist care to be provided in the community to prevent people being in hospital if they don’t need to be, and to enable people to leave hospital when they are ready. This webpage explains the role of NHS-Led Provider Collaboratives and includes case studies that demonstrate how they are helping to transform specialised mental health services.
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Content ArticlePharmaswiss 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.
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Content ArticleThe 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.
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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. -
Content ArticleIn 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.
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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 -
Community Post
Long waits for ADHD diagnosis and treatment - share your experience
Patient-Safety-Learning posted a topic in Conditions
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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- Posted
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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.
