Jump to content
 View Profile  See their activity

  • Posts

    3,769

  • Joined

  • Last visited

Patient-Safety-Learning

PSL Moderators

 Content Type 

Everything posted by Patient-Safety-Learning

  1. 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. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety.
  2. Content Article
    A doula, according to Doula UK (2022), provides ‘support in pregnancy, birth and in the postnatal period by providing information, advocacy, and practical and emotional support to the whole family’. This blog by the Healthcare Safety Investigation Branch (HSIB) maternity team outlines why HSIB decided to investigate the role of doulas in maternity safety and the results of their investigation. It highlights discrepancies in doula training and several cases where doulas stepped outside of the boundaries of their role. HSIB argues that there is a need for further work to understand how families view the role of doulas during pregnancy and birth.
  3. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply the Systems Engineering for Patient Safety (SEIPS) approach. This 2.5 hour masterclass will focus on using SEIPS in maternity. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. The course costs £50 per person. Pre and post class materials will be provided. Book a place
  4. Content Article
    The Learning Together Evaluation framework for Patient and Public Engagement (PPE) in research is an adaptable tool which can be used to plan and to evaluate patient engagement before, during and at the end of a project. The Learning Together Framework can be used in multiple ways with the purpose of mutual learning and understanding by all partners. It is rooted in seven guiding principles of patient engagement defined by the patient-oriented research community: Relationship building Co-building Equity, diversity and inclusion Support and barrier removal Transparency Sustainability Transformation
  5. Content Article
    The tenth anniversary this year of the publication of the Francis Report in 20131 is marked by the largest scale of industrial action ever taken by nurses in the UK for better pay and conditions and, especially, safe staffing. In this article in the Future Healthcare Journal Alison Leary and Anne Marie Rafferty reflect on opportunities missed in the last decade in the attempt to secure safe staffing in nursing. They consider the aftermath of the public inquiry into Mid Staffordshire NHS Foundation Trust and its consequences for nursing, and how policymakers have consistently ignored a growing body of evidence outlining the benefits of safe staffing.
  6. Content Article
    In this podcast, Care Opinion Chief Executive James Munro speaks to Alex Gillespie and Tom Reader of the Department of Psychological and Behavioural Science at LSE about their research paper 'Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents'. Their research analysed over 146,000 stories on Care Opinion using an automated machine-learning approach. Key findings included: automated analysis can reliably detect patient safety issues reported by patients. online patient safety concerns are associated with hospital level mortality. staff reported patient safety concerns are not associated with hospital level mortality.
  7. Content Article
    Cervical cancer disparities persist for Black women despite targeted efforts. Reasons for this vary; one potential factor affecting screening and prevention is perceived discrimination in medical settings. This US study in the Journal of Racial and Ethnic Health Disparities aimed to describe experiences of perceived discrimination in medical settings for Black women and to explore the impact on cervical cancer screening and prevention. The authors concluded that Black women engaging in healthcare are experiencing perceived discrimination in medical settings. They suggest that future interventions should address the poor quality of medical encounters that Black women experience.
  8. Content Article
    Technologies to assist with diabetes treatment and care have evolved rapidly over the past two decades. With each new innovation coming to the market, there are hopes that technologies will solve the numerous, complex issues related to diabetes. However, although it has been demonstrated that overall, these technologies—when available—bring major benefits to people living with diabetes, they do not make the condition disappear. This article in Diabetes Epidemiology and Management discusses the interconnections between technologies and diabetes distress, an often under-acknowledged consequence of the continuous demands of diabetes.
  9. Content Article
    Transformative reflection is based on the idea is that people's perspectives on the world around them change when they reflect on new experiences that challenge their world view. NHS England (NHSE) says that reflection can be hugely valuable for patient care, staff morale and for doctors themselves. In this interview, Dr Alison Sheppard, a national clinical fellow who contributed a new NHSE guide on transformative reflection, talks about what transformative reflection is and how it can be helpful for doctors.
  10. Content Article
    In the UK today, nearly 40% of the population are living in poverty because of low income. This means that nurses and midwives are likely to meet people experiencing poverty and deprivation as part of their everyday work and should be ready and able to help them access the assistance they need to overcome the associated challenges. This article in the British Journal of Nursing examines the link between financial status and people's health and wellbeing. The article includes a case study and suggestions as to how nurses and midwives can promote financial wellbeing.
  11. Content Article
    This article explains Quality and Safety Education in Nursing (QSEN), a US initiative to align nursing education and nursing best practices in quality and safety standards. The six focus areas of QSEN are: Patient-centred care Evidence-based practice Teamwork and collaboration Safety Quality improvement Informatics
  12. News Article
    The chief executive of the Royal College of Speech and Language Therapists (RCSLT) said it is "alarming" that a survey found almost 1 in 4 jobs are vacant across the UK. A survey by the professional body found speech and language therapy (SLT) vacancies across the UK had reached 23% with almost all children's services (96%) and 9 out of 10 adult services (90%) which responded saying recruitment is more or much more challenging than at any time in the past three years. A delay to receiving SLT support can affect a person's ability to communicate with friends and family or to eat and drink as well as a child's ability to access the school curriculum, to regulate their behaviour or to form friendships. The COVID-19 pandemic added to the pressure on SLT services, exacerbating waiting times for assessment and support, as well as adding referrals to see young children whose language and social development was hampered by pandemic restrictions which meant they were not mixing with other children or adults at play groups, nurseries, and schools. RCSLT's new Chief Executive, Steve Jamieson, said, "By the time they are seen by a SLT their needs are a lot more complex and difficult to manage and to treat.” Read full story Source: Medscape, 5 April 2023
  13. News Article
    Disruption caused by the coronavirus pandemic is being blamed for the first recorded rise in tuberculosis (TB) cases and deaths in Europe for two decades. Some 27,300 people died from TB in the World Health Organization’s Europe region in 2021, up from 27,000 deaths the previous year, according to a new surveillance report by WHO and European Union’s disease prevention agency. The rate of new cases and relapses in the region is also estimated to have increased by 1.2 per cent compared to 2020, in a reversal analysts said “reflects the impact of disruption to TB services caused by the Covid-19 pandemic.” The report comes days after the UK Health Security Agency (UKHSA) reported a 7.3 per cent rise in cases in England in 2021, a year that saw new 4,425 cases. Dr Esther Robinson, head of the UKHSA's TB unit, said, "Tuberculosis remains a risk to some of the most vulnerable people in our society and this data highlights that progress towards elimination has stalled." Read full story Source: Independent, 3 April 2023
  14. Content Article
    In this blog, Dr Timothy Ferris, NHS England National Director of Transformation and Rachel Power, Chief Executive at The Patients Association, look at patient access to health records. Dr Ferris writes about NHS England's ambition that patients are able to see their GP health record "at the touch of a button" and Rachel explains why it's important that patients have access to their records. Three patients also share why they find digital access to their records so useful.
  15. Content Article
    In this article for Chamber UK magazine, Lyn Brown MP warns that hysteroscopy could be the next big women's health scandal and calls for dramatic improvements in care. She describes the accounts of women being encouraged to undergo hysteroscopy without anaesthesia and appropriate pain relief, and how lack of informed consent is leaving women feeling violated and scared to undergo future gynaecological procedures. She also describes how she raised the issue in the House of Commons and outlines the failure of the Royal College of Obstetrics and Gynaecology's new 'Good Practice Paper' to properly address the decision making process and acknowledge the severity of the pain experienced by many women who undergo hysteroscopy. The article can be found on page 64 of the e-magazine.
  16. News Article
    The manufacturer of eyedrops recently linked to deaths and injuries lacked measures to assure sterility at its factory in India, according to U.S. health inspectors. Food and Drug Administration officials uncovered about a dozen problems with how Global Pharma Healthcare made and tested its eyedrops during an inspection from late February through early March. The FDA released its preliminary inspection report Monday. The company uses procedures that can’t actually ensure its products are sterile, FDA staff wrote. In particular, the inspectors found that the plant had used “a deficient manufacturing process” between December 2020 and April 2022 for products that were later shipped to the US. The plant in India’s southern Tamil Nadu state produced eyedrops that have been linked to 68 bacterial infections in the U.S., including three deaths and eight cases of vision loss. Four people have had their eyeballs surgically removed due to infection. The drops were recalled in February by two U.S. distributors, EzriCare and Delsam Phama. In a statement, the FDA's Jeremy Khan wrote, “We urge consumers to stop using these products which may be harmful to their health.” Read full story Source: NBC News, 4 April 2023
  17. Content Article
    This paper, published by the National Bureau of Economic Research (NBER) aimed to explore how parental wealth and race affect maternal and infant health outcomes in California. The authors used administrative data that combines the California birth records, hospitalisations and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide new evidence on economic inequality in infant and maternal health. The paper also used birth outcomes and infant mortality rates in Sweden as a benchmark, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.
  18. News Article
    A former nursing home manager has been fined £40,000 after pleading guilty to two offences of failing to provide safe care and treatment to two residents at Rossendale Nursing Home in Lancashire. Caroline Taylforth, who established her first residential care home in 1997, was prosecuted by the CQC. She was the registered manager at Rossendale Nursing Home at the time of the incidents, and admitted mistakes she had made that meant two residents did not receive safe care and treatment, and resulted in "avoidable harm" while in her care, said a CQC spokesperson. The first offence was for failures in the care of resident Patricia Sutton, aged 77, who was admitted to the home on 11 October 2018 and had a significant medical history. On 6 November 2019, Patricia Sutton was eating dinner in the dining room and started choking. She was taken to hospital and died later that day. Ms Sutton had previously been involved in three other choking incidents and should have been referred to a speech and language therapist after the second one occurred to properly assess the risks, said the CQC. However, Ms Taylforth "did not safely assess, monitor or manage the risk or make this referral", the CQC concluded. The CQC also prosecuted Ms Taylforth for another incident concerning Dereck John Chapman, aged 82, who was admitted to the home on 22 October 2019 with multiple health issues and was also prone to having falls. Following admission to the home, Mr Chapman suffered at least 14 falls. Ms Taylforth "failed to mitigate" the risk of falls and "failed to ensure" Mr Chapman was promptly referred to appropriate services, such as the falls team, GP, and local authority following known incidents, particularly those resulting in injuries, criticised the CQC. Read full story Source: Medscape, 6 April 2023
  19. News Article
    A scandal-hit children’s mental health hospital set to close after an investigation uncovered allegations of severe abuse could reopen within months due to a legal loophole, it can be revealed. Taplow Manor hospital, in Maidenhead, will shut in May after the Independent exposed claims of “systemic abuse” and poor care from more than 50 former patients. Police are currently carrying out two investigations into the hospital–one into a patient death and a second into the alleged rape of a child involving staff. Active Care Group, which runs the hospital, announced last week that would close but in letters sent to staff since then, it said it was looking to retrain them with plans to “reopen as an adult acute service” in a matter of months. A loophole in the regulations means that there is nothing to stop healthcare providers from applying to the watchdog, the Care Quality Commission, to reopen, even if serious concerns have been raised about the closed operation. Read full story Source: Independent, 4 April 2023
  20. Content Article
    Improving medication safety during transitions of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. This study in the journal Therapeutic Advances in Drug Safety aimed to characterise the nature and contributory factors of medication-related incidents during transitions of care from secondary to primary care. The authors found several themes for future research that could support the development of interventions, including: commonly observed medication classes older adults increase patient engagements improve shared care agreements for medication monitoring post hospital discharge.
  21. Content Article
    In this joint statement, National Voices, a coalition of health and social care charities in England, supported by 82 charities and professional bodies, call on the Government to act on the serious challenges faced by the NHS and social care workforce, which it states are badly impacting upon people’s experience of health and care. Patient Safety Learning is one of the signatories of this statement.
  22. News Article
    Nurses and physiotherapists can now provide ill patients with “fit-notes” to stay off work in an attempt to ease pressure on GP services. A range of health staff including pharmacists and occupational therapists are certifying illness sign-offs under moves to free up doctors to tackle the treatment backlog. NHS Grampian has successfully completed a pilot scheme at a GP practice which staff described as “really positive” and a step in the right direction. David Cooper, a GP from Old Machar Medical Practice in Aberdeen, said: “It is a more efficient way for us to work as a practice. For the nurses, physiotherapists and others who are working closely with a patient, it makes sense for them to be able to work on fit-notes without having to refer back to a GP for sign off. “We have found it works particularly well for those with chronic, long-term conditions or illness and the process behind the scenes is also now electronic so it saves paper, time and energy.” Paul Gray, a physiotherapist at Old Machar, said: “It makes the patient’s journey easier and it is better for people to access them from those who are assessing your physical capabilities." Read full story (paywalled) Source: The Times, 6 April 2023
  23. Content Article
    In this article, critical criminologist Sharon Hartles looks at the ongoing fight for justice by families affected by the hormone pregnancy test (HPT) Primodos. Primodos was given to thousands of women in the 1960s and 70s which has been linked to miscarriages, birth defects and stillbirth. The Department of Health and Social Care (DHSC) and pharmaceutical company Bayer are applying to strike out court proceedings against them in a civil litigation case brought by the Association for Children Damaged by Hormone Pregnancy Tests (ACDHPT). This would prevent a five-day hearing scheduled to take place at the Royal Courts of Justice in May 2023 from going ahead. The article outlines the argument brought by the DHSC and Bayer that no additional evidence has been found to warrant the case being brought by the ACDHPT. It then goes on to highlight recent research that has established a causal link between HPTs and birth malformations and that therefore gives credence to the litigation. Sharon highlights the importance of the legal system acknowledging and confronting the damage inflicted upon the families affected by the use of Primodos, many of whom have been seeking justice for decades. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021)
  24. News Article
    Just three years of breathing polluted air can increase a person’s risk of lung cancer, a study has found. Scientists have found, for the first time, the mechanism that proves air pollution causes lung cancer to develop. Research funded by Cancer Research UK and conducted by the Francis Crick Institute showed that small pieces of carbon particulates, known as PM2.5, enter deep into the lungs and lead to tumour development. A key gene, known as EGFR, mutates and then the presence of the air pollution exacerbates the growth and expansion of these mutated cells, the study found. The scientists are hopeful that by shedding light on how lung cancer develops they can help to prevent it. Prof Charles Swanton, the chief clinician for Cancer Research UK and lead investigator on the study, said a statin-like drug to protect against lung cancer and ensure the inflammation that can lead to the disease is kept under control could be developed in as little as 10 years. Prof Swanton said: “Our study has fundamentally changed how we view lung cancer in people who have never smoked." Read full story (paywalled) Source: The Telegraph, 5 April 2023
  25. News Article
    Lives could be saved by a new tool that identifies those most at risk of developing lung cancer, according to researchers. The CanPredict tool can spot those most at risk of developing the disease over the next decade and put them forward for screening tests earlier, researchers from the University of Oxford and the University of Nottingham said. They created and tested CanPredict using the anonymised health records of more than 19 million adults from across the UK and hope it can save “time, money and, most importantly, lives”. Lung cancer is the leading cause of cancer deaths worldwide and the second most common form of the disease, but early diagnosis has been shown to improve survival rates. Professor Julia Hippisley-Cox, senior author and professor of clinical epidemiology and general practice at the Nuffield Department of Primary Care Health Sciences, University of Oxford, said: “We hope that this new validated risk tool will help better prioritise patients for screening and ultimately help spot lung cancer earlier when treatments are more likely to help. We’d like to thank the many thousands of GPs who have shared anonymised data for research without whom this would not have been possible.” Read full story Source: The Independent, 6 April 2023
×
×
  • Create New...