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Content Article
More than just physical blog
Patient-Safety-Learning posted an article in Patient stories
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." -
Content ArticleHealth 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.
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Content ArticleGuidance 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."
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Content ArticleFor 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.
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Content ArticleThis 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.
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Content ArticleA 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.
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Content ArticleHospital 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.
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Content Article
Top picks: Six resources about hand hygiene
Patient-Safety-Learning posted an article in Infection control
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. -
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. -
Content ArticleThis article in USA Today looks at how the Covid-19 pandemic has caused setbacks in hospitals' patient safety progress. It looks at data from a report by the US non-profit health care watchdog organisation, Leapfrog, which show increases in hospital-acquired infections, including urinary tract and drug-resistant staph infections, as well as infections in central lines. These infections spiked during the pandemic and remain at a five-year high. The article also looks at the case study of St Bernard Hospital in Chicago, which was rated poorly by Leapfrog on handwashing, medication safety, falls prevention and infection prevention, but then made huge progress in improving safety. It describes the different approaches and interventions taken by St Bernard.
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Content ArticleDuring the first waves of the Covid-19 pandemic, the UK shielding policy was introduced with the intention to protect people at the highest risk of harm from Covid-19 infection. This study in the journal Public Health aimed to describe intervention effects in Wales at one year. The authors retrospectively compared linked demographic and clinical data for cohorts of people identified for shielding from 23 March to 21 May 2020 with the rest of the population. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). The study found that: Deaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders, but lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.
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Content ArticleThe Relatives and Residents Association (R&RA) is conducting a survey which aims to gather evidence on the impact of the Covid-19 pandemic on access to healthcare services for those living in care homes. R&RA is seeking responses from people who were living in care homes at any point during the pandemic, or from their relatives and friends. Our analysis of the responses will be shared with the UK Covid-19 Inquiry, including anonymised examples. The survey should take around 10-15 mins to complete.
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Content ArticleWhen something goes wrong in health or care, patients need to understand their rights to complain and seek resolution. The Equality Advisory Support Service Helpline (EASS) supports individuals who wish to achieve an informal resolution when they feel they have experienced discrimination or want to understand their human rights. This article, written by the EASS for The Patients Association, explains an individual's rights under the Equality Act 2010 and what to do if you believe they’ve been violated.
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EventuntilGlobal healthcare sectors contribute significantly to climate change. Healthcare makes up more than 4% net global climate emissions. If it were a country, it would be the fifth-largest climate polluter on the planet. Most health sector emissions, up to 70% are embedded in the supply chain, including pharmaceuticals and medical devices. In globalised supply chain contexts, it would not be wise for any single nation to set standards that few others intend to follow. Now that the UK is a single market in a global marketplace, it is more important than ever that the UK’s leaders find consensus among their peers before ushering in new supplier rules and regulations. Without international alignment, the UK risks multinational corporations retreating from the NHS while start-ups and small to medium enterprises become internationally uncompetitive. This session will explore how the decarbonisation of the NHS supply chain is going from NHS and industries perspectives. Speakers will include: Ian Milimo, Project Manager, United Nations Development Programme Lisa Dittmar, Net Zero and Sustainable Supply Chain Lead at NHS England Sign up for the webinar
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EventuntilWhat does it take to successfully implement an award-winning virtual ward? This webinar from GovConnect looks at Leicester Glenfield’s AF virtual ward for cardiovascular disease monitoring and uncovers how the ward was built, assesses the patient recruitment process and explores the meaningful relationships made along the way. Stella Vig will speak to the pioneering clinicians behind the award-winning virtual ward to discuss how they created a secure clinical pathway centred around patients to deliver ground-breaking virtual care. The webinar will increase understanding of the benefits and insights of patient engagement in integrated care and how it can lead to effective digital transformation. It will also explore how medical data was gathered using transformative tech-enabled devices, the challenges and results of a multidisciplinary approach, and the technologies available to support remote patient monitoring. In the webinar you will learn about: How to implement a successful, secure, and scalable virtual ward The challenges and results of a multidisciplinary approach The technology available to support patients from the comfort of their home Register for the webinar
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Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist -
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. Beverley talks to us about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. -
Content ArticleSignificant Event Audit (SEA) ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided. This guidance from the Royal College of General Practitioners (RCGP) aims to enable primary care teams to conduct an effective SEA with the aim of improving care for all patients.
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Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content ArticleIn 2002, a dedicated group from Pennsylvania passed the Medical Care Availability and Reduction of Error (MCARE) Act, the most robust state-level legislation of its kind. Its legacy remains 21 years later. In this interview with the journal Patient Safety, Pennsylvania's Patient Safety Authority chair, Dr Nirmal Joshi, discusses ways care has improved, what challenges persist, and how to achieve the unachievable—true culture change.
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Content ArticleThis briefing by the NHS Confederation provides overview and analysis of the health and care bill.
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Content ArticleMedical equipment, supplies, and devices (ESD) serve a critical function in healthcare delivery and how they function can have an impact on patient safety. ESD-related safety issues include malfunctions, physically missing ESDs, sterilisation and usability. Describing ESD-related safety issues from a human factors perspective that focuses on user interactions with ESDs can provide additional insights to address these issues. This article in the journal Patient Safety reviewed ESD patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System to identify ESD-related safety issues.
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Content ArticleThis book published by the US Food and Drug Administration (FDA) looks at risk communication—the communication approach used for situations when people need good information to make sound choices. It is distinguished from public affairs (or public relations) communication by its commitment to accuracy and its avoidance of spin. Effective risk communication between healthcare professionals and patients is important to ensure patient safety, and in various chapters of the book, the authors look at how to maximise effective communication in healthcare scenarios.
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Content ArticleTargets have been applied to a wide range of public services over the past 40 years. This report analyses whether targets improve the performance of public services and the reasons for this, making recommendations on when and how government should set targets. It focuses on national targets and examines what evidence there is for how they have affected how efficiently public money is turned into outcomes for the public.
