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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This article for Forbes looks at new data suggesting that for almost 70% of people, their manager has more impact on their mental health than their therapist or their doctor—and it’s equal to the impact of their partner. It outlines leadership approaches to improve employees' mental health, including self-management, impact recognition, fostering connection, offering choice and providing challenge.
  2. Content Article
    The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality rate twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. This aim of this study in The British Journal of Anaesthesia was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was developed using data from 8799 patients in 168 African hospitals. It includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The authors concluded that the ASOS Surgical Risk Calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.
  3. Content Article
    Wound care is rarely considered a strategic objective within health and care, but it has considerable impact on patients and on health service resources. In this blog, Ameneh Saatchi, Senior Partnerships and Policy Manager at Public Policy Projects looks at the growing burden of wound care on the health service and what can be done to tackle the problem.
  4. Content Article
    The Diabetes Record Information Standard defines the information needed to support a person’s diabetes management. It includes information that could be recorded by health and care professionals or the person themselves that is relevant to the diabetes care of the person and should be shared between different care providers. It was commissioned by NHS England and developed in partnership with the Professional Record Standards Body (PRSB). The Diabetes Self-Management Information Standard defines the information that could be recorded by the person themselves (or their carer) at home (either using digital apps or medical technology, for example, continuous glucose monitors or insulin pumps) and shared with health and care professionals.
  5. Content Article
    Patient Participation Groups (PPGs) are generally made up of a group of volunteer patients, the practice manager and one or more of the GPs from a practice. PPGs meet on a regular basis to discuss the services on offer, and how improvements can be made for the benefit of patients and the practice. The Patients Association has produced this set of videos and resources for PPGs, including: information on why GP practices and Primary Care Networks need patient groups step-by-step guide to establishing a GP patient group reasons to have a patient group and what’s in it for the GP practice and patients effectively working together in partnership recruitment, increasing diversity and communicating with the wider patient population.
  6. Content Article
    The ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
  7. Content Article
    To thrive and deliver the best healthcare, healthcare professionals depend on their ability to self-reflect and adapt their working behaviours. This skill is developed through self-awareness, an openness to alternative perspectives, proactively seeking feedback and a willingness to change behaviours as a result of reflecting. Transformative reflection is a type of reflective practice that can transform a person's sense of work-based identity, sense of purpose and how they work, ultimately influencing the collective wellbeing. This guide explains what transformative reflection is, how to create an environment in which it can take place and suggests formats and resources to aid organisations in encouraging transformative reflection.
  8. Content Article
    Between 2000 and 2010, multi-year funding increases and a series of reforms resulted in major improvements in NHS performance. However, performance has declined since 2010 as a result of much lower funding increases, limited funds for capital investment and neglect of workforce planning. Constraints on social care spending have also resulted in fewer people receiving publicly funded social care and a repeated cycle of governments promising to reform social care but failing to do so.  As a result, the health and social care sector now finds itself facing unprecedented challenges, from increasing demand and growing waiting lists, to a workforce in crisis. This report by Chris Ham, former Chief Executive of The King’s Fund, analyses how a major public service that is highly valued by the public was allowed to deteriorate. It focuses on the period since 2010 and the factors that contributed to the decline of the NHS after the progress that had been made in the previous decade.   While the current situation can feel overwhelming, the improvements that occurred between 2000 and 2010 show that change is possible where the political will exists. The paper concludes by setting out what now needs to be done to sustain and reform the NHS, with a focus on spending decisions, moderating demand and sharing responsibility with patients and the public, alongside a long-term perspective.
  9. Content Article
    Samuel Howes was 17 when he died by suicide in September 2020. Samuel had ongoing mental health issues including anxiety and depression. This led to his use of drugs and dependency on alcohol, which in turn further worsened his mental health. This blog by his mother Suzanne details her experience of the final day of the inquest into her son's death, which found multiple failings on the part of Child and Adolescent Mental Health Services (CAMHS), social services and the police.
  10. 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.
  11. 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.
  12. 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
  13. 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
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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
  21. 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
  22. 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
  23. 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.
  24. 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.
  25. 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
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