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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    These Guidelines for the Provision of Anaesthetic Services (GPAS) support the development and delivery of high quality anaesthetic services. GPAS chapters have previously focused on a particular aspect of clinical service delivery. However, experience has identified a requirement in GPAS to describe what it is about a department of anaesthesia itself, beyond the different aspects of the clinical service delivery, that contribute to a successful department.  The Good Department chapter has been developed to address this requirement, describing current best practice for developing and managing a safe and high quality anaesthesia service in terms of the non-clinical aspects of the service that underpin the clinical provision. The guidance makes recommendations in terms of: leadership, strategy and management workforce education and training clinical governance support services.
  2. 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. Rob talks to us about his passion for using human factors to improve safety in emergency departments, how allowing doctors to choose their own shifts can make staffing safer and how better integrating technology could help doctors diagnose and treat patients more safely and effectively.
  3. Content Article
    Fatigue is increasingly considered as one of the most significant hazards to aviation safety and other safety-critical industries. Both the academic community and industry have focused on understanding the phenomenon of fatigue and the factors that contribute to it in order to prevent it, but also to mitigate its possible consequences. As a result, procedures and regulations have been developed for operators to comply with and there is now a requirement for operators to demonstrate that they are actively managing fatigue. The aim of this white paper by Clockwork Research is to provide safety practitioners with a better understanding of the process of investigating fatigue.
  4. Content Article
    In this opinion piece for US website Stat, Michael Millenson explores how financial factors have contributed to the lack of progress in reducing avoidable harm in the US over the past decade. He argues that the private, insurance-based system means that hospitals make more money from patients with complications, therefore patient safety improvements reduce healthcare organisations' profits. He highlights that research demonstrating this link is only now uncovering what hospital executives have known for years—that current payment structures may “reduce the willingness of hospitals to invest in patient safety.”
  5. Content Article
    In this opinion piece for the BMJ, Partha Kar, consultant in diabetes and endocrinology, argues that in spite of extensive research and discussion around the need to tackle race inequalities in the medical workforce, little progress has been made at a system level. He highlights the importance of ensuring the Medical Workforce Race Equality Standard (WRES) Action Plan is implemented effectively, with special attention being paid to tracking GMC referrals and competency reviews that appear to be based on ethnicity.
  6. Event
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    This workshop will educate delegates about the principles of health inequality and the relationship between health equity and human rights. The workshop will cover the principles and definitions of health inequalities and how they can be measured and studied. Delegates will be given practical guidance on how to translate this knowledge into their own practice. The workshop will include a range of guest speakers from Public Health Wales, and will provide real world examples from Wales and across the world. Register for the webinar
  7. Event
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    In this webinar you will hear directly from young people who will share their experiences of the barriers they face in leading healthy lives and accessing healthcare services. We will also highlight the latest available data on ethnicity and health outcomes, demonstrating where inequalities exist for young people aged 10-25. During the event we will be launching two major publications that explore in more detail the role of ethnicity in understanding young people’s health, this will be the first opportunity to hear the learnings and recommendations from this research. The webinar is hosted jointly by the Association for Young People's Health and the Race Equality Foundation and will be Co-Chaired by a young person with experience on this topic. We will be joined by a range of expert speakers. Sign up for the webinar
  8. Content Article
    This Quality Standard from the National Institute for Health and Care Excellence (NICE) has been updated to instruct healthcare professionals to diagnose women under the age of 65 with a urinary tract infection (UTI) if they have two or more key symptoms.
  9. Content Article
    The Healthy Leadership Framework was developed by the NHS Leadership Academy, out of recognition of the impact good leadership and management have on employee wellbeing. The aim was to identify a behavioural framework that could be used flexibly to support healthy leadership development and help leaders promote positive wellbeing in the workplace. The organisation HWBInspiration was commissioned to undertake scope the relationship between health and wellbeing and leadership, while exploring the leadership behaviours that enable and encourage employee health and wellbeing in the workplace. Their final report outlines the research and its findings, as well as highlighting practical ways that leaders and organisations can embed the identified Healthy Leadership Framework. 
  10. Content Article
    It is important that patients and their medical team work in partnership when making decisions about using antibiotics, whether that’s when a GP prescribes an antibiotic or if you’re in hospital and need antibiotics. The Patients Association has developed these resources to help patients make informed decisions about taking antibiotics. They were developed in partnership with patients, carers, healthcare professionals and Pfizer Ltd., who funded and supported the project. The information will help patients partner with their medical team when deciding about using antibiotics. These resources focus on when a patient is in the hospital, but they may also be used as a helpful reminder whenever you are considering taking antibiotics. The resources include a patient leaflet and animated video.
  11. Event
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    This webinar will explore the similarities and differences between solitary confinement, seclusion, isolation and long term segregation in light of the current review of the Mental Health Act and the forthcoming Long Term Segregation Oversight Panel report. With contributions from professionals and people with lived experience sharing their experiences and views of the impact of each, the webinar will explore the importance of language and the implications of different definitions. There will also be time for reflection and discussion. The webinar will be chaired by Dave Atkinson, Restraint Reduction Network Trustee, Consultant Learning Disability Nurse and NHS Improvement Programme Manager. Speakers include: Baroness Sheila Hollins, Jennifer Kilcoyne (Mersey Care NHS Trust), Roland Dix, Dr Sharon Shalev and Alexis Quinn (RRN Manager). Register for the webinar
  12. Content Article
    A patient participation group (PPG) is a group of people who are patients of a GP surgery and want to help it work as well as it can for patients, doctors and staff. The NHS requires every practice to have a PPG. In this blog, Alan Bellinger reflects on what he has learned during his time as chair of his GP surgery's PPG, highlighting three key lessons: Be collaborative not combative If patients don’t engage with the PPG it’s your fault for not being engaging Never lose sight of the value-add you create for the practice
  13. Content Article
    This summary of how a National Patient Safety Board (NPSB) will benefit patients and families was coproduced by the NPSB Advocacy Board with Patients for Patient Safety US. It outlines how the NPSB would ensure more comprehensive learning from patient safety incidents, ensure patients and families have a core role in governance and priority setting and that data is used to better understand patient safety in the US.
  14. Content Article
    Quality improvement is a methodology used routinely in emergency departments (EDs) to bring about change to improve outcomes such as waiting times, time to treatment and patient safety. However, introducing the changes needed to transform the system in this way is seldom straightforward with the risk of “not seeing the forest for the trees” when attempting to make changes. This article in Annals of Emergency Medicine aims to demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem (“the forest”) and to support quality improvement planning, identifying priorities and patient safety risks.
  15. Content Article
    These system leadership behaviour cards have been designed as a practical development tool. Developed by the NHS Leadership Academy, the set of 13 double sided cards are colour coded by theme; each card describes one of the behaviours and includes three question prompts on the reverse. The aim is to consider how the key themes and behaviours ‘play-out’, from an individual, organisational and system perspective. The questions support conversation and prompt self-reflection in the context of system-level working.
  16. Content Article
    Against the backdrop of the Covid-19 pandemic, ensuring the safety of health and social care services remains a serious, ongoing challenge. This report examines how patient safety governance mechanisms in Organisation for Economic Co-Operation and Development (OECD) countries have withstood the test of Covid-19. It provides recommendations for further improving patient safety governance and strengthening health system resilience in OECD countries. This working paper was produced by the OECD for the 5th Global Ministerial Summit on Patient Safety, held in Montreux, Switzerland in February 2023.
  17. News Article
    Thousands of patients are being forced to wait more than 18 months for treatments such as knee and brain surgery as the health service is set to miss its flagship target because of NHS strikes. NHS England last week claimed it was “on track” to hit the mandated target, but senior sources have warned that the impact of prolonged walkouts combined with unprecedented demand for emergency care means that this is now unlikely. The sources say it is probable that up to 10,000 patients will still be waiting for 18 months or more by the end of March, as a knock-on effect of the cancellation of 140,000 appointments because of strike action. More walkouts are planned over the coming weeks. Patricia Marquis, RCN director for England, said the backlog was “yet even more evidence of what happens when you fail to invest in the workforce. If ministers are serious about preventing a further exodus and cutting the backlog, they need to hear the calls of NHS leaders and come to the table and talk about pay. Only then will patients receive the care they need and waiting lists start to come down.” Read full story Source: The Independent, 15 February 2023
  18. Content Article
    This National Workforce Implementation Plan outlines a series of practical actions that will act as enablers to accelerate the Welsh Government's ten-year vision for its Workforce Strategy. It addresses the following issues:Governance and accountabilityWhat does our workforce look like now?What will our workforce of the future look like?Fill the workforce gapsRetain our workforce: Engage, support and developPlan for the future
  19. Event
    The implementation of policies from the centre, getting systems talking to each other and bridging the gap between analysts and clinicians all remain system-wide issues. The HSJ Data & Analytics Forum is a unique opportunity to challenge thinking, discuss challenges openly and share best practice through a blend of keynote speeches, panel sessions and intimate round-table discussions. Register for this event
  20. News Article
    GPs are attempting to deal with up to 3,000 patients each, amid worsening staff shortages, according to new analysis commissioned by the Liberal Democrats. The research shows that the number of patients per GP has risen sharply, as rising numbers of doctors reduce their hours, or opt for early retirement. The figures, which track the number of “full-time equivalent” fully qualified GPs, show the number has fallen from 29,320 in 2016 to 27,372 last year. The trend follows a rise in part-time work, with the average GP now working a three-day week. On average, there are now 2,273 patients per fully qualified doctor, up from 1,981 in 2016, the research commissioned by the Liberal Democrats shows. While the total number of GPs fell by almost 2,000, the number of registered patients grew from 58 million to 62.2 million, according to the House of Commons Library. Professor Kamila Hawthorne, chairwoman of the Royal College of GPs, said the research “shows yet again how GPs and our teams are working above and beyond to deliver care to an ever-growing patient population, with falling numbers of fully qualified, full-time equivalent GPs.” Read full story (paywalled) Source: The Telegraph, 14 February 2023
  21. News Article
    A health board has been fined £180,000 for failing to protect a vulnerable pensioner who died after repeatedly falling in hospital. Colin Lloyd, 78, was assessed as posing a high risk of falling and required one-to-one care after being admitted to Raigmore Hospital in Inverness. Despite repeated requests for more nursing staff none were made available and the pensioner suffered falls on the ward, which caused fatal injuries. Fiona Hogg, NHS Highland’s director of people and culture, said: “We are deeply sorry for the failures identified in our care. Our internal review following the incident identified several areas of improvement and we have made a number of changes to our practice.” Read full story (paywalled) Source: The Times, 15 February 2023
  22. News Article
    The number of GPs seeing patients outside standard surgery hours in Scotland has dropped by almost a quarter in three years. Nurses and paramedics have had to fill in for doctors in the out-of-hours urgent care centres because GPs could not be found to cover the shifts. Some health boards have had to close their centres and send patients to overstretched A&Es instead because of the GP shortage. Dr Andrew Buist, chairman of the British Medical Association’s Scottish GP committee, said, “Patient demand is outstripping GP capacity across the whole service, including out-of-hours. We simply do not have enough GPs in Scotland. Those who are working in out-of-hours may be doing more hours now than they perhaps did in 2019 which comes as no surprise if there are fewer GPs to go around but it is unsustainable and puts those working in the service at risk of exhaustion and burnout.” Read full story (paywalled) Source: The Times, 15 February 2023
  23. News Article
    Healthcare leaders have been warned by nearly 200 doctors that plans to give more work to private hospitals will “drain” money and staff away from NHS services, leaving the most ill patients at risk. In a letter seen by The Independent, almost 200 ophthalmologists urged NHS leaders to rethink plans to contract cataract services to private sector hospitals, as to do so “drains money away from patient care into private pockets as well as poaching staff trained in the NHS”. The doctors have called for “urgent action” to stop a new contract from being released, which would allow private sector hospitals to take over more cataract services. Professor Ben Burton, consultant ophthalmologist and one of the lead signatories of the letter, said, “What is needed is a long-term sustainable solution rather than a knee-jerk reaction which risks the future of ophthalmology as an NHS service. The long-term solution will be achieved by investing in NHS providers to deliver modern, efficient care, and the private sector only used as a last resort.” Read full story Source: The Independent, 10 February 2023
  24. News Article
    Some doctors say that however reasonable guidelines may seem, their cumulative burden causes “constant frustration” to medical practice. A team of doctors wrote a study last year for the Journal of General Internal Medicine which suggested that if an American doctor followed all of the guidelines for preventive, chronic and acute disease care issued by well-known medical groups, it would require nearly 27 hours per day. Guidelines have become “a constant frustration,” said Dr. Minna Johansson, a general practitioner in Uddevalla, Sweden, who also directs the Global Center for Sustainable Healthcare at the University of Gothenburg. “A lot of guidelines may seem reasonable when considered in isolation, but the cumulative burden of all guideline recommendations combined is absurd.” Read full story (paywalled) Source: New York Times, 14 February 2022
  25. News Article
    Around half of the largest trusts are not buying all their electricity from renewable sources despite a national requirement to do so, as prices of this type of energy rocket. NHS England previously committed to the service purchasing only renewable energy from April 2021, as part of efforts to meet its target to be net zero for emissions it can control–including electricity–by 2040. However, NHSE information seen by HSJ shows that nine of the largest 20 trusts have not been buying 100 per cent renewable electricity this financial year, amid soaring costs. Several trusts told HSJ they had abandoned previous decisions to only use electricity which was “guaranteed” to be renewable. Read full story (paywalled) Source: HSJ, 15 February 2023
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