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Patient-Safety-Learning

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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. Ian talks to us about rebuilding patient trust in the healthcare system, how the Private Healthcare Information Network (PHIN) is helping to improve decision making for patients in the private sector, and why recognising the link between physical and mental health is vital to patient safety.
  2. News Article
    Junior doctors across England will walk out for 72 hours in March if a ballot for industrial action is successful, the British Medical Association has told ministers. The BMA confirmed the move ahead of the opening of its ballot on Monday (9 January). The union is calling for real terms pay cuts over the past decade to be reversed, claiming the last 15 years have led to a 26 per cent decline in the value of junior doctors’ pay. Robert Laurenson and Vivek Trivedi, co-chairs of the BMA’s junior doctors committee, said: “Pay erosion, exhaustion and despair are forcing junior doctors out of the NHS, pushing waiting lists even higher as patients suffer needlessly.” Read full story (paywalled) Source: HSJ, 8 January 2023
  3. Content Article
    A prolonged stay in the emergency department before moving on to an in-hospital bed, another facility or departing home, is believed to have a negative effect on clinical outcomes for patients. This international systematic review and meta-analysis in the Journal of Clinical Medicine aimed to investigate the link between emergency department length of stay (EDLOS) and in-hospital mortality. The study's findings suggest two key associations with increased in-hospital mortality: low EDLOS EDLOS exceeding 24 hours The authors suggest that: long stays in the emergency department should not be allowed. special attention should be given to patients admitted after a short stay in the emergency department.
  4. News Article
    Thousands of NHS patients in England will be moved into care homes as part of the government's plan to ease unprecedented pressure on hospitals. The NHS is being given £250m to buy thousands of beds in care homes and upgrade hospitals amid a winter crisis. The move aims to free up hospital beds so patients can be admitted more quickly from A&E to hospital wards. The plans will be included in an emergency package to be unveiled by Health Secretary Steve Barclay. Helen Whately, minister for care, said, "Getting people out of hospital on time is more important than ever. It's good for patients and it helps hospitals make space for those who need urgent care." Read full story Source: BBC News
  5. Content Article
    Electroconvulsive therapy (ECT) is a technique that has been used since 1938 to treat several psychiatric disorders as a replacement for chemically induced seizures. Despite its history of stigma, controversy and low accessibility, ECT is found to be beneficial and efficient in severe cases of depression where medication fails to bring results. This article in Experimental and Therapeutic Medicine aimed to summarise the research conducted on the efficacy of ECT on major depressive disorder and variables studied such as technique, comorbidities and medication as well as the effects and outcomes of this procedure.
  6. Content Article
    In this blog for the Citizens Commission on Human Rights, Jane London shares her account of how electroconvulsive therapy (ECT) has affected her life since early adulthood, resulting in severe memory loss and heart problems. Jane shares how her physical medical problems including appendicitis and a severe heart attack were put down to depression, and how she was nearly forced to have ECT against her will in England in 1966. When her abusive marriage ended in 1968 and Jane returned to Australia her mother insisted she have ECT, despite her depression being temporary and related to her marriage ending. After 14 treatments, Jane left the treatment facility and received talking therapy to help her recover. Jane talks about the dramatic adverse effect ECT has had on the rest of her adult life.
  7. Content Article
    In this article for The Guardian, psychiatrist Rebecca Thomas talks about the benefits and problems related to electroconvulsive therapy (ECT) treatments, which are used in cases of severe depression. Having had 70 individual ECT treatments for depression herself, Rebecca highlights that although the therapy can be very effective, doctors need to acknowledge the issues it can cause for patients. She talks about the memory issues ECT can cause, and highlights that as a therapy it has been stigmatised, which spreads fear about a treatment that can be necessary and life-saving. Concluding that decisions around ECT therapy should be clinical and not moral, she urges doctors not to be complacent about the risks, and patients to be careful about stigmatising an effective treatment.
  8. Content Article
    The NHS and social care system in the UK are under immense strain, and this is increasingly causing harm to patients. This is seen in the current crisis in urgent and emergency care, but is present throughout the system. This BMJ article looks at a collaborative document produced by the Royal College of Physicians (RCP), Royal College of Emergency Medicine (RCEM), Royal College of General Practitioners (RCGP), Royal College of Psychiatrists (RCPsych) and the Society for Acute Medicine (SAM). The document highlights key actions and priorities that may help mitigate part of the crisis facing the NHS. As part of these recommendations, the authors call on the UK governments to increase and prioritise investment in primary care, social care, mental health and ambulance services.
  9. Content Article
    Fatigue and sleep deprivation may affect healthcare professionals' skills and communication style and also may affect clinical outcomes. However, there are no current guidelines limiting the volume of deliveries and procedures performed by a single individual, or on the length of time that they can be on call. This Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) analyses research relating to fatigue and performance in healthcare professionals in order to make recommendations to doctors and managers to improve staff and patient safety.
  10. Content Article
    In this video published by Patient Safety Movement, Kimberly Cripe, CEO of the Children's Hospital of Orange County (CHOC), discusses how her hospital has incorporated Actionable Evidence-Based Practices to improve patient safety culture in a paediatric setting. She describes the many benefits of the approach including for staff morale and making financial savings.
  11. Content Article
    The Dahlgren-Whitehead rainbow model outlines determinants of health inequity on multiple hierarchical levels, and suggests that these determinants may interact both within and between levels. Since the model was developed, the involvement of digital technologies has come to have a much greater impact on health inequities. The authors of this article suggest adapting the Dahlgren-Whitehead model to reflect these developments, proposing a model that allows formulating testable hypotheses, interpreting research findings, and developing policy implications against the background of the global spread of digital technologies.
  12. Content Article
    This video by Solent NHS Trust looks at the role of Community Partners in helping the Trust engage in conversations with the community in a meaningful, sustained way. It includes interviews with: Anastasia Lungu-Mulenga, Head of Community Engagement at Solent NHS Trust Annie Clelow, Manager of Communicare Southampton Anne Cato, Community Partner Joe Jennes, Senior coordinator, Carers in Southampton Ellie and Ray from the CAMHS youth participation group Sapna Vohra, Community engagement facilitator Sarah Balchin, Associate director, community engagement
  13. Content Article
    This article presents data on how deprivation affects life expectancy and health life expectancy at birth. It highlights a difference in life expectancy of around 9 years for males and 8 years for females between the most and least deprived deciles of society.
  14. Content Article
    The prevalence and impact of musculoskeletal conditions (MSK) are not experienced equally across the population. Musculoskeletal conditions are linked to deprivation and age, are more prevalent in women and disproportionately affect some minority ethnic groups. Although the issue of health inequalities is a current area of focus for the NHS, MSK receives a low profile in this work. This presentation by Liz Lingard, Delivery Partner for System Improvement at NHS England (North East & Yorkshire), looks at what drives inequalities in musculoskeletal health, and what can be done to address this.
  15. Content Article
    This article in The Lancet aimed to review published work about the efficacy and safety of electroconvulsive therapy (ECT) with simulated ECT, ECT versus pharmacotherapy and different forms of ECT for patients with depressive illness. The authors designed a systematic overview and meta-analysis of randomised controlled trials and observational studies. They concluded that: ECT is an effective short-term treatment for depression, and is probably more effective than drug therapy. bilateral ECT is moderately more effective than unilateral ECT. high dose ECT is more effective than low dose.
  16. Content Article
    This webpage by mental health charity Mind provides information on electroconvulsive therapy (ECT). It explains when ECT might be used and what happens during the treatment, as well as describing the potential short- and long-term side effects of ECT, including memory loss.
  17. Content Article
    Air pollution is an issue that affects us all; it is associated with impacts on lung development in children, heart disease, stroke, cancer, exacerbation of asthma, increased mortality and other health issues. This year’s Chief Medical Officer's report lays out the scale of the challenge of reducing air pollution and the substantial progress that has been made. It highlights achievable solutions across different sectors and makes the case that we need to continue to be active in reducing outdoor air pollution.
  18. Content Article
    Healthcare-associated infection (HAI) prevention has been difficult for healthcare providers to maintain during the Covid-19 pandemic. This study summarises themes for maintaining infection prevention activities learnt from the implementation of a quality improvement (QI) programme in intensive care units (ICUs) during the pandemic. The authors of the study conducted qualitative analysis of participants’ semi-structured exit interviews, self-assessments on HAI prevention activities, participant-created action plans, chat-box discussions during webinars and informal correspondence. The study identified four themes for successful maintenance of infection prevention activities during the pandemic: the value of a pre-existing infection prevention infrastructure flexibility in approach broad buy-in for maintaining QI programmes the facilitation of idea-sharing.
  19. Content Article
    This prevention of future deaths report looks at the death of Ben King, who died of acute respiratory failure, obesity hypoventilation syndrome and use of sedative medication. Ben had Down's Syndrome and obstructive sleep apnoea and had been detained under the Mental Health Act at Jeesal Cawston Park (JCP) from 2018. Ben’s weight as at June 2019 was recorded at 85.2 kg which had risen to 106 kg by June 2020. He was given the sedative Promethazine after becoming agitated and found unresponsive on 29 July 2020. He died later that day at  Norfolk and Norwich University Hospital.
  20. Content Article
    Roughly 16 million Americans are living with Long Covid, but many are not getting the right medical care. In this article in Popular Science, Miles Griffis argues that one way to improve the system is by letting patients lead. He describes his own disabling case of Long Covid, the issues he has faced in gaining access to Long Covid clinics and the lack of treatment options available to him. He argues that at some point, the demand from patients for treatment will force progress in Long Covid research.
  21. Content Article
    Up to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. This study in the Journal of Patient Safety surveyed healthcare staff in the UK and Australia to identify safety practices perceived to be of low value. Staff who took part in a survey as part of the study frequently identified the following categories of practices as being low-value: paperwork, duplication and intentional rounding. Five cross-cutting themes (for example, 'covering ourselves') offered an underpinning rationale for why staff perceived these practices to be of low value. The authors conclude that in healthcare systems under strain, removing existing low-value practices should be a priority.
  22. Content Article
    Cancer Research UK, in partnership with London-based tech company Stitch, are piloting an app for patients to use whilst participating in a clinical trial. The Trialmap app, which was co-created with patients, is being piloted on a clinical trial run by Cancer Research UK’s Centre for Drug Development. The aim of the app is to ensure patients feel valued for their participation, and to improve patient experience during clinical trials. This article looks at how the app: allows patients to easily view information about the trial gives reminders about appointments and what patients might need to do to prepare for them gives patients the opportunity to provide real-time feedback regarding their time on the trial.
  23. Content Article
    This is the recording of a webinar hosted by The Patients Association, about working with partners in industry to allow patient voices to influence care and treatment. The webinar was part of Patient Partnership Week 2022 and featured: Sarah Louis, patient participant and Sarah Whitehead, External Relations and Public Affairs Manager, Novo Nordisk talking about a biosimilars project Carolyn Wheatley, patient participant and Robert Browne MSc, Senior Scientific Affairs Manager, Nutricia, talking about the nutrition checklist Fran Husson, patient participant and Dr Aman Gupta, Medical Affairs Manager Pfizer, on work in antimicrobial resistance.
  24. Content Article
    Musculoskeletal disorders (MSDs) are one of the main causes of ill health in the workplace, leaving many employees with painful long-term injuries. Health and social care are industries with a particularly high incidence of MSDs among staff. This infographic by the Chartered Institute for Ergonomics and Human Factors (CIEHF) lists the warning signs to be aware of and gives lots of easy-to-follow practical advice on how to prevent or reduce the risk of developing symptoms. There’s also a link to find exercises that could help prevent injuries occurring.
  25. Content Article
    This report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.
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