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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The School And Public Health Nurses Association (SAPHNA) has coproduced this vaccination toolkit with children and young people. It aims to increase young people's awareness of what vaccines are, why they are important and what to expect from different types of vaccines.
  2. Content Article
    The combination of emerging patient safety threats and the growing amount of published patient safety research, patient safety resources and accrediting body standards makes it increasingly difficult to prioritise adopting and implementing evidence-based practices. The US Agency for Healthcare Research and Quality's (AHRQ’s) fourth iteration of Making Healthcare Safer intends to address this issue by publishing evidence-based reviews of patient safety practices and topics as they are completed. This intentional release of updated reviews will aid healthcare organisation leaders in prioritising implementation of evidence-based practices in a timelier way. The report will also help researchers identify where more research is needed and assist policymakers in understanding which patient safety practices have the supporting evidence for promotion.
  3. Content Article
    Progress on cardiovascular disease (CVD) was a significant driver of better population health and greater prosperity in the latter half of the 20th century. However, progress has recently stalled, with indications it may be in reverse. This may be due to policy choices made in the last 15 years, particularly since the global financial crisis, above and beyond the more recent impact of the Covid-19 pandemic. This report by Chris Thomas from the Institute for Public Policy Research (IPPR) shows, among other findings, that people are more likely to leave work due to a heart condition than any other health issue.
  4. Content Article
    Older people’s mental health has long been overlooked and poor mental health is often dismissed by health professionals as an ‘inevitable’ part of getting older. And despite NHS Talking Therapies having higher than average recovery rates among the over-65s, this service is less likely to be offered to older people. Commissioned by Age UK, this briefing from the Centre for Mental Health summarises evidence about the mental health of older people in England. It finds that ageist attitudes underpin a system that discriminates against older people, while fatalistic assumptions about what people can expect for their mental health in later life undermine the provision of effective support to promote wellbeing, prevent mental ill health and treat mental health difficulties. The briefing finds that while older people may possess many protective factors for good mental health, they face numerous risk factors, including poorer physical health, reduced mobility and, for some, poverty and racism. Tackling the risk factors and boosting protective factors can increase wellbeing in later life and either prevent or stop the escalation of mental health problems.
  5. Content Article
    The theme of this year’s International Long Covid Awareness Day is ‘Confront Long Covid: Recognise, prevent, act’. In this interview, we speak to retired occupational physician Dr Clare Rayner about her work in understanding Long Covid and its impact on individuals, the health service and the wider economy. She talks about recent guidance she has developed on people with Long Covid returning to work and outlines the impact Long Covid has on the workforce. She calls on healthcare leaders and the Government to invest in treatment-related research as well as highlighting the significant health risks associated with Covid reinfection.
  6. Content Article
    The total value of clinical claims associated with emergency medicine was nearly £700m in 2022/23, making them the second highest total value of claims by speciality. This podcast focuses on clinical negligence claims from the emergency department, and how insights from claims data can be used by emergency medicine teams to help improve safety. Hosted by Justine Sharpe from NHS Resolution's Safety and Learning team, the episode features guests from NHS England’s Getting It Right First Time team and the Royal College of Emergency Medicine. Topics covered include: The key themes and recommendations from NHS Resolution's 2022 ED reports, including discussion of cauda equina and aortic dissection How to use local claims data from NHSR and operational performance data from GIRFT to inform safer patient care Insights into specialty reviews and handover, communication and the importance of multidisciplinary ED teams.
  7. Content Article
    This blog identifies important features of the NHS Long Term Workforce Plan and looks at how focussing on these areas might help systems and providers develop their own plans and take agency to solve local challenges. The author, Nick Richmond, spotlights the following aspects of the plan: ‘All levers at all levels’ approach Diverse time frames for different levers The ‘train’ actions are the most significant investment in domestic supply ever The plan is integrated with service and financial planning – future demand is ‘owned’ by the government and the NHS.
  8. Content Article
    Despite major gains in diagnosis and treatment, England continues to experience high disparities in cancer outcomes, with social and financial deprivation major drivers. This article from the thinktank Public Policy Projects looks at the underlying issues that lead to variation in both the likelihood of developing cancer, such as dietary differences, and in diagnosis, such as inaccessible screening programmes
  9. Content Article
    This cross-sectional study in JAMA Network aimed to assess whether a large language model can transform discharge summaries into a format that is more readable and understandable for patients. The findings suggest that a large language model could be used to translate discharge summaries into patient-friendly language and format, but implementation will require improvements in accuracy, completeness and safety.
  10. Content Article
    In this Medscape article, nephrologist F Perry Wilson explains the findings of a binational cohort study using the universal electronic health record systems of South Korea and Japan. Data from more than 20 million individuals living in these countries from 2020 to 2021 was used to investigate the effect of Covid-19 on long-term risk for incident autoimmune rheumatic diseases (AIRD) such as rheumatoid arthritis, lupus and vasculitis, over various follow-up periods. The study authors found that, compared with those infected with flu, those infected with Covid-19 were more likely to be diagnosed with any autoimmune condition, connective tissue disease, and in Japan, inflammatory arthritis. Wilson observes that although we can't draw causal conclusions from the results, the study highlights that Covid-19 has very different long term effects to other respiratory viruses. 
  11. Content Article
    This article tells the story of how the This Is My Story (TIMS) initiative developed at John Hopkins Medicine, and how it is giving care teams a humanising window into the lives of patients who can’t speak for themselves. Initiated by Chaplain Elizabeth Tracey, who saw the toll not being able to communicate with intubated patients was having on healthcare workers during the first wave of the Covid-19 pandemic, TIMS provides healthcare teams with a short audio recording about each patient. The patient's family shares details about their loved one, such as information on hobbies, personal interests and the patient's career. Staff have reported the TIMS recordings having a big impact on how they view their patients, and the scheme has been rolled out across John Hopkins services.
  12. Content Article
    A common administrative framework of healthcare involves focus upon costs, quality and patient satisfaction—this is known as The Triple Aim.  However, this framework does not allow the experience and human factors of providing care to be integrated into high-level decision making. This report describes the process of transition from The Triple Aim to The Quadruple Aim administrative framework of healthcare delivery at the University of Rochester Medical Center, which resulted in an integrative model of patient safety and clinician wellbeing. Developing the fourth aim of improving the experience of providing care was widely accepted and aligned with other health system goals of optimisation of safety, quality and performance by applying a human factors/ergonomic (HFE) framework that considers human capabilities and human limitations.
  13. 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. Joy talks to us about why we need to reduce the use of restrictive practices in healthcare, the role of research in identifying unsafe practices and how the Restraint Reduction Network shares and helps organisations implement safer approaches to care.
  14. Content Article
    The health action process approach (HAPA) is a social-cognitive model that specifies motivational and volitional determinants of health behaviour. This meta-analysis of studies applying the HAPA in health behaviour contexts estimates the size and variability of correlations among model constructs, test model predictions and test effects of past behaviour and moderators on model relations.
  15. Content Article
    In this opinion piece for inews, Dr Punam Krishan describes the increasing levels of verbal and physical abuse GPs are experiencing from patients in the NHS. She describes how a shift in the public's perception of GPs since the pandemic has contributed to this increase in aggression and highlights that although it is only a minority of patients who display abusive behaviour, it has a big impact on GPs wellbeing and ability to treat other patients. She goes on to outline stricter measures her practice has had to put in place to crack down on abuse from patients.
  16. Content Article
    This parliamentary briefing discusses the NHS workforce in England, focusing on the clinical professions, including doctors and nurses. It gives an overview of workforce demographics and workforce policy and planning since 2019. It also looks at turnover and vacancy rates, the use of temporary staffing and how safe staffing levels are decided. It considers trends in domestic and international recruitment and factors affecting both recruitment and retention, including staff wellbeing, pay and pensions, and bullying, harassment and discrimination.
  17. Event
    An estimated 8% of injuries to healthcare workers in the hospital setting and 17% of worker injuries in the surgical setting are associated with scalpels. Scalpel-related injuries occur most commonly when blades are being attached to or removed from the scalpel handle. In addition to posing infection concerns, such incidents carry a high risk of causing structural damage to the hand, requiring extensive intervention and rehabilitation. Although the Occupational Safety and Health Administration mandates that employers "identify, evaluate, and implement" safer medical devices for healthcare workers, data indicates that such alternative devices are rarely used. In December, ECRI published evaluation findings for 11 scalpel blade removers—devices designed to facilitate safe blade removal and exchange in a variety of settings. Join experts from ECRI's Device Evaluation team as they discuss how this technology impacts patient safety and how to determine the best product for your needs. During this lab webcast, the following learning objectives will be discussed: The prevalence of scalpel-related injuries in healthcare Products available and ECRI's testing methodology Keys to successful implementation of the technology Register for the webcast
  18. Content Article
    This annual report from ECRI and the Institute for Safe Medication Practices (ISMP) presents the top 10 patient safety concerns currently confronting the healthcare industry. It is a guide for a systems approach to adopting proactive strategies and solutions to mitigate risks, improve healthcare outcomes and enhance the well-being of patients and the healthcare workforce. Drawing on ECRI and ISMP’s evidence-based research, data and insights, this report sheds light on issues that leaders should evaluate within their own institutions as potential opportunities to reduce preventable harm. Some of the concerns represent emerging risks, some are well known but still unresolved, but all of them pertain to areas where organisations can make meaningful change.
  19. Content Article
    Some studies suggest a higher incidence of diagnosis of autoimmune inflammatory rheumatic diseases (AIRDs) among patients with a history of Covid-19 compared with uninfected patients. This binational cohort study of patients in Korea and Japan aimed to investigate the effect of Covid-19 on long-term risk for incident AIRD over various follow-up periods. The authors found that Covid-19 infection was associated with increased risk for incident AIRD compared with matched patients without Covid-19 infection or with influenza infection. The risk for incident AIRD was higher with greater severity of acute Covid-19.
  20. Content Article
    With the launch of Pharmacy First in England, pharmacists have a leading role within primary care across the UK in the treatment of many common minor ailments. These resources on have been compiled by the Pharmaceutical Journal and are mapped to cover the conditions specified by the Welsh common minor ailments service, NHS Pharmacy First Scotland and the Pharmacy First service for England. There are resources relating to the following areas: Respiratory Eye, ear and oral health Gastrointestinal Infections and parasites Dermatology CNS and pain management
  21. Content Article
    Central venous catheters (CVCs) are widely used in US critical care settings for medication administration, monitoring and reliable venous access. Despite the benefits of CVCs, complications, particularly infections, have become a major focus of US hospital quality improvement efforts due to federal and state initiatives that emphasise patient safety, transparency and accountability. In this commentary in JAMA Network, the authors look at recent research surrounding CVC complications and highlight approaches to help tackle these issues.
  22. Content Article
    This article in the Pharmaceutical Journal outlines best practice principles and practical advice for structuring antimicrobial reviews and effective stewardship practices. It aims to equip pharmacists to: Understand the role of essential antimicrobial stewardship tools and frameworks to improve antibiotic prescribing; Structure an antimicrobial review effectively, covering all relevant details; Personalise the antimicrobial review to ensure patient-centred care and effective antimicrobial stewardship practices; Develop skills for effective antimicrobial review and stewardship practices to mitigate antimicrobial resistance threat.
  23. Content Article
    This study aimed to determine whether the use of video telemedicine for paediatric consultations to referring hospital emergency departments (EDs) results in less frequent medication errors than the current standard of care—telephone consultations. The authors found no statistically significant differences in physician-related medication errors between children assigned to receive telephone consultations vs video telemedicine consultations.
  24. Content Article
    This article looks at US study showing that the simple act of a doctor sitting in a chair during hospital bedside discussions improves the experience for both doctors and patients. The research team examined whether educating internal medicine residents on the value of sitting and adding a wall-mounted folding chair in plain sight to hospital rooms would motivate doctors to use chairs. The study also measured the impact of whether this physician behaviour impacted patient perceptions. The results showed that: Education alone improved sitting frequency to 15%, but adding dedicated chairs for the clinicians in addition to any patient or visitor chairs improved sitting to 45%. In units where residents were given only education on the value of sitting, patients reported 49% of the time residents always spent enough time by the bedside with them, compared to 73% when a chair was available. In units with education only, 67% of the time residents always checked to ensure the patient understood everything, compared to 87% when a chair was present.
  25. Event
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    The Duty of Candour, introduced in 2014, requires healthcare professionals to be honest with patients when things go wrong. They must also be open with colleagues, employers, and relevant organisations and participate in reviews and investigations when requested. Our training developed with industry experts - Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. The training focuses on empathy and compassion and equips you to navigate the Duty of Candour effectively. The training will cover the following areas: Overview of the Duty of Candour Legislation Requirements and expectations of the Care Quality Commission (CQC) The importance of empathy and compassion in implementing the Duty of Candour Balancing compliance with the human side of the duty Empowering and supporting individuals responsible for the Duty of Candour Understanding the emotional component behind the duty Providing evidence of compliance with the legislation Impact of meaningful interactions on patients, families, and colleagues Avoiding harm when providing an apology Price: £245 + VAT per person Discounted rate for bookings of 3 or more: £220 + VAT per person Event details and booking page Discount Code – Early bird 10% discount code valid until 2 April Hub discount code: DoC-Hub-10 Alternatively, the training can be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
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