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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This report from the National Child Mortality Database (NCMD) covers the two-year period from 2019 to 2021, and is unique in two ways. It is the first national report to have investigated all unexpected deaths of infants and children—not just those that remained unexplained. It is also the first national review of the 'multi-agency investigation process' into unexpected deaths. The report found that, of all infant and child deaths occurring between April 2019 and March 2021 in England, 30% occurred suddenly and unexpectedly, and of these 64% had no immediately apparent cause. Other key findings relating to sudden and unexpected infant deaths (under 1 year) include: 70% were aged between 28 and 364 days, and 57% were male Infant death rates were higher in urban areas and the most deprived neighbourhoods For sudden and unexpected infant deaths that occurred during 2020 and had been fully reviewed, 52% were classified as unexplained (Sudden Infant Death Syndrome) and 48% went on to be explained by other causes such as metabolic or cardiac conditions.
  2. Content Article
    Many people who usually go to their GP for ear wax removal have recently been told this service is no longer available on the NHS. As a result, they are now being advised to manage their own ear wax build-up or to seek ear wax removal from private providers. However, advice on self-management is inconsistent and sometimes dangerous, and the cost of private removal can make it unaffordable.  The Royal National Institute for Deaf People (RNID) wants to make sure everyone is offered clear advice on managing excess ear wax safely themselves and has access to professional removal on the NHS if self-management doesn’t work. This campaign page highlights research by RNID and outlines how people can get involved in the campaign by writing to their MP and local healthcare organisations.
  3. 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. Tracey talks to us about how her love of applying psychology led to her role in patient safety, the importance of putting users at the centre of developing the Patient Safety Incident Response Framework (PSIRF), and what we can learn from magicians about patient safety.
  4. Content Article
    This study in Plos One used a prospective error analysis method—the Systematic Human Error Reduction and Prediction Approach (SHERPA)—to examine the process of dispensing medication in community pharmacy settings and identify solutions to avoid potential errors. These solutions were categorised as strong, intermediate or weak based on an established patient safety action hierarchy tool. The authors identified 88 potential errors with a total of 35 remedial solutions proposed to avoid these errors in practice. Sixteen (46%) of these remedial measures were categorised as weak, 14 (40%) as intermediate and 5 (14%) as strong according to the Veteran Affairs National Centre for Patient Safety action hierarchy. The authors suggest that future research should examine the effectiveness of the proposed remedial solutions to improve patient safety.
  5. Content Article
    This report by The Patient Experience Library looks at patient experience in urgent and emergency care (UEC), reviewing four years' worth of studies from sources including government bodies, policy think tanks, academic institutions and the local Healthwatch network.
  6. Content Article
    This article in the journal Contemporary Nurse discusses how appreciative inquiry (AI) may be used to promote workforce engagement and organisational learning and facilitate positive organisational change in a health care context.
  7. Content Article
    For patients living at home with advanced illness, deterioration in health can happen at any time of the day or night. This research report funded by the charity Marie Curie looks at issues faced by people with advanced illness and their informal carers in accessing out-of-hours care. The report highlights new evidence on out-of-hours care, based on: UK data on out-of-hours emergency department attendance among people who are in the last year of life. interviews with health professionals about out-of-hours services across the UK. a patient and public involvement (PPI) workshop.
  8. Content Article
    The waiting list in England stood at more than seven million in September 2022, up by 1.2 million since September 2021 and 2.6 million since 2019. This analysis by the King's Fund outlines what different patients on the waiting list are waiting for, breaking this figure down into: different medical and surgical specialties whether patients are waiting for admission, diagnostics or decisions It highlights that many on the waiting list are awaiting further diagnostics or decisions before treatment can commence, and others are waiting for treatment that does not require admission to hospital.
  9. Content Article
    In this episode of the What the HealthTech? podcast, Radar Healthcare's Chief Product Officer Mark Fewster speaks to Helen Hughes, Chief Executive of Patient Safety Learning. to get the lowdown on NHS England's new Patient Safety Incident Response Framework (PSIRF). Helen talks about how PSIRF is going to drive an open and just culture, what can be expected after the transition and why the implementation process is key to PSIRF's success. Listen on Spotify Listen on YouTube
  10. Content Article
    This US study in the journal Medical Care aimed to investigate the extent of physician practice adoption of patient engagement strategies nationally. The authors analysed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on adoption of patient engagement strategies. They found that there was modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments.
  11. Content Article
    In this episode of the NICE talks podcast, Consultant Respiratory Physician Dr Hitasha Rupani, Medicines Consultant Clinical Adviser at the National Institute for Health and Care Excellence (NICE) Jonathan Underhill and asthma patient Sheba Joseph discuss NICE’s recently published patient decision aid on asthma inhalers and climate change. The tool supports people with asthma to consider whether they might be able to use inhalers which have a smaller carbon footprint as part of their treatment plan. View the NICE patient decision aid on asthma inhalers and climate change
  12. Content Article
    In this blog, Louise Pye, Head of Family Engagement at the Healthcare Safety Investigation Branch (HSIB) highlights how the Patient Safety Incident Response Framework (PSIRF) can help NHS trusts involve patients and families in the face of extreme winter pressures. She highlights how the seven themes set out in the PSIRF guidance will help patient safety leaders ensure the involvement of patients and families is maintained even when services are dealing with extreme pressures.
  13. News Article
    Scarlet fever cases have surged by tenfold in a year, official data shows, as pharmacists grapple with a shortage of antibiotics during a Strep A outbreak. Strep A bacteria usually only causes mild illness, including scarlet fever and strep throat, which is treated with antibiotics. But in rare cases, it can progress into a potentially life-threatening disease if it gets into the bloodstream. Infections are higher than normal for this time of year, and at least nine children have died after contracting the bacteria in recent weeks. Pharmacists say they are struggling to get their hands on antibiotics to treat Strep A infections – despite the government insisting there is no shortage. “We are worried because we are having to turn patients away,” said Dr Leyla Hannbeck, the head of the Association of Multiple Pharmacies (AIMP). Read more Source: The Independent, 8 December 2022
  14. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE.
  15. Content Article
    This article by the Betsy Lehman Center in Massachusetts draws attention to research by ECRI, a US non-profit research and risk management firm, which shows that efforts to address racial inequalities in medical care need to include an examination of the way in which patient safety events are reported. Research by ECRI shows that existing patient safety reporting systems may be undercounting events experienced by patients who are Black , Latino or from other ethnic groups. It also highlights that racial, ethnic and other demographic data about patients is missing in adverse event reports from most US healthcare organisations.
  16. Content Article
    In this webinar, patients, carers, and partners from the Patient Information Forum (PIF) and NHS Hertfordshire and West Essex Integrated Care Board talk about how the health system is partnering with patients. You can also download the webinar slides.
  17. Content Article
    This study in eClinicalMedicine aimed to bring together the global evidence on the prevalence of persistent symptoms in people who had experienced Covid-19 infection. The authors found, across the 194 studies included in the systematic review, that 45% of Covid-19 survivors, regardless of hospitalisation status, were experiencing a range of unresolved symptoms at around four months after infection. The authors state that current understanding is limited by heterogeneous study design, follow-up durations and measurement methods, and highlight that definition of subtypes of Long Covid is unclear, which hampers effective treatment and management strategies.
  18. Content Article
    This article looks at the potential to use the continuous flow model to tackle unprecedented levels of overcrowding in emergency departments. The continuous flow model, also known as full capacity protocols, was first introduced in North America in the late 1990s. It mandates that a set number of patients are moved at set times from the emergency department to inpatient wards, regardless of whether a bed is available. This might mean putting an extra patient in a bay or two patients in a side room or boarding them in hospital corridors. In turn, this encourages wards to discharge existing patients, allows ambulances to offload new patients in the space created in the emergency department, and relieves pressure on the whole system. This article looks at the fact that evidence to support the continuous flow model is scarce, although positive, and that there are a number of important factors to consider before implementing the model, to ensure that it does not result in increased patient harm.
  19. Content Article
    Hospital boards generally focus attention on measures to answer questions about risk, such as 'How safe are we now?' They are ultimately accountable for the quality of care delivered in hospitals, and data review is a key component of effective board governance. This editorial in BMJ Quality & Safety highlights the lack of guidance on the most effective format for presenting data to determine progress against key risks and targets. The authors argue that data must not be overly simplified and that charts prepared for boards should include monthly data points in graphic format over a longer period of time. This allows trends to be more visible and denotes whether an observed change is significant, helping hospital boards avoid erroneous conclusions tied to random variation.
  20. Content Article
    Questions have been raised as to whether medical masks offer similar protection against Covid-19 compared with N95 respirators. This study in The Annals of Internal Medicine aimed to determine whether medical masks are noninferior to N95 respirators in preventing Covid-19 in healthcare workers providing routine care. The authors of the study conducted a multicentre, randomised, noninferiority trial at 29 healthcare facilities in Canada, Israel, Pakistan and Egypt. The study found that among healthcare workers who provided routine care to patients with Covid-19, the overall estimates rule out a doubling in hazard of PCR–confirmed Covid-19 for medical masks when compared with N95 respirators.
  21. Content Article
    On 9 November 2022, The Professional Standards Authority hosted the Safer care for all conference to discuss questions and issues highlighted in the report Safer care for all – solutions from professional regulation and beyond. This webpage contains video summaries of the conference sessions. The conference provided an opportunity to hear experts’ views as well as consider and contest the themes raised in the report, including the PSA's main recommendation, the creation of a health and social care safety commissioner in all four UK countries. Speakers and delegates came from both professional and system regulators as well as patient organisations, the ombudsman, the NHS, health and care sector organisations and major healthcare inquiries.
  22. Content Article
    In this video, Yvonne Silove from the Healthcare Quality Improvement Partnership (HQIP), presents on HQIP datasets and offers top tips for data access. Yvonne's presentation was originally given at the Using Health and Social Care Datasets in Research event 'Lifting the lid on data—meet the data custodians'.
  23. News Article
    The NHS should “urgently investigate” after Byline Times uncovered “disturbing” figures showing that more than 4,000 patients, visitors and NHS staff were raped or sexually assaulted in hospitals over the past four years, the Shadow Health and Social Care Secretary has said. An investigation by Byline Times has unearthed that 4,100 patients, visitors and NHS staff were raped (1,364) or sexually assaulted (at least 2,744) in a hospital setting between January 2019 and September 2022–with 633 raped or assaulted while on a hospital ward. At least three of the incidents were against a female child aged under 13. Data from 31 police forces in England and Wales based on reported rapes and assaults revealed the scale of sexual violence within hospital settings, with victims including patients and staff members. Labour’s Shadow Health and Social Care Secretary Wes Streeting said, “Hospitals ought to be safe places for patients and staff, but these disturbing findings show that is not the case for far too many people. The NHS should urgently investigate why these disgusting crimes are allowed to happen and on such a widespread scale.” Read more Source: Byline Times, 5 December 2022
  24. Content Article
    Making Families Count (MFC) aims to improve outcomes for families affected by serious harm and traumatic bereavements in health and social care services. In this webinar, which was part of The Patients Association's Patient Partnership Week programme, members of MFC talk through their guide for patients and families on working with the system after a serious incident.
  25. News Article
    Covid is causing liver damage lasting months after infection, according to new research. Researchers at Massachusetts General Hospital, Boston, discovered Covid-positive patients had a “statistically significant” higher liver stiffness than the rest of the population. Liver stiffness could indicate long-term liver injury such as inflammation or fibrosis, the buildup of scar tissue in the liver. Dr Firouzeh Heidari a Research Fellow at Massachusetts General Hospital, said their findings show damage caused by Covid persists for a long time. She said, “Our study is part of emerging evidence that Covid-19 infection may lead to liver injury that lasts well after the acute illness. We don’t yet know if elevated liver stiffness observed after Covid-19 infection will lead to adverse patient outcomes.” Read more Source: The Independent, 4 December 2022
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