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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Regina Kamoga, Executive Director of the Community Health And Information Network (CHAIN) in Uganda, delivered this presentation to the 6th Annual Pharmacovigilance Stakeholder Meeting on 30 November 2022. The presentation outlines how CHAIN is working to develop and support expert patients and patient groups in underserved communities in Africa, as well as highlighting the key medication safety issues faced by these communities, including low health literacy, poor reporting culture and healthcare worker knowledge gaps. The presentation then looks at how CHAIN implemented the World Health Organization's (WHO) Global Patient Safety Challenge in Ugandan communities through patient engagement and healthcare worker education. To conclude the presentation, Regina makes recommendations to improve medication safety: Sustain advocacy for medication safety and become a voice to the voiceless Adopt a culture of safety that incorporates the patient as a care team member not a perceived receiver of care Build and strengthen networks on patient safety Communication and open discussion between healthcare providers and patients to improve patient doctor relationship Increase collaboration with civil society organisations and patient organisations Adopt Start Early In Life initiative to instil a safety culture early in life Establish medication safety multidisciplinary working group Patient, family and community engagement should be at the core of key stakeholders interventions
  2. Content Article
    This article in Science News looks at the impact of the growing global burden of Long Covid during 2022. It describes "a tidal wave of people with lingering symptoms—some mild, some profoundly disabling" which has commanded the attention of researchers and doctors, who are still looking for answers on how to diagnose and treat Long Covid. The article also highlights risk factors, symptoms and the need to focus on people whose lives are most severely restricted by the condition.
  3. Content Article
    This report commissioned by the NHS Confederation and written by the Centre for Mental Health sets out a vision for what mental health, autism and learning disability services in England should look like in ten years’ time. It brings together research and engagement with a wide range of stakeholders including people who bring personal and professional experience. The report identifies ten interconnecting themes that underpin the vision and three key requirements that would turn the vision into reality.
  4. Content Article
    In the UK, the focus of osteoporosis care in the NHS has been on people who have sustained a fragility fracture as a result of their underlying condition. Not much has been done to try and prevent the first fracture by promoting good bone health and proactively identifying people at higher risk. This report by the APPG on Osteoporosis and Bone Health presents the results of its inquiry into primary care provision for people with osteoporosis and those at high risk of fracture, launched in March 2022. The inquiry aimed to establish the current quality of care being offered to patients.
  5. Content Article
    The Patients Association's Patient Partnership Week brought together patients, carers and healthcare professionals to talk about patient partnership.
  6. Content Article
    In this blog for Medpage Today, US doctor Diane Solomon talks about the power of apologising to patients. Outlining the tendency of healthcare professionals to defend their practice, she describes how being honest and open with patients about errors demonstrates humanity and compassion. She talks about the importance of being sincere when apologising and outlines how taking responsibility builds trust and can positively change future outcomes.
  7. Content Article
    This online comic has been developed by the Royal College of Anaesthetists and the Association of Paediatric Anaesthetists of Great Britain and Ireland to help children aged 7-11 understand what it’s like to have a general anaesthetic, using familiar Beano characters to help reduce any anxiety they may have about surgery. It is a fun and playful way to help children understand more about their operation and how to prepare for it, and includes links to other resources. Readers can accompany Dennis on a fun-filled journey as he prepares to have his tonsils removed, from diagnosis to discharge from hospital. The comic answers children's questions, including: what is a general anaesthetic and is it safe?  how will I feel when I wake up?  how can I prepare for my operation? what should I do if I am worried or have questions? 'Dennis has an anaesthetic' will also help children and their parents and carers understand what happens in the run-up to an operation, the care children will need afterwards and how they can best prepare.
  8. Content Article
    This article for ABC News looks at a study conducted by researchers from the Bond University and other Australian universities about the impact of the 'hero' and 'angel' narratives applied to nurses during the Covid-19 pandemic. They interviewed critical care nurses in the UK, Australia and North America about their perceptions of these terms. The study found that nurses felt the labels devalued their professionalism, created unreasonable expectations, contributed to gender stereotypes and increased burn-out by putting emphasis on showing up for work even when nurses are unwell. The study also highlighted that nurses responded more positively to the terms 'hero' and 'angel' when used by patients, as opposed to governments and the media.
  9. Content Article
    In February 2022, we launched our Patient Safety Spotlight interview series to share stories and insight from people working on the frontline of patient safety—from patient campaigners and healthcare professionals to researchers and health and care leaders. For our final Patient Safety Spotlight of 2022, members of the Patient Safety Learning team share a personal patient safety reflection from the past 12 months and talk about their hopes for next year.
  10. Content Article
    In this episode of the Wild Card - Whose Shoes? podcast, Rachel Power, CEO of the Patients' Association talks about the importance of treating patients as equal partners in the health service. She shares insight on how to measure impact in difficult areas and overcoming barriers to shared decision making.
  11. Content Article
    In this editorial. Peter Walsh reflects on 20 years as Chief Executive of Action against Medical Accidents (AVMA) as he retires from the role. AvMA also marks its 40th anniversary this year, and Peter examines the organisation's unique role in focusing on patient safety and justice for patients. He highlights that healthcare systems and patient safety practice still have a long way to go in offering fairness and support to families affected by avoidable harm in healthcare, and argues that focusing on patients and their families must be a top priority when looking at system safety. He highlights the vital role that AvMA has played in bringing Duty of Candour into law in the countries of the UK, and argues that legal action is an important right that must be retained for patients and families who have come to harm as a result of medical error. He also talks about AvMA's recent development of a Harmed Care Pathway in collaboration with the Harmed Patients Alliance, which outlines the specific set of needs that should form part of a package of care for harmed patients and families.
  12. Content Article
    This editorial in the Journal of Patient Safety and Risk Management reflects on the achievements of the organisation Action Against Medical Accidents (AvMA) over the past 40 years and looks at the emerging role of Patient Safety Learning amongst organisations working for patient safety. Helen Hughes, Chief Executive of Patient Safety Learning, and Albert Wu, Editor-in-chief of the journal, reflect on the purpose and value of patient safety charities and not-for-profit organisations, highlighting the ways in which they channel and champion the patient voice and campaign to address specific areas of recurrent harm. They discuss the vital nature of the patient perspective in driving safety improvements in healthcare, and look at how these organisations amplify this. They also talk about the role of Patient Safety Learning and what it is doing to both drive system change at policy level, and share widely the knowledge of risk and good practice for safer care. They discuss the ways in which Patient Safety Learning delivers its aim to "listen to and promote the voice of the patient safety front line - patients, families and staff.”
  13. Content Article
    This guide by the Patient Information Forum (PIF) provides practical support for translating health information. It offers tips on overcoming key challenges and links to useful resources. It is mainly focused on foreign language translation, but the principles can also be applied to British Sign Language and Braille. Research shows that in the UK, up to a million people cannot speak English well or at all, and these people have a lower proportion of good health than English speakers. Providing culturally appropriate, translated health information can help people manage their own health and take part in shared decision making. Translation is consistently raised as a key challenge by health information producers. Please note, you will need to join PIF to view this content.
  14. Content Article
    The Communication, Apology and Resolution model (CARe) offers healthcare organisations a detailed process for responding to unanticipated adverse outcomes, which includes proactively communicating with patients and families, examining and explaining what happened, avoiding recurrences by improving systems of care and, where appropriate, apologising and offering financial compensation. The model recognises that clinicians and staff will need peer support and training to effectively communicate with patients and families. In June 2022, advocates of the CARe model held an annual forum to highlight the successes of CARe programs in Massachusetts and to look at challenges health care providers face in doing this work consistently across their organisations. This article by the Betsy Lehman Center highlights video recordings shared at the forum including: A family member testimonial by Jane Bugbee, whose healthy daughter, Lindsay, died of Strep A and sepsis shortly after giving birth to her third child in July 2018 A simulation of a resolution conversation with a family A simulation of a conversation with provider after an adverse event.
  15. Content Article
    This report published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) assesses the quality of care provided to adult patients with a pre-existing epilepsy disorder, or who were subsequently diagnosed with epilepsy and presented to hospital following a seizure, between 1 January and 31 December 2020.
  16. Content Article
    This short report from the National Vascular Registry (NVR) provides information on medical devices implanted during primary and revision abdominal aortic aneurysm (AAA) repair procedures during the past three years. In response to the Cumberlege review in 2020, the NVR has enabled information on implantable devices used in aortic aneurysm repairs to be entered in its datasets from July 2020. This was accompanied by the launch of the revision aortic datasets, which capture revision procedures both after open repair and endovascular stent grafting for abdominal aortic aneurysm (AAA). In total, there were 10,678 AAA procedures in the NVR performed from 1st January 2020 to 31st July 2022 and 5,383 (50%) contained information on implanted devices. This report also contains information on the: patterns for elective and non-elective procedures. type of repair for elective and non-elective surgery, for example, open procedures. type of device and components used during the procedures.
  17. Content Article
    Poor mental health is an important and increasingly prevalent issue facing farmers and the farming industry. This article in the journal Sociologia Ruralis seeks to understand the factors that influence the adaptability of support systems for farmers facing mental health issues, especially at a time of crisis. The authors undertook a literature review as well as conducting interviews with 22 mental health support providers and an online survey of people working within support systems and farmers themselves. The study found that support-giving organisations adapted during the pandemic using a range of interventions, but that implementation was affected by organisational and operational challenges such as limited digital training, funding shortfalls, staff trauma, lack of capacity, the rural digital divide, tension between providers and stigma. The authors discuss how landscapes of support for farming mental health can be made more sustainable to deal with future shocks.
  18. Content Article
    Writer and commentator Roy Lilley writes a daily email about what's happening on the ground in the NHS, and how this relates to policy decisions and guidance. Roy describes his eLetters as "a combination of opinion, my take on issues of the day and a news digest of things that I think are important or interesting." In this email, Roy shares several recent accounts sent to him by doctors and other healthcare professionals working in NHS hospitals. They describe dangerous staff ratios, overcrowding and medication shortages. The common theme is dangerously long working hours that could impact on patient safety. Sign up to receive Roy Lilley's daily eLetter.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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.
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