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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The Sentinel Stroke National Audit Programme (SSNAP), which assesses the care provided for patients during and after they receive inpatient care following a stroke, has published its ninth annual report. Based on data from April 2021 to March 2022, the report aims to identify which aspects of stroke care need to be improved with a particular focus on changes in stroke care over the last two years and the ‘roads’ that need to be followed in order to restore the quality of care. SSNAP measures the process of care against evidence-based quality standards referring to the interventions that any patient may be expected to receive. These standards are laid out in the latest clinical guidelines and include: whether patients receive clot busting drugs (thrombolysis). interventions for clot retrieval (thrombectomy). how quickly they receive a brain scan. how much therapy is delivered in hospital and at home.
  2. Content Article
    The National Vascular Registry, which measures the quality and outcomes of care for adult patients who undergo major vascular procedures in the NHS, has published its latest annual report. This report provides comparative information on five major emergency and elective vascular interventions between 2019 and 2021: Repair of aortic aneurysms, including elective infra-renal, ruptured infra-renal, and more complex aneurysms Lower limb bypass Lower limb angioplasty/stenting Major lower limb amputation Carotid endarterectomy The report also includes the results from an organisational audit of NHS vascular services in 2022.
  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 the role of NHS Supply Chain in ensuring the products procured through the NHS Supply are of high quality and are safe for healthcare organisations to use. She also highlights the vital importance of complaints and the need for staff who don’t work in direct care delivery to recognise their role in patient safety.
  4. Content Article
    This interactive tool developed by the Office for National Statistics (ONS) can be used to explore how health changed in each local authority area across England between 2015 and 2020, according to the Health Index.
  5. Content Article
    Established in 2006, the National Neonatal Audit Programme (NNAP) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and delivered by the Royal College of Paediatrics and Child Health (RCPCH). It assesses whether babies admitted to neonatal units receive consistent high-quality care in relation to the NNAP audit measures that are aligned to a set of professionally agreed guidelines and standards. The NNAP also identifies variation in the provision of neonatal care at local unit, regional network and national levels and supports stakeholders to use audit data to stimulate improvement in care delivery and outcomes. This report summarises the key messages and national recommendations developed by the NNAP Project Board and Methodology and Dataset Group, based on NNAP data relating to babies discharged from neonatal care in England and Wales between January and December 2021.
  6. Content Article
    Teamwork is critical in delivering quality medical care, and failures in team communication and coordination are substantial contributors to medical errors. This study in JAMA Internal Medicine aimed to determine the effectiveness of increased familiarity between medical resident doctors and nurses on team performance, psychological safety and communication. The authors found that increased familiarity between nurses and residents promoted rapid improvement of nursing perception of team relationships and, over time, led to higher team performance on complex cognitive tasks in medical simulations. They argue that medical systems should consider increasing team familiarity as a way to improve doctor-nursing teamwork and patient care.
  7. Content Article Comment
    Thanks for your comment Laura, some of the references should be helpful in understanding the link. You might also like to read this article by Emer Joyce which explores the issue further. I've been in touch with the author of the blog, and this is what they said in response to your question: "Is there a cure for myocarditis linked to Covid? I think the key things to do are to avoid exercise in the middle of an acute viral infection. If myocarditis is present, there is a small risk of sudden cardiac death. The other thing is to make sure chest pain and fast heart rate are investigated. Avoiding significant exertion for 3-6 months can allow the heart to heal. Treatment would be according to what a cardiologist advises. We do not know what the long term outcomes are yet."
  8. Content Article
    This document describes the development of the The Northumbria Local Health Index, a collaborative project between Northumbria Healthcare Trust and the Office for National Statistics (ONS). The Health Index aims to produce a more holistic measure of health, recognising health as an asset to the nation and communities. It is a composite measure of 56 indicators across three over-arching domains—healthy people which covers health outcomes, healthy lives which includes behavioural risk factors and healthy places which captures social and wider determinants of health. The Northumbria Local Health Index has created a deeper understanding of how health and the drivers of health differ between areas within the local authorities of Northumberland and North Tyneside and provides a data driven framework that could enable effective and collaborative work to tackle health inequalities. It demonstrates the potential for the Health Index to become a ‘small area’ health tool for planning health and healthcare provision.
  9. Content Article
    Always Events are defined as “those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the health care delivery system”. NHS England has been leading an initiative for developing, implementing, and spreading an approach to reliably integrate Always Events into routine frontline services. Always Events® is a co-production quality improvement methodology which seeks to understand what really matters to patients, people who use services, their families and carers and then co-design changes to improve experience of care. Genuine partnerships between patients, service users, care providers, and clinicians are the foundation for co-designing and implementing reliable solutions that transform care experiences with the goal being an “Always Experience.” This webpage contains: information on the Always Events national programme Always Events toolkit Evaluation of Always Events Always Events film
  10. Content Article
    Safety conversations are an important step in building a proactive patient safety culture. They’re a respectful discussion about safety between two or more people involved in organising, delivering, and seeking or receiving care. This collection of tools and resources, from quick tip sheets to comprehensive reports and frameworks, aims to help healthcare professionals to have effective safety conversations and support safer care of older adults.
  11. Content Article
    Making Families Count aims to improve outcomes for families affected by serious harm and traumatic bereavements in health and social care services. They offer peer support, training, information, advice and guidance to families who have suffered a traumatic bereavement. They also provide independent training in the importance of good family engagement for NHS Trusts, public health and social and care organisations. The training includes working with families after serious incidents, developing Family Liasion work, good engagement throughout treatment and developing resilience for professional staff. The charity's vision is that the NHS, social care and other public bodies will make families count by ensuring that families are integral to health and social care investigations, leading to better investigations, better learning, safer services and the right support for families.
  12. Content Article
    100 days into her role as interim Chief Inspector at the Healthcare Safety Investigation Branch (HSIB), Dr Rosie Pennyworth reflects on her focus so far. She talks about spending time developing close relationships with HSIB staff to ensure she is able to effectively guide them through the transformation process as the organisation becomes the Health Services Safety Investigations Body (HSSIB). She also talks about keeping patients and families at the centre of future strategy and developing an international network with counterpart organisations in the US, Sweden and Norway.
  13. Content Article
    This article in the BMJ highlights a number of recent articles that reflect on the realities facing the health service after the first brutal years of the Covid-19 pandemic. It summarises and links to articles in the BMJ about the elective care backlog, A&E waiting times, remote appointments, Government pressures that stop senior clinicians speaking out about pressures, and the need for credible policy solutions. It also highlights an article outlining how Brexit and the Northern Ireland Protocol have resulted in the UK being denied access to European research funding and meetings.
  14. Content Article
    Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. In this blog, he reflects on what he has learned from 25 years as a human factors expert, highlighting that human factors is essentially about improving work, via design.
  15. Content Article
    You're still entitled to free NHS care if you choose to pay for additional private care. This guidance from the NHS outlines how receiving both private care might affect treatment on the NHS. It looks at the following points: What does 'as clear a separation as possible' mean? Receiving private and NHS care at the same time What treatments can my doctor tell me about? What if I have complications?
  16. Content Article
    Macarthys Laboratories (trading as Martindale Pharma, an Ethypharm Group Company), has notified the MHRA that a limited number of Prenoxad kits (also called packs) in a batch marketed in France have missing needles. Naloxone is a drug that reverses the effects of an opioid overdose. If no needles are present in the kit, there is a risk that patients, members of the public and/or healthcare professionals may not be able to administer life-saving doses of naloxone from these kits in an emergency. This may impede the treatment for a patient with an opioid overdose, which may result in delay to intervention and possible death. Although no reports of UK marketed kits with missing needles have been received to date, the potential for kits to contain fewer than two needles in all distributed batches cannot be excluded based on the investigation by the company. However, due to the critical need for this product, the specified batches are not being recalled. This alert is for action by: primary and secondary care, specifically those involved in outreach services.
  17. Content Article
    In this blog, Melanie Ottewill, National Investigator and Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB), explains how HSIB's work is supporting the NHS to adopt a systems approach to local safety investigations through the Patient Safety Incident Response Framework (PSIRF). She looks at how PSIRF promotes a proportionate response to patient safety incidents, highlights the importance of organisations developing patient safety incident response plans and explores how PSIRF promotes compassionate involvement in patient safety incidents. She also highlights guidance to support staff in planning PSIRF implementation.
  18. Content Article
    The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk NHS Foundation Trust, reflects on her trust's experience of being a PSIRF early adopter. Lucy talks about the benefits of PSIRF and how to make it work in practice. She highlights the need for effective collaboration between teams and the importance of engaging with patients, families and staff in new ways.
  19. Content Article
    Cornerstone is a free publication for anyone passionate about evidence-based healthcare, including Quality Improvement (QI), audit and clinical effectiveness professionals, and those who plan, deliver and receive healthcare. It is produced by the Healthcare Quality Improvement Partnership (HQIP), which was established in 2008 to increase the impact of clinical audit on healthcare quality improvement and support improved outcomes for patients.
  20. Content Article
    Maternal Mortality Review Committees (MMRCs) in the US are multidisciplinary committees that convene at the state or local level to comprehensively review deaths during or within a year of pregnancy. MMRCs have access to clinical and non-clinical information to more fully understand the circumstances surrounding each death, determine whether the death was pregnancy-related, and develop recommendations for action to prevent similar deaths in the future. This article summarises the data from MMRCs in 36 US states between 2017 and 2019, demonstrating variations in prevalence and cause of death according to race, ethnicity and geographical area. The data suggests that over 80% of pregnancy-related deaths examined were determined to be preventable.
  21. Content Article
    It is well known that pausing planned hospital care during the pandemic worsened growing waiting lists, and that waits for routine care now stand at record-breaking levels. This research from the Nuffield Trust, supported by the NHS Race and Health Observatory, looks at how the fallout from the pandemic affected people across different ethnic groups, and whether that impact was spread evenly.
  22. Content Article
    The NHS Friends and Family Test (FFT) is designed to be a quick and simple mechanism for patients and other people who use NHS services to give feedback. This feedback can then be used to identify what is working well and to improve the quality of any aspect of patient experience. This guidance sets out the requirements of the FFT and is intended to support all provider organisations that are required to deliver the FFT.
  23. Content Article
    Think Local Act Personal (TLAP) is a national partnership of more than 50 organisations committed to transforming health and care through personalisation and community-based support. TLAP developed the Making It Real framework to support good personalised care for providers, commissioners and people who access services. These "I" statements are part of Making It Real, and they articulate what good care and support looks like if you are someone who accesses services.
  24. Content Article
    This Australian study in Health Expectations aimed to evaluate the implementation of 'Calling for Help'(C4H), an intervention for parents to escalate care if they are concerned about their child's clinical condition. The study used a convenience sample of 75 parents from inpatient areas during the audit, and the authors held interviews with ten parents who had expressed concern about their child's clinical condition and five focus groups with 35 ward nurses. The authors found that there was an improvement in the level of parent awareness of C4H, which was viewed positively by both parents and nurses. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required and further strategies will be required for parents to feel confident enough to use C4H and to address communication barriers.
  25. Content Article
    This standard operating procedure (SOP) for Leicester Royal Infirmary Children's Hospital outlines the process to be followed at times of increased pressure on services caused by increased acuity or activity in the pathway for non-elective care.
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