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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. 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.
  2. 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.
  3. 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.
  4. 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'.
  5. 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
  6. 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.
  7. 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
  8. News Article
    The NHS in Wales could move to a model in which most or all nursing care is outsourced to private companies, if its increasing reliance on agency staff continues, a union report has claimed. According to the Royal College of Nursing, the Welsh health service risks moving to a situation where it no longer directly employs staff to provide patient care. NHS Wales spent between £133m and £140m on agency nursing during 2021-22, based on different freedom of information (FOI) requests and official figures, the RCN’s report suggested. RCN Wales said, “If this trend continues, Wales will move to a situation where NHS Wales no longer directly employs staff to provide patient care and instead moves to a model in which most or all nursing care is outsourced to private companies.” Read more Source: Nursing Times, 4 December 2022
  9. News Article
    A new report by the World Health Organization shows evidence of a higher risk of premature death and illness among many persons with disabilities compared to others in the society. The Global report on health equity for persons with disabilities published today shows that because of the systemic and persistent health inequities, many persons with disabilities face the risk of dying much earlier—even up to 20 years earlier—than persons without disabilities. They have an increased risk of developing chronic conditions, with up to double the risk of asthma, depression, diabetes, obesity, oral diseases, and stroke. Many of the differences in health outcomes cannot be explained by the underlying health condition or impairment, but by avoidable, unfair and unjust factors. Read more Source: WHO, 2 December 2022
  10. Content Article
    An estimated 1.3 billion people—16% of the global population—experience a significant disability today. People with disabilities have the right to the highest standard of health, however, this report by the World Health Organization (WHO) demonstrates that while some progress has been made in recent years, many people with disabilities continue to die earlier and have poorer health than others. The report demonstrates how these poor health outcomes are due to unfair conditions faced by people with disabilities in all areas of life, including in the health system itself.
  11. News Article
    Whistleblowers at one of England's worst performing hospital trusts have said a climate of fear among staff is putting patients at risk. Former and current clinicians at University Hospitals Birmingham (UHB) NHS Trust allege they were punished by management for raising safety concerns, a BBC Newsnight investigation found. One insider said the trust was "a bit like the mafia." The trust said it took "patient safety very seriously." It said it had a "high reporting culture of incidents" to ensure accountability and learning. Staff concerns included a dangerous shortage of nurses and a lack of communication leading to some haematology patients dying without receiving treatment, an investigation by BBC Newsnight and BBC West Midlands found. Read more Source: BBC News, 2 December 2022
  12. News Article
    In September, Shine Lawyers won a $300 million settlement in two class actions over the failed mesh products by Johnson & Johnson Medical and Ethicon. However, the law firm is proposing to take up to $99.5 million from the payout in costs, just under a third of the total sum. Of 11,000 women involved in the class action, Janelle Gale is one of 200 who is not happy with Shine Lawyers' compensation proposal. Representatives of the group said there was mass confusion over what compensation they might be eligible for and how many hoops they would have to jump through to receive a payment. Despite having barely any leakage before her 2014 surgery, afterwards Janelle became heavily incontinent. She was a drag-racing champion, but that came to a halt. She said it destroyed her marriage, she couldn't have sex and she still can't work. Read more Source: ABC News, 3 December 2022
  13. Content Article
    There is a huge challenge to improve technology adoption and readiness across the NHS. This article in HSJ looks at a partnership between tech services company Agyle and Dorset County Hospital (DCH) which aimed to develop a digital patient record strategy which places user experience at the heart of its approach. DCH's objective was for its staff to access a decreasing number of systems, designed around clinical processes, with data flowing seamlessly between those systems. The article looks at how Agyle and DCH worked together to achieve improved clinical safety, interoperability, cost-effectiveness and future-proofing through their strategy.
  14. Content Article
    In this HSJ article, Gemma Dakin and George Croft from the Health Innovation Network share their reflections on the HSJ Patient Safety Congress. They highlight key themes that emerged including the need to listen to patients, service users, and carers stories, and encourage their involvement to bring about a cultural change. They argue that humanity will be central to making progress in quality improvement and patient safety.
  15. Content Article
    On 31 January 2023, the clinical trial information system (CTIS) will become the single entry point for sponsors and regulators of clinical trials in the European Union (EU). The CTIS includes a public searchable database for healthcare professionals, patients and the public. This webpage contains information on how clinical trials are regulated in the EU, and what changes the CTIS will make to how clinical trials are registered, performed and regulated.
  16. Content Article
    This report by the Beryl Institute and Ipsos explores the core trends impacting healthcare and patient experience overall in the United States. It highlights key issues expressed by consumers in an online survey relating to quality of care and experience of care, taking into account the impact of the Covid-19 pandemic and how it has altered the delivery of healthcare.
  17. Content Article
    In this blog for The Patients Association, Patient Safety Commissioner Henrietta Hughes looks at the importance of patient involvement in improving patient safety. She argues that patient voices should be embedded in the design and delivery of healthcare, and highlights that services and organisations need to seek feedback from patients from a wide variety of backgrounds. She also outlines why shared decision making and consent are vital to ensure patients are safe and have more control over their care and treatment.
  18. Content Article
    The Secretary of State for Health and Social Care, Rt Hon Steve Barclay MP has announced that Dr Ted Baker has been formally appointed as the new chair of the Health Services Safety Investigations Body (HSSIB). This blog describes Dr Baker's experience and outlines what his new role will involve, including setting up the new board for HSSIB. He said, “My focus will be to build on the strong legacy of the HSIB and make sure, as the HSSIB, that we take even greater strides along our journey to improving patient safety.”
  19. Content Article
    In this interview for the Betsy Lehman Center in Massachusetts, Lee Kim Erickson, Senior Vice President and Chief Quality Officer at Wellforce, talks about maintaining a focus on patient safety during times of crisis, the impact of the Covid-19 pandemic on training for healthcare workers and the importance of maintaining a focus on care from the patient's point of view.
  20. Event
    until
    This session hosted by the Advancing Quality Alliance (Aqua) aims to help Senior Leaders in the NHS understand the what, why and how of the Patient Safety Incident Response Framework (PSIRF) and what it means in terms of responsibilities, assurance, and review of investigation outcomes (moving from blame towards learning and improvement). This event is aimed at Executive and Non-Executive Directors. Register
  21. Event
    until
    This session hosted by the Advancing Quality Alliance (Aqua) aims to help Senior Leaders in the NHS understand the what, why and how of the Patient Safety Incident Response Framework (PSIRF) and what it means in terms of responsibilities, assurance, and review of investigation outcomes (moving from blame towards learning and improvement). This event is aimed at Executive and Non-Executive Directors. Register (Please note, this event will be repeated on 5 December 2022)
  22. Content Article
    In this opinion piece for the Daily Mail, journalist Tom Utley recounts his recent experience of a seven hour wait at A&E after receiving abnormal blood test results from his GP. He argues that fear of litigation is causing GPs to refer patients on to A&E unecessarily, contributing to the overcrowding happening at emergency departments. He also highlights inefficiencies in the system and states that lack of staff capacity to tell him he didn't require any treatment meant he stayed an additional hour and a half in the waiting room.
  23. Content Article
    This editorial by Barbara Fain, Chief Executive of the Betsy Lehman Center in Massachusetts, highlights the need to focus on system safety and moving away from a culture of individual blame, in order to improve patient safety. Referring to the case of nurse RaDonda Vaught who was convicted of negligent homicide for a medication error at a Tennessee hospital, Barbara looks at research that demonstrates that people generally believe the best way to reduce the likelihood of medical errors is by choosing the right doctor, and argues that this cultural belief played into Vaught's conviction. She highlights the need to use evidence-based strategies to communicate with healthcare professionals and the public about the wider picture of patient safety and systems thinking.
  24. Content Article
    This video by the NHS England National Patient Safety Team provides tips for patients on keeping safe during a hospital stay. It highlights simple things you can do as a patient to help keep yourself safe during a hospital stay, such as asking for help when needed, protecting yourself from slips and falls and helping to prevent blood clots. A British Sign Language (BSL) version of the video is also available, as well as a leaflet translated into these languages: English Arabic Cantonese French Gujarati Mandarin Polish Portuguese Punjabi Romanian Spanish Urdu
  25. Content Article
    In this podcast, the Learn from Patient Safety Events (LFPSE) team talks to the National Director for Patient Safety about the new LFPSE service, why it’s important, and the benefits he thinks it will bring for patient safety.
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