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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This webpage provides information about patient rights and responsibilities while under the care of John Hopkin's Children's Center. It includes the following resources and guides: Patient and family handbook Preparation Pain management Your child’s care team Rooms Meals Visitation Patient safety Parent and family journal
  2. Content Article
    This report by the US non-profit organisation the Emergency Care Research Institute (ECRI) was commissioned by the US Food and Drug Administration (FDA) to determine the safety profile of polypropylene (PP) mesh used in a variety of surgical procedures. ECRI performed a comprehensive literature search and systematic review to identify the current state of knowledge about how patients' bodies respond to PP mesh.
  3. Content Article
    Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place.
  4. Content Article
    This opinion piece in the New Scientist looks at the persistence of the gender pain gap and highlights research that demonstrates its persistence in healthcare systems. An increasing number of studies have shown how bias against women’s expressions of pain negatively affect diagnosis and treatment of their health conditions; misinterpretations of female pain as anxiety contribute to women being around 50% more likely to be misdiagnosed after a heart attack. It also looks at how women who are Black, Asian or from ethnic minority backgrounds experience more underestimation of their pain by healthcare professionals than white women. The author argues that gendered myths about pain have had a powerful impact on centuries of scientific and biomedical advances.
  5. Content Article
    This article by the consultancy firm Carnall Farrar looks at the opportunity the newly established Integrated Care Systems (ICSs) have to improve health outcomes, tackle inequalities, enhance productivity and support broader social and economic development. The relationship between deprivation and health outcomes is well known and evidenced, and by working collaboratively, the NHS, local authorities and Voluntary, Community and Social Enterprise (VCSE) organisations can address the wider determinants of health outcomes, starting with the impact of deprivation.
  6. Content Article
    Drugwatch is a US consumer advocacy organisation that works with certified medical and legal experts to educate the public on dangerous drugs and medical devices and to empower consumers to assert their legal rights. In this article, Terry Turner, writer for Drugwatch, examines the history of the medical tech company C.R. Bard, which specialises in vascular, urology, surgery and oncology devices. Bard manufactures thousands of medical devices and sells them worldwide. The article looks at how the company was established and then examines several legal issues Bard has faced, including criminal charges stemming from medical fraud and accusations of selling defective devices that have killed patients or caused serious complications. The author looks at criminal charges concerning heart catheters to which Bard pleaded guilty. They also highlight problems with Bard's transvaginal and hernia mesh products and inferior vena cava (IVC) filters—devices designed to catch blood clots before they reach the lungs or the heart.
  7. Content Article
    This report by the National Medical Examiner, Dr Alan Fletcher, summarises the progress made by medical examiner offices in 2021 and outlines areas of focus going forward. It highlights that medical examiners continued to receive positive feedback from bereaved people—many said they appreciated being given the opportunity to have a voice in the processes after a death and knowing any concerns were listened to. It includes information on: The national medical examiner system Implementation Guidance and publications Training Stakeholders Increasing the number of non-coronial deaths scrutinised Feedback received by medical examiners in England and Wales
  8. Content Article
    The General Medical Council (GMC) commissioned this research to understand the decision-making processes of doctors leaving the UK workforce to practise medicine overseas. This research built on previous work by exploring migration ‘decision journeys’ and the practical steps and considerations involved at each stage of the process.
  9. Content Article
    This study in Health Expectations aimed to identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H). Guided by the Theoretical Domains Framework, the authors carried out audits, semi-structured interviews and focus groups in an Australian paediatric hospital where a parent escalation of care process was introduced in the previous six months. The authors found that although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organisational behaviour changes.
  10. Content Article
    This document outlines the standard operating procedure (SOP) adopted by University Hospitals Bristol NHS Foundation Trust, relating to parental involvement in escalation of clinical care for acutely ill children. It aims to clarify the process of empowering parents to escalate concerns if they are worried about the clinical condition and care being delivered to their child, or themselves if they are a patient. It also aims to ensure accurate and appropriate information is provided to parents on admission (elective and acute) regarding how they should escalate concerns about the care their child is receiving.
  11. Content Article
    The Beryl Institute formed a working group of patient experience leaders from a variety of healthcare organisations to develop its definition of patient experience. The group shared perspectives, insights and backgrounds on what patient experience means to them and collaboratively created a definition, which is described in this video.
  12. Content Article
    This paper in the Journal of Patient Safety and Risk Management addresses the issue of untested products being used on the basis of 'equivalent' products having undergone regulatory testing. Manufacturers of competing products often use each other’s evidence, arguing that the published evidence is generally applicable even if the original tests and trials were performed on only one specific product. In this study, the authors looked at prophylactic dressings for pressure injury prevention to demonstrate how patient safety may be compromised if study conclusions are projected onto unstudied products.
  13. Content Article
    Shaped by the contributions and learning of the Beryl Institute community, these foundational frameworks provide a path for organisations to guide and assess their experience journey. Each framework offers strategic concepts, suggests practical actions and links to applicable resources. There are three frameworks available: Guiding principles - Foundational commitments to build your experience strategy Experience framework - Integrated strategy to frame your experience efforts The new existence- Roadmap to transform human experience in healthcare
  14. Content Article
    In this blog, Luke Yamaguchi describes his experience of hernia mesh surgery and the impact the procedure had on his health. He tells his story of having laparoscopic hernia repair using polypropylene (PP) mesh, which left him with severe chronic pain. After nine years, he underwent mesh removal surgery. Alongside his story, he describes the risks associated with surgical mesh and the use of PP as a material, highlights the lack of research about its side-effects and draws attention to the role of industry in promoting the use of mesh.
  15. Content Article
    This webinar hosted by GovConnect features three presentations about digital wound management:Digital data and information (National Wound Care Strategy Programme)York Community Services approach to engagement of staff in digital changeDigitising wound care in the community: The challenges and successes (Livewell Southwest)
  16. Event
    This conference will allow NHS organisations, local councils and others to come together and discuss collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve. Attendees from the NHS and Local Authorities will learn that by working alongside each other, and drawing on the expertise of others such as local charities and community groups, they can help people to live healthier lives for longer, and to stay out of hospital when they do not need to be there. Buy tickets
  17. Content Article
    This study in BMJ Open Quality examines aspects of workplace culture, employee motivation and leadership behaviours that support continuous learning and improvement, in an effort to measure the transition to high reliability. It reports on the development of two scales (trust in team members and trust in leadership) in a US children’s hospital which was seeking to assess progressive movement towards a ‘culture of safety'. The scales were designed to measure two cultural conditions fostered by the five high reliability principles and a composite measure on local learning activities.
  18. Content Article
    This analysis by The Health Foundation looks at NHS staff pay over the ten years to 2021. During those 10 years, there was very little change in overall average basic pay for NHS staff, after accounting for inflation. However, the analysis found considerable variation in how pay has changed across different NHS staff groups over the same period. After accounting for inflation, pay declines are particularly visible for nurses and health visitors, midwives, and scientific, therapeutic and technical staff.
  19. Content Article
    This article outlines how the first trials relating to harm caused by the LifeCell Strattice biologic patch will proceed. The Strattice patch is a form of surgical mesh used to treat hernias, but unlike other polypropylene mesh devices, it is composed of pig skin preserved in a solution that chemically links together proteins in the tissue. Patients involved in the US litigation complain that they suffered painful injuries from the Strattice patch. They claim that the manufacturer knew it had problems following multiple reports from patients, but failed to act to stop its use. The US Food and Drug Administration (FDA) received at least 450 adverse event reports on Strattice from September 1990 until September 2020. Among those reports were six patient deaths and 340 patient injuries, and many patients have had to undergo mesh removal.
  20. Content Article
    In this article for The Times, Deborah Ross describes her negative experience of NHS maternity care during and after labour, and how this has put her off having more children. During her 72-hour labour and subsequent hospital admission, she was denied pain relief, did not feel listened to and was not informed as to why her baby had been transferred to NICU.
  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. Kathy tells us about the importance of breaking down barriers to share patient safety tools, and talks about changes she has implemented to make surgery safer.
  22. Content Article
    World Pharmacist Day is an initiative by the International Pharmaceutical Federation (FIP) to promote the role that pharmacists play in improving patient safety. In this blog, Roohil Yusuf, Global Pharmacy Advisor at Save the Children, looks at the work of different partners in delivering safe pharmacy services in Afghanistan, Yemen and Sudan.
  23. Content Article
    When a loved one dies, any delay in the registration or release of a deceased patient’s body can be distressing for the bereaved. The medical examiner system is being introduced in England and Wales to provide bereaved families with greater transparency and opportunities to raise concerns, improve the quality and accuracy of medical certification of cause of death, and ensure referrals to coroners are appropriate. These good practice guidelines set out how the National Medical Examiner expects medical examiner offices to operate during the non-statutory phase of the programme.
  24. Content Article
    The REACH Toolkit provides information, resources and quality improvement (QI) tools for managers and clinicians to improve patient, carer and family recognition and escalation of clinical deterioration in NSW health services. The resources can be adapted to suit local needs including initial program implementation, to review and improve current practices or to support current practice.
  25. Content Article
    The HypoBaby blog is written by the parents of Noah, a young boy who was diagnosed with type 1 diabetes as a baby. In this post, they describe Noah's diagnosis and why it took so long to work out that it was diabetes causing his symptoms. Noah ended up in diabetic ketoacidosis (DKA) and needed emergency treatment. They highlight the importance of being aware of the symptoms of type 1 diabetes, stating that if they had been aware of the symptoms, he may have been diagnosed sooner.
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