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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections.
  2. Content Article
    This webpage outlines the role of Medical Examiner Officers (MEOs), who provide the continuity and oversight that the medical examiner service requires to have the maximum benefit. It includes information on training, induction and recruitment, as well as a model job description for an MEO.
  3. Content Article
    Locum GP Manjula Arora was given a month’s suspension by the Medical Practitioners Tribunal Service (MTPS) in May 2022 after a complaint to the General Medical Council (GMC) that centred on whether or not she had been promised a laptop by her employer. The ruling was overturned and the GMC conducted a review of the case that found that a legal test around dishonesty was incorrectly applied. The two co-chairs of the GMC review highlight some of its recommendations in this opinion piece in the BMJ. They argue that while the NHS is very diverse, it is not very inclusive and that structural racism affects the treatment of and opportunities available to staff from different cultural backgrounds. They call for greater compassion and cultural competency in the GMC, and for healthcare services to manage concerns on a local level before referring cases to the GMC.
  4. Content Article
    This series of short guides aims to help providers and commissioners better understand the use of patient insight and to use it effectively in delivering local services. These topics are covered in the guides: Seeking feedback in distressing or highly emotional situations Writing an effective questionnaire Building greater insight through qualitative research Helping people with a learning disability to give feedback How and when to commission new insight and feedback Insight – what is already available? The National Patient Reported Outcome Measures (PROMS) programme
  5. Content Article
    In this blog, Roger Kline, Research Fellow at Middlesex University Business School, highlights the lack of support from the Government and NHS that healthcare staff with Long Covid face. He looks at the impact of the Government’s decision to scrap extended sick pay for NHS staff with Long Covid and argues that healthcare workers deserve better support. The blog includes accounts from 31 NHS nurses and midwives with Long Covid; some are having to use annual leave as they cannot work their full hours and some have been threatened with redundancy. Others describe their experiences of phased return to work and applying for the NHS Injury Allowance or ill health early retirement.
  6. Content Article
    This editorial in BMJ Quality & Safety examines literature that looks at the negative side effects of quality improvement (QI) approaches and initiatives, arguing that QI can contribute to staff burnout, stress and reduced engagement. The authors make a number of recommendations for avoiding the negative side effects of QI.
  7. Content Article
    Ryan Saunders is a little boy who died in 2007 from an undiagnosed streptococcal infection, which led to Toxic Shock Syndrome. According to the Queensland Clinical Excellence Division, when Ryan’s parents were worried he was getting worse, they did not feel their concerns were acted on in time. This blog outlines Ryan's Rule, a process introduced by the Queensland Department of Health to try and prevent similar events happening in future. Ryan's Rule allows patients and their families and carers to escalate serious concerns about their own or a family member's condition.
  8. 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, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, talks about her experience as an early adopter of PSIRF. She describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. She talks about the open way in which investigation reports are compiled and reviewed to ensure everyone involved is happy with the way events are presented.
  9. Content Article
    On 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
  10. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment. This is the second interim bulletin published as part of this investigation, and findings so far emphasise that an effective response should consider the interactions of the whole system: an end-to-end approach that does not just focus on one area of healthcare and prioritises patient safety. The reference event in this investigation involves a patient who was found unconscious at home and taken to hospital by ambulance. They were then held in the ambulance at the emergency department for 3 hours and 20 minutes and during this time their condition did not improve. The patient was taken directly to the intensive care unit where they remained for nine days before being transferred to a specialist centre for further treatment.
  11. Content Article
    How can NHS provider organisations and systems reliably and sustainably improve care? Historically, most improvement interventions have been discrete, small-scale efforts run by individual teams, often without reference to what else is taking place in their trust. However, it is now widely accepted that a patchwork of local interventions is unlikely to deliver sustained improvement or efficiencies on the scale that policymakers and local leaders want. This report by the Health Foundation outlines learning from the evaluation of the NHS partnership with Virginia Mason Institute, which examined how five NHS trusts in England attempted to build a culture of continuous improvement.
  12. Content Article
    These reports outline the findings of separate investigations into the deaths of three teenage girls who were detained mental health patients in the care of Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV). The reports uncover many systemic failings at West Lane Hospital in Middlesbrough, the secure mental health unit for children where Christie Harnett and Nadia Sharif, both 17 years old, died and where Emily Moore, 18, was placed prior to her death in Lanchester Road Hospital, Durham. The girls had been friends and spent time together at West Lane, and all three deaths were self-inflicted. The reports highlight a total of 119 care and service delivery problems at West Lane including ineffective management, reduced staffing, lack of leadership, aggressive handling of disciplinary problems, issues with succession of crisis management and failures to respond to concerns from patients and staff. Although West Lane was closed in 2019, it was reopened in May 2021 under the new name of Acklam Road Hospital. Subsequent Care Quality Commission (CQC) inspections and further deaths demonstrate that dangerous cultures and practices are still operating in the Trust's inpatient mental health units. In June, the Care Quality Commission (CQC) announced that they will be bringing criminal charges against TEWV in relation to Christie’s death. This document contains three separate investigation reports relating to Christie Harnett, Nadia Sharif and Emily Moore's individual cases.
  13. Content Article
    This article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
  14. Content Article
    Inflammatory rheumatic disease (IRD), such as rheumatoid arthritis, can cause poor outcomes in pregnancy, and the health of the mother and developing foetus must be balanced when making decisions about medication. This updated guideline from the British Society for Rheumatology contains evidence and best practice for prescribing rheumatology medications during pregnancy and breastfeeding. It includes a table that summarises information about drug compatibility in pregnancy and breastfeeding.
  15. Content Article
    The Department for Health and Social Care has launched an investigation into allegations made by 22 former patients of mental health units run by private firm The Huntercombe Group. The group ran at least six children’s mental health hospitals between 2012 and 2022. In this Independent article, young women who were subject to humiliating and sometimes abusive treatment talk about their time as inpatients. Some of the experiences they recount are harrowing: "I would get awoken by staff members restraining me out of bed and dragging me down to the de-escalation room to force-feed me." "Patients were left naked in their rooms under anti-ligature blankets because they wouldn’t buy anti-ligature clothing." "I distinctly remember someone saying ‘if you hit me again, I’ll hit you back ten times harder because there are no cameras in here and you can’t cry to [name of nurse] about it’."
  16. Content Article
    Conversations that leaders have with their team members are the drivers of psychological safety. In this blog, Tanmay Vora looks at how to start conversations that build psychological safety in teams. He includes two infographics which highlight suggested conversation starters for team leaders and team members.
  17. Content Article
    This toolkit from the Institute for Healthcare Improvement (IHI) includes the tools and templates you need to launch a successful Quality Improvement (QI) project and manage performance improvement. The QI tools include: Cause and effect diagram: Also known as the Ishikawa or fishbone diagram, this tool helps you analyse the root causes contributing to an outcome. Failure modes and effects analysis: Also used in Lean management and Six Sigma, FMEA is a systematic, proactive method for identifying potential risks and their impact. Run charts: These charts help you monitor performance over time. PDSA worksheet: Plan-Do-Study-Act rapid-cycle testing helps teams assess whether a change leads to improvement using a methodical learning process. You will need to create an IHI account in order to download the toolkit. You can then download the complete toolkit with all ten tools, or download individual tools as you need them to guide your continuous improvement work.
  18. Content Article
    This tool developed by the Office for Health Improvement and Disparities aims to provide intelligence about the wider determinants of health to help improve population health and reduce health inequalities. Wider determinants, also known as social determinants, are a diverse range of social, economic and environmental factors which impact on people’s health. They are influenced by the local, national and international distribution of power and resources which shape the conditions of daily life, and they determine the extent to which different individuals have the physical, social and personal resources to identify and achieve goals, meet their needs and deal with changes to their circumstances. The tool is updated on an ongoing basis and provides data on the wider determinants, as well as resources to help organisations take further action to tackle health inequalities.
  19. 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
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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
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