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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Psychological safety refers to creating and maintaining an environment in which members of a team feel able to speak up without fear of negative consequences. It allows healthcare professionals to take the interpersonal risks needed to engage in effective teamwork and to maintain patient safety. This Padlet board set up by Becky Thomas is a place to post resources and articles related to promoting psychological safety.
  2. Content Article
    In this blog, The Patients Association's Chief Executive Rachel Power argues that the findings of the independent investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust demonstrate the repeated failure of maternity services in England to offer safe and compassionate care to families. She outlines the key findings of the report, including catastrophic failures in the organisation's culture, team working and professionalism, and failure to listen to patients. She highlights that the lack of honesty shown by the Trust to individuals and families harmed by the hospitals' failures is shocking, and compounded the suffering felt by each family.
  3. Content Article
    The Social Care Institute for Excellence (SCIE) and Think Local Act Personal have been facilitating a Community of Practice (CoP) for commissioners looking to work with co-operatives and community businesses. The CoP brings together nine local councils with a shared ambition to move away from large scale ‘time and task’ home care. This report details learnings from phase one of the CoP which has concentrated on sharing the ambition, opportunities, risks and barriers to developing community businesses and co-operatives.
  4. Content Article
    This series of short articles by the Nuffield Trust looks at common criticisms of the NHS, and provides evidence as to why they are untrue. The articles look at the following four interrelated arguments: We already spend too much on our health and despite this our outcomes are poor The NHS is a ‘sacred cow’ and has not been reformed We should copy other countries and adopt a social insurance model There is not enough use of competition and choice
  5. Content Article
    In this opinion piece for The BMJ, David Oliver, consultant in geriatrics and acute general medicine, highlights the findings of three recent reports into the growing crisis in social care: Falling short: How far have we come in improving support for unpaid carers in England? (The Nuffield Trust) The state of the adult social care workforce in England 2022 (Skills for Care) The Cost of Caring: Deprivation and Poverty among Residential Care Workers in the UK (The Health Foundation) The reports evidence a lack of support for unpaid carers, growing vacancies in the sector and a high proportion of the residential care workforce living in poverty and food insecurity. David Oliver highlights that in spite of Government promises, there is still no feasible, future-proof plan to protect social care and its staff.
  6. News Article
    The NHS faces an “exodus” of female doctors who are struggling to work due to a lack of menopause support, a report has warned. The Medical Protection Society, which helps doctors in legal and ethical disputes, said that many quit or reduce their hours over fears that their menopause symptoms, such as brain fog, insomnia and hot flushes, will cause them to accidentally harm patients. A survey found that 36 per cent of female doctors have considered reducing their hours because of menopause symptoms, while one in five have considered early retirement. “With females making up most of the healthcare workforce, it is crucial that they can access the support they need to avoid an exodus from the profession,” the report said. Read full story (paywalled) Source: The Times, 26 October 2022
  7. Event
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    This winter The Patients Association is bringing patients, carers and healthcare professionals together to talk about patient partnership. Join the following speakers to hear some great examples of regional working: Helen Hassell to talk about work the Patients Association is doing with Notts ICS on the MSK pathway Dr Debbie Freake, GP and member of the National Centre for Rural Health and Care Heather Aylward, and Lauren Oldershaw, from NHS Hertfordshire and West Essex Integrated Care Board, on their work with 155 GP practices' patient participation groups, which the Patients Association is supporting Register for this event
  8. Event
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    This winter The Patients Association is bringing patients, carers and healthcare professionals together to talk about patient partnership. As part of the week, Dr Henrietta Hughes, Patient Safety Commissioner for England, will be in conversation with our Chief Executive, Rachel Power. Register for this event
  9. Event
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    This winter The Patients Association is bringing patients, carers and healthcare professionals together to talk about patient partnership. Join the following speakers to hear some great examples of shared decision making: Aimee Robson, Deputy Director, Personalised Care, NHS England, & Duvie Dafinone, Patient and Public Voice Partner, on decision support tools launched this summer to support shared decision making. Dr Sam Finnikin, GP, Sutton Coldfield and clinical research fellow, University of Birmingham, on Our Health – Our Knowledge, a new resource designed to help people who are thinking about choices in healthcare. Register for this online event
  10. Event
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    This online workshop will be co-hosted by the General Osteopathic Council and the Collaborating Centre for Values Based Practice, St Catherine's College, Oxford. It will explore the benefits and importance of shared decision making to both practitioners and patients as well as the challenges in making shared decision making a reality in consultations. It will also introduce a range of resources co-produced with patients and health practitioners to help patients and clinicians to express what is important to them in a consultation. Speakers include: Rachel Power, Chief Executive of the Patients Association Professor Ashok Handa, and Professor Bill Fulford, Co-Directors of the Collaborating Centre for Values Based Practice Register for the workshop
  11. Content Article
    In this BMJ feature, journalist Emma Wilkinson looks at how a shortage of health visitors in England is leaving babies and children exposed to safeguarding risks, late diagnosis and other problems. An estimated third of the health visitor workforce has been lost since 2015, and research by the Parent-Infant Foundation suggests that 5000 new health visitors are needed. Families are not getting the minimum recommended number of contacts with health visitors during the first three years of life, and research into the impact of this on children's outcomes is ongoing. Emma speaks to different mothers, including Phillippa Guillou, who had a baby in 2020 and struggled to breastfeed. Philippa felt unsupported and ignored by her local health visiting service, who only saw her once by videocall when her baby was one year old.
  12. News Article
    Children’s hospitals are under strain in the United States as they care for unusually high numbers of kids infected with RSV and other respiratory viruses. Respiratory syncytial virus, a common cause of cold-like illness in young children known as RSV, started surging in late summer, months before its typical season from November to early spring. This month, the United States has been recording about 5,000 cases per week, according to federal data, which is on par with last year but far higher than October 2020, when more coronavirus restrictions were in effect and very few people were getting RSV. Jesse Hackell, a doctor who chairs the committee on practice and ambulatory medicine for the American Academy of Pediatrics, said, "It’s very hard to find a bed in a children’s hospital — specifically an intensive care unit bed for a kid with bad pneumonia or bad RSV because they are so full.” Read full story Source: The Washington Post, 21 October 2022
  13. Content Article
    A toxic organisational culture has been shown to contribute more to staff leaving and reporting ill health, than pay and other factors. In this blog, Brandi Neal, Director of Content Creation & Marketing at the consultancy Radical Candor, looks at three traits of a toxic company culture: obnoxious aggression, ruinous empathy and manipulative insincerity. She highlights the value of the radical candor approach, which involves caring personally for staff while challenging them directly, and building genuine relationships with your team,
  14. Content Article
    Patient lead users can be defined as patients or relatives who use their knowledge and experience to improve their own or a relative’s care situation and/or the healthcare system, and who are active beyond what is usually expected. This study in the BMJ Open aimed to explore patient lead users’ experiences and engagement during the early Covid-19 pandemic in Sweden, from 1 June to 14 September 2020. The authors recruited 10 patient lead users living with different long-term conditions and undertook qualitative in-depth interviews with each of them. They found that health systems were not able to fully acknowledge and engage with the resource of patient lead users during the pandemic, event though they could be a valuable resource as a complementary communication channel.
  15. Content Article
    They play a vital role in society, but workers in adult social care – who are mostly women – are among the lowest paid in the UK and experience poor working conditions. This report by The Health Foundation analyses national survey data from 2017/18 to 2019/20 to understand rates of poverty and deprivation among residential care workers in the UK. It then compares these rates to other sectors including health, retail, hospitality and administration. The analysis demonstrates that: over a quarter of the UK’s residential care workers lived in, or were on the brink of, poverty. Nearly 1 in 10 experienced food insecurity. Around 1 in 8 children of residential care workers were ‘materially deprived’, meaning they may not have access to essential resources such as fresh fruit and vegetables or adequate winter clothing. the prevalence of poverty and deprivation in residential care is similar to hospitality, retail and administration. But residential care workers experienced much higher rates than most workers – and were at least twice as likely to experience poverty and food insecurity than health workers. Their dependent children were nearly four times as likely to experience material deprivation than children of health workers. The report highlights that political and economic conditions have changed since the data they looked at was collected, meaning that the situation is likely to have worsened for many social care workers. The poorest households in the UK are being disproportionately affected by sharp rises in inflation and poverty is set to increase. The report also highlights chronic underfunding in the social care sector, particularly in England, and calls on the new Government to make it a priority to ensure social care workers are paid fairly.
  16. Content Article
    Since 2013/14, there has been a growth in the volume and value of clinical negligence claims involving patients with diabetes-related lower limb complications. The majority of claims have involved patients with a diabetic foot ulcer who went on to undergo a major lower limb amputation. This thematic review by Nicole Mottolini, Clinical Fellow at NHS Resolution, looks at 92 claims of negligence for lower limb problems involving patients with diabetes. The author used qualitative analysis to identify recurrent clinical themes leading to patient harm including unacceptable delays in diagnosis, delayed referral to specialised care and failures in the Multidisciplinary Diabetic Foot Team (MDFT). Her report highlights shortcomings in diabetes foot care in England, makes recommendations to improve patient care and proposes certain standards which should be put into practice and regularly audited.
  17. News Article
    Harm to patients has become “normalised” as burned-out paramedics are working without breaks, the national care watchdog has warned. Concerns over the pressures on staff at South East Coast Ambulance Service have been raised by the Care Quality Commission (CQC). Senior staff told the CQC that patients were being adversely affected by ambulance delays but it was now being seen as “part of the culture”. The CQC found pressures on staff within the South East Coast Ambulance Service, such as long waits outside of the emergency department, had led to low morale and staff feeling they were not valued. It said: “Staff described feeling frustrated and burnout and that senior leaders did not understand or respond to the challenges or concerns they raised. Some local senior managers described that harm to patients, caused by delays in reaching them, had become normalised as a culture.” “At times there were many outstanding category 3 [urgent] patients awaiting an ambulance or assessment by a paramedic practitioner. At busy times, these patients waited for extended lengths of time for crews and callbacks. Therefore, this group of patients were at risk of deterioration whilst they were waiting for a response.” Read full story Source: The Independent, 26 October 2022
  18. News Article
    People with suspected cancer in England are facing a higher risk of “worrying” outcomes owing to unacceptable delays in being referred to hospital, experts have said, as figures show seven in 10 NHS trusts are failing to hit a key target. The number of NHS trusts missing the national target for urgent cancer referrals is the highest it has been for at least three years, according to analysis of NHS data. In England, the maximum waiting time for a hospital appointment for suspected cancer is two weeks from the day the hospital receives a referral letter from a GP. At least 93% of patients should be seen within 14 days, according to the NHS. But analysis by the PA news agency, using data from August 2019 to August 2022, shows this target is routinely being missed, putting patients at greater risk of poor outcomes. Minesh Patel, head of policy at Macmillan Cancer Support, said: “There are huge pressures even at that early stage of the cancer pathway, let alone when you get to treatment, and it is really worrying for somebody’s prognosis. If somebody starts treatment later, the more worrying the outcome could be in terms of their ability to survive their cancer, to have minimal after-effects after a treatment. This is about survival and giving people the best chance and improving their quality of life, ultimately.” Read full story Source: The Guardian, 26 October 2022
  19. News Article
    Cuts to public health budgets will hit poorest communities the hardest, the new government is being warned. Directors of public health say local authorities - which pay for initiatives such as smoking cessation services - are on a financial cliff edge. Rising inflation means ventures will cost more to run. Any reduction in funding in next week's spending announcement will have a direct impact on the lives of the most vulnerable, they said. David Finch, assistant director of healthy lives at The Health Foundation, said: "Public health interventions have been shown to be really cost effective. Investing in these preventative measures that help to keep people in good health in the first place means you're protecting against future costs to the economy and society by keeping people healthy and reducing poor health in the future." Read full story Source: BBC News, 26 October 2022
  20. Content Article
    According to a recent research study published in the journal Annals of Internal Medicine, over a million people with diabetes in the US rationed their insulin in the past year. When people with diabetes ration their insulin, either by taking less than they need or skipping doses, it poses a serious safety risk and has a negative impact on their long-term health. This article highlights that the main cause of insulin rationing is the high cost of insulin in the US, with pharmaceutical companies increasing prices annually even though the product remains the same. It outlines the main issues caused by insulin rationing and looks at the need for reform to ensure that all Americans with diabetes are able to access adequate insulin. The author speaks to Stephanie Arceneaux who has had type 1 diabetes for 30 years. Stephanie describes her experiences of deciding whether or not to eat and therefore use more insulin, and of having to ration blood glucose test strips.
  21. Content Article
    In this blog, Eve Namisango, Programs and Research Manager at the African Palliative Care Association, looks at the importance of patient and public involvement and engagement (PPIE) in palliative care research. She highlights recent work with the Uganda Cancer Society to explore best practices for engaging patients and caregivers and looks at key issues to consider when structuring PPIE in research.
  22. Content Article
    Since 2018, Nicola Burgess has led a team from Warwick Business School that evaluated the partnership between the English NHS and the Virginia Mason Institute in the USA. The partnership aimed to implement a systematic approach to quality improvement (QI) in five English NHS trusts and learn lessons about how to foster a culture of continuous improvement across the wider health and care system. In this blog, she summarises six key lessons from the evaluation report for health and care leaders looking to build a systematic approach to QI. Build cultural readiness as the foundation for better QI outcomes Embed QI routines and practices into everyday practice Leaders show the way and light the path for others Relationships aren’t a priority, they’re a prerequisite Holding each other to account for behaviours, not just outcomes The rule of the golden thread: not all improvement matters in the same way
  23. Content Article
    The Patients Included charters were created by Lucien Engelen in 2010. Fed up of hearing people talk about 'what the patient wants' at medical conferences where no patients were present, he decided he would no longer speak at or attend conferences where patients were not speaking, offered bursaries to attend or part of the organising committee. The charters provide organisations with a way to demonstrate their commitment to incorporating the experience and insight of patients into their organisations by ensuring that they are neither excluded nor exploited. The charters that have been published so far include: Conferences (v.1.0 May 2015) Journals (v.1.0 April 2016) Patient information resources (v.1.0 December 2016) Ethics (v.1.0 April 2018) The Patients Included logo can also be used by conferences who adopt the conference charter.
  24. Content Article
    This NHS England podcast examines how the application of system-based approaches to learning from patient safety incidents will be vital to the success of the Patient Safety Incident Response Framework (PSIRF). Guests Darren Thorne from the consultancy Facere Melius, Jane Carthey, a Human Factors and Patient Safety Consultant and Laura Pickup from the Healthcare Safety Investigation Branch (HSIB) discuss NHS England's learning response toolkit.
  25. News Article
    The cost of living crisis could force dying patients to move into hospice beds as they can no longer afford to heat their homes, it is claimed. The stark warning comes as the care sector faces soaring energy bills of its own, with the industry predicting a huge hike in costs next year. Speaking about the impact the cost of living crisis is having on patients, Paul Marriot, Chief Executive of North East hospice St Cuthbert’s, said: “Here in the North East, for example, many of our patients are already on low incomes and the fact that they are ill increases their costs. The key thing is that they are in a time in life when they’ve got less choice around what they do about [costs]. So it’s not an opportunity for them to switch off the heating, it’s not an option for them, just to wear more clothes, it’s not an option for them to see it out until the spring, because they may not be here in the spring." Read full story Source: The Independent, 17 October 2022
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