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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Event
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    The concerns about the state and stability of the NHS were deeply entrenched before 2020 and then of course the pandemic hit. The additional pressures and longer waiting times for appointments and treatment have only grown following a time when the NHS staff have experienced stresses like they never have before. The situation has led to increased fears of privatisation and increasing staff shortages as so many seek work elsewhere. But where does this leave our national health service and what does the future hold for a life saving institution which is struggling to survive itself? Join the Independent’s latest panel discussion as part of our virtual event series where our health correspondent Rebecca Thomas will ask a panel of experts including Dr Alexis Paton, director at the Centre for Health and Society, Hannah Barham-Brown, a GP and also deputy leader of the Women’s Equality Party and Dr Suzanne Tyler, RCM's Executive Director, Trade Union, about how they think the NHS can be healed and how it’s future can be secured. Register for the event
  2. News Article
    An expert panel convened by the US Food and Drug Administration voted 14-1 on Wednesday to recommend withdrawing a preterm pregnancy treatment from the market, saying it does not work. During the sometimes contentious three days of hearings, the drugmaker Covis Pharma, backed by some clinicians and patient groups, had argued there is evidence to suggest the drug, called Makena, might work in a narrower population that includes Black women at high risk of giving birth too soon. But FDA experts and others said the data does not support such a view. In closing arguments, Peter Stein, director of the Office of New Drugs at the FDA’s Center for Drug Evaluation and Research, agreed on the urgent need for a drug to reduce the incidence of preterm birth — a leading cause of infant mortality in the United States. But he said the data indicates that Makena is not that drug. Stein said, “Hope is a reason to keep looking for options that are effective,” he said. “Hope is not a reason to take a drug that is not shown to be effective, or keep it on the market.” Read full story Source: The Washington Post, 19 October 2022
  3. Content Article
    This Health and Social Care Select Committee report examines the pressure currently facing general practice, which is leading to low morale, GPs leaving the profession and problems recruiting new GPs. In turn, patients are increasingly dissatisfied with the level of access they receive. The root cause of the situation is that there are not enough GPs to meet the ever-increasing demands on the service, coupled with patients presenting with increasing complexity due to an ageing population. The report outlines the Committee's assessment of the key issues, including the problems with reliance on locum doctors and lack of continuity of care, and outlines what the Government should do to equip general practice for the future.
  4. News Article
    The main corridor of an acute hospital has been closed to patients and staff and turned into a ‘makeshift ward’, in what sources describe as an ‘absolutely unprecedented’ situation. The move by Aintree Hospital comes after staff clashed with paramedics last week about whether ambulance patients could be brought into the crowded emergency department. One staff member, who wished to remain anonymous, said: “It’s exceptional for this to happen, but I can see it happening more over winter. It’s a rock and a hard place… either you wait in the ambulance if the queue is too long, or you wait in the main hospital corridor. Neither option is ideal.” Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said: “Across the country, the urgent and emergency care system is in unprecedented crisis. Emergency medicine teams and our paramedic colleagues are doing their very best to deliver effective care in exceptionally difficult circumstances. Circumstances like these require ICB leaders to engage, take control of the situation and accept their responsibility. This will both help to de-escalate the situation and ensure the right decision is made for the patients, the ED teams and ambulance crews." Read full story Source: HSJ, 19 October 2022 (paywalled)
  5. Content Article
    This opinion piece by GP educator and writer John Launer looks at the current delays and cancellations to routine appointments facing patients with long term conditions. He describes his personal experience of waiting three years with no face-to-face of phone appointment to review his condition, when this should happen every six months. John outlines the fact that routine outpatient care in some hospitals is unravelling, but with no monitoring of the situation and without publicity. He highlights the risks for patients who are not receiving the regular contact with healthcare professionals that they need, including medical complications, emergency admissions and even preventable deaths. There is particularly risk to patients who do not feel able to contact their consultant or specialist. When speaking to the hospital department about how the risks were being mitigated, John was concerned to discover that there were no screening procedures in place for clinicians to determine which patients were at highest risk; no prioritisation as going on and there was no system in place to monitor the consequences of this.
  6. Event
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    This webinar from The Yorkshire Quality and Safety Research Group explores a recent research study into how vulnerable patients are able to contribute to their safety. Over the last decade a wealth of studies have explored the way that patients are involved in patient safety internationally. Most begin from the premise that patients can and should take on the role of identifying and reporting safety concerns. Most give little attention, however, to the impact of the patient’s health status and vulnerability on their ability to participate in their safety. Drawing on qualitative interviews with 28 acute medical patients, this article aims to demonstrate how patients’ contributions to their safety in the acute medical context are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. Our analysis is underpinned by theories of vulnerability and risk. This enables us to provide a deeper understanding of the ways vulnerability shapes patients’ involvement in their safety. Acute medical patients engage in reassurance-seeking, relational and vigilance work to manage their vulnerability. Patients undertake reassurance seeking to obtain evidence that they can trust the organisation and the professionals who work in it and relational and vigilance work to manage the vulnerability associated with dependence on others and the unpredictability of their status as acute medical patients. We argue that patients are involved in the process of creating patient safety at the point of care. Foregrounding the theory of vulnerability and its relationship to risk offers new insights into the potentials and limits of patient involvement in patient safety in the acute care context. Liz Sutton is a Research Associate in the Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester. She has considerable expertise in qualitative research including: qualitative interviewing, focus group facilitation and ethnography. Her ethnographic projects have been conducted in different settings including hospital acute care and in care homes, where she has explored such issues as the quality and safety of care and how context affects antibiotic prescribing. Her PhD research explored how vulnerability affects patient involvement in patient safety. Her other interests include dementia care, healthcare quality improvement and health inequalities. Register for the webinar
  7. Content Article
    In this blog, Dr Amy Proffitt, Royal College of Physicians (RCP) patient involvement officer, explores how the patient voice is represented in patient safety. She highlights the importance of engaging patients from a diverse range of backgrounds and responding to research that highlights particular populations who are experiencing worse outcomes. Eddie Kinsella, chair of the RCP’s Patient and Carer Network, then goes on to share his thoughts on patient safety, highlighting the role of patient partners in bringing about culture change in the NHS, and as advocates for the wider community, especially those who are most disadvantaged.
  8. Content Article
    In this blog, Jen Flatman, medicines safety and governance pharmacist, discusses a resource to support people to continue to use their medicines safely once they leave hospital. The medicines safety checklist was designed by patients and carers, for patients and carers, helping bridge the transition between hospital and the next destination. The points on the checklist are designed to act as a prompt, ensuring individuals are aware of key information to continue to use their medicines safely. They also act as a reminder to the reader to ask questions if they are unsure about anything.
  9. Content Article
    Patients are increasingly feeding back about their healthcare experiences online and NHS Trusts are adopting different approaches to responding. This study in the journal Digital health aimed to explore the sociocultural contexts underpinning three organisations who adopted different approaches to responding to online patient feedback. The authors identified a range of barriers facing organisations who ignore or provide generic responses to patient feedback online and demonstrated the sociocultural context in which online interactions between staff and patients can be used to inform improvement. However, they highlight that this represented a slow and difficult organisational journey.
  10. Content Article
    In this blog, peer researchers Saffron, Bianca and Alysha describe their involvement in a study about violence and mental health funded by the UKRI Violence, Abuse and Mental Health Network. The study looked at how adolescents’ experiences of violence and neighbourhood disorder—such as vandalism and muggings—affects their mental health as they move into adulthood. As peer researchers, they helped analyse data and used their lived experience to interpret the findings and co-author an academic research paper. They highlight the value of involving people with relevant lived experience in research studies.
  11. Content Article
    This article by Carrie Murphy looks at the practice of inserting a 'husband stich' or 'daddy stitch', where midwives or obstetricians make an unnecessary extra stitch when repairing episiotomies or tearing from birth. The belief is that it will make the vaginal opening tighter and therefore increase pleasure for the woman's sexual partner. The author highlights that this is a real practice that has been carried out on women for many years, and describes the ongoing impact it can have on women affected, many of whom don't realise they have been given too many stitches. This misogynistic and unethical practice can cause additional pain for women during sex. The women featured in this article state that they did not consent to the practice, being vulnerable after childbirth and in many cases unaware of what a 'husband stitch' was. Angela Sanford reports only finding out that she had a 'husband stitch' five years after birth at a cervical screening appointment where the nurse expressed concern. Murphy expresses her concern that the practice may still be carried out without women's consent, leaving them feeling violated and in pain.
  12. Event
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    2022 marks the 10th anniversary of “Journalen” in Sweden. It was in 2012 that Region Uppsala first give citizens online access to their electronic health records (EHR) for the first time. Since then, a lot has happened in Sweden, and today people all over Sweden have direct online access to their EHR through the e-health service “Journalen” on 1177.se. Online access to EHRs is also highly relevant internationally, and we have also invited international researchers to Uppsala to share experiences of the implementation and effects of patients online access to records throughout the world. It will be a 2-day event with invited speakers from both the US and Europe. The conference will have a scientific focus and will also be open to the public. Conference programme Register for the conference
  13. Content Article
    This video by Joyce Harper, Professor of Reproductive Science at the Institute for Women's Health at University College London, highlights short-term and long-term menopause symptoms, outlines their causes and suggests ways that women can deal with them. Her key message is that everyone should understand these symptoms and anyone suffering should go to see their health professional—no one should have to put up with symptoms that affect their life.
  14. Content Article
    This simple poster highlights the main symptoms of the menopause including hot flushes. headaches, mood swings, palpitations and tiredness. It encourages women to recognise the symptoms and seek help from their GP.
  15. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Judy talks to us about the power of After Action Reviews (AARs) to promote learning and bring about lasting improvements in healthcare. She also discusses the opportunity that the new Patient Safety Incident Response Framework (PSIRF) offers to take a more people-focused approach to learning from patient safety incidents.
  16. Content Article
    This toolkit has been co-produced by the School and Public Health Nurses Association (SAPHNA) with school nursing services, mental health campaigners, eating disorder experts, education colleagues and young people with lived-experience of eating disorders. It is aimed at qualified, trained and skilled nurses who have access to robust supervision. The toolkit is free of charge, but you will need to enter your details in order to receive a PDF copy by email.
  17. Content Article
    This webpage has been put together by The Patients Association to provide resources for patients and members of the public who want to start a local campaign about a specific issue related to health and social care. It includes: advice on how to campaign. information on who you should contact. template letters to MPs and other officials.
  18. Content Article
    In January 2023, The Patients Association celebrates its 60th anniversary. In this interview, CEO Rachel Power talks about why The Patients Association was set up and how the organisation still aims to  ensure that everyone can access and benefit from the health and care they need to live well. She describes the benefits of shifting to free membership, how patient partnership is vital to improving health and care services and The Patients Association's role in highlighting the key issues facing patients to the Government. She also highlights the key role that pharmacies play in promoting health information and delivering services to the communities they serve.
  19. Content Article
    This guide by the charity Menopause Support offers advice for women who may be experiencing menopause symptoms about how to approach an appointment with their GP. It covers preparing for the appointment with research, making a note of your symptoms, how to ask questions, taking a friend or family member to support you, and further support you can request during the consultation.
  20. Content Article
    Transitions of care between hospital departments are necessary, but they may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals, but they frequently experience exclusion from care planning during intrahospital transfers (IHTs). This has the potential to decrease their awareness of patients’ clinical status, postdischarge needs and carer preparation. This study aimed to explore family carers’ perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care.
  21. Content Article
    This article in The Atlantic by Adam Gaffney, a doctor who works in both primary and secondary care, looks at the difficulty of defining and estimating the number of people living with Long Covid. The condition presents in a variety of different ways in people who were hospitalised with Covid-19, as well as people who had mild illness. He argues that incomplete and limited perspectives on what Long Covid is or isn’t, limits people's understanding of who is suffering and why, and of what we can do to improve the lives of people with the condition. More research is needed to understand the mechanisms involved in varied presentations of Long Covid.
  22. Content Article
    This joint report by the APPG on Baby Loss and the APPG on Maternity is a culmination of over 100 submissions to an open call for evidence from staff, service users and organisations, on the maternity staffing crisis. It paints a picture of a service that is at breaking point and staff that are over-worked, burnt out and stressed.
  23. Content Article
    The Healthcare Safety Investigation Branch's (HSIB's) local investigation pilot aimed to evaluate the organisation's ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning. It differs from HSIB's usual national investigations, which make safety recommendations to organisations that can make changes at a national level across the NHS in England. The pilot published three investigations focused on cross boundary and multi-agency safety events: Investigation 1: incorrect patient identification Investigation 2: incorrect patient details on handover Investigation 3: transfer of a patient with a stroke to emergency care The report summarises how the HSIB local investigation pilot was undertaken, and shares findings applicable to local healthcare systems including healthcare organisations and Integrated Care Systems.
  24. Content Article
    The Health and Care Act 2022 will establish the Healthcare Safety Investigations Branch (HSIB) as the Health Services Safety Investigations Body (HSSIB) in April 2023, a fully independent arm’s-length body. This blog by Dr Sean Weaver, Deputy Medical Director at HSIB, outlines what HSSIB's new powers will be.
  25. Content Article
    The Stroke Association's Saving Brains campaign aims to raise awareness of thrombectomy, a game-changing surgical treatment for stroke that many patients in the UK are currently missing out on. Thrombectomy can prevent further damage occurring to the brain in people having a stroke. It is a time-critical treatment and there is variation in access to the procedure across the country, In this video, stroke patients Karen and Phil talk about their experiences of treatment. Karen was able to have a timely thrombectomy and regained full mobility immediately following the procedure. Phil wasn't able to access thrombectomy due to the service not being available in his area at weekends; as a result, his recovery has been slower and more difficult.
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