Patient-Safety-Learning
PSL ModeratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleLeadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aimed to identify a framework, metrics and tools to improve surgical leadership and safety outcomes. It identified three areas of leadership needed to build a culture of safety in surgery: Control risk (risk management) Drive progress (opportunity management) Rally support for the mission (people management) A leadership assessment tool (SLAM) was developed to provide objective metrics of surgical leadership behaviours based on nine key performance indicators.
-
Content ArticleOver the past decade, the implementation of simulation education in health care has increased exponentially. Simulation-based education allows learners to practice patient care in a controlled, psychologically safe environment without the risk of harming a patient. Facilitators may identify medical errors during instruction, aiding in developing targeted education programs leading to improved patient safety. However, medical errors that occur during simulated health care may not be reported broadly in the simulation literature. This study in the Journal of Patient Safety aimed to identify and categorise the type and frequency of reported medical errors in healthcare simulation.
-
Content ArticleThis annual report published by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) contains findings relating to people aged 10 and above who died by suicide between 2011 and 2021 across all of the UK. View an infographic outlining the report's key findings.
-
Content ArticleIn this Guardian opinion piece, John Harris looks at reports of people with severe eating disorders being discharged from NHS services in the East of England. He shares the stories of several patients who are desperate to recover from their eating disorders, but have been discharged from specialist services because they are not showing progress in recovery. The article looks at the growth of a narrative that suggests some patients should not be treated if their eating disorder has reached a very severe state and highlights the way that this may be affecting practice and posing a significant risk to patient safety.
-
Content ArticleEarly-onset colon cancer (EOCC) is increasing in the US and disproportionately affects African-Americans. This analysis in the American Journal of Surgery aimed to compare EOCC survival among Black and White patients after matching relevant socio-demographic factors and stage. The authors found that Black patients with stage 3 EOCC are less likely to receive chemotherapy and have worse survival than White patients. They call for further research to identify potential factors driving this inequality.
-
Content ArticleThere is currently a lack of research addressing the impact of patient suicide on GPs. This qualitative study in BMJ Open aimed to examine the personal and professional impact of patient suicide, as well as the availability of support and why GPs did or did not use it. The authors found that GPs are impacted both personally and professionally when they lose a patient to suicide, but may not access formal help due to commonly held idealised notions of a ‘good’ GP who is regarded as being unshakable. Fear of professional repercussions also plays a major role in deterring help-seeking. A systemic culture shift which allows GPs to seek support when their physical or mental health requires it is needed, and this may help prevent stress, burnout and early retirement.
-
Content ArticleFemale urologists report higher rates of work-related physical discomfort compared to male urologists. This study in the American Journal of Surgery compared ergonomics during simulated ureteroscopy—the most common surgery for kidney stones—between male and female urologists. The authors found that across all conditions, women required greater muscle activation in multiple muscle groups and had greater NASA Task Load Index (NASA-TLX) scores compared to men. These results suggest there may be gender differences in ergonomics during ureteroscopy based on muscle activation and subjective workload. There is therefore potential for personalising surgical workspaces and equipment.
-
Content ArticleThis report by The King's Fund argues that the health and care system in England must shift its focus away from hospital care to primary and community services if it is to be effective and sustainable. It looks at a wholesale shift in the focus towards primary and community health and care across leadership, culture and implementation. Successive governments have repeated a vision of health and care services focused on communities rather than hospitals, but that vision is very far from being achieved. The report outlines research that explored the underlying factors that have prevented change, and what might need to be done to achieve the vision. The researchers analysed published evidence and national datasets, and interviewed stakeholders across the health and care system. The report concludes that to achieve community-based care, political and other national leaders will need to completely shift their focus away from hospitals towards primary and community health and care.
-
Content ArticleBrain fog is one of the most common, persistent complaints in patients with Long Covid, affecting up to 46% of patients, many of whom also deal with other cognitive concerns like memory loss and difficulty concentrating. This Medscape article looks at new research suggesting these symptoms may be the result of a viral-borne brain injury that causes cognitive and mental health issues that persist for years. This may offer new options for treating brain fog and other cognitive symptoms associated with Long Covid.
-
Content ArticleAiring Pain is a podcast from Pain Concern. Each edition brings together people in pain and top specialists to talk about resources that can help. This edition investigates the significant inequalities and disparities in treatment among primary care pain management services. It features the following participants: Professor Jonathan Hill, Director of Research for the School of Allied Health Professionals and Professor of Physiotherapy at the Keele School of Medicine; Dr Ama Kissie, post-doctoral fellow at the University of Ghent and a Clinical Psychologist; Dr Whitney Scott, clinical psychologist who lectures at Kings College London and is the research lead at the INPUT Pain Management Unit at Guy’s & St Thomas’ Hospital.
-
Content ArticleThis descriptive and cross-sectional study in the Journal of Patient Safety aimed to examine the impact of nurses’ fear of Covid-19 on their nursing care behaviour during the pandemic. 450 nurses providing one-on-one care to Covid-19 patients between January and March 2021 took part in the study. The results showed that nurses providing care to patients during the pandemic feared Covid-19, that their care behaviours were generally at a good level, and that the care behaviours of nurses with a high degree of fear were negatively and significantly impacted.
-
Content ArticleThis report by the Patients Association analyses the opinions and experiences of diagnostic testing services of more than 1,000 NHS patients. It highlights that patients view diagnostics as a fundamental part of the NHS—and one that should be prioritised. Most respondents (93%) want testing capacity to be invested in over the coming years so that patients can receive tests and diagnosis more quickly. Patients place such importance on diagnostics that 60% would consider paying for the tests they need if they faced a long wait on the NHS.
-
Content Article
Can I be seen? Birthing while Black (17 February 2024)
Patient-Safety-Learning posted an article in Maternity
In this Lancet article, Lioba Hirsch shares her experience of labour and birth as a Black woman. She describes dismissive behaviours and blaming comments from several healthcare professionals that left her feeling unable to ask questions and advocate for herself and her baby. She suggests that the lack of compassion and dignity she was shown are a risk to patient safety: "I am so glad that my child was safe that day, but many children and their birthing parents are not and the slope from disrespect and disregard to dismissal and its consequences is a slippery one." -
Content ArticleThe Government plans to expand physician associate (PA) and anaesthesia associate (AA) roles and to establish the General Medical Council (GMC) as their statutory regulator. There has been concerted opposition to the plans by groups including the Doctors’ Association UK (DAUK) and the British Medical Association (BMA). Earlier this month, the House of Lords sent the draft legislation to the main chamber for proper scrutiny, stating that this was the procedure when an issue "is politically or legally important or gives rise to issues of public policy". In this Medscape article, Dr Sheena Meredith outlines the Government's proposals and why the issue has become so contentious.
-
Content ArticlePrimary care appointments may provide an opportunity to identify patients at higher risk of suicide. This study in the British Journal of General Practice aimed to explore primary care consultation patterns in the five years before suicide to identify suicide high-risk groups and common reasons for seeing a healthcare professional. The authors found that frequent consultations (more than once per month in the final year) were associated with increased suicide risk. The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation, including females, patients experiencing less socioeconomic deprivation and those with psychiatric conditions. The commonest reasons that patients who went on to commit suicide requested consultations in the year before their death, were medication review, depression and pain.
-
Content ArticleInfection Control Matters is a podcast in which infection control professionals discuss new research and issues on the topic of infection prevention and control. In this episode, Martin Kiernan and Phil Russo talk to Professor Michael Borg from the Faculty of Medicine & Surgery at the University of Malta They discuss a recent paper describing the stages that brought about a 90% reduction in MRSA bloodstream infections over a ten-year period.
-
EventuntilThis webinar hosted by the Patients Association provides an opportunity to hear about the new Pharmacy First Service. Speakers include: David Webb, Chief Pharmaceutical Officer for England Pallavi Dawda, Head of Delivery, Clinical Strategy Community Pharmacy, NHS England Leighton Colegrave, member of Hertfordshire and West Essex ICB's Patient Engagement Forum Tunde Sokoya, community pharmacist, Essex Lindsey Fairbrother, community pharmacist, Derbyshire. The Patients Association Chief Executive Rachel Power will chair the webinar. Register for free.
-
EventuntilThis webinar will explore the findings from the Patients Association's Patient Experience of Diagnostics report and consider its recommendations. The panellists are: Professor Sir Mike Richards, who was the first National Cancer Director at the Department of Health Karen Stalbow, Head of Diagnostic Policy at NHS England Dr Ashton Harper, Head of Medical Affairs at Roche Diagnostics Ltd. Patients Association Chief Executive Rachel Power will chair the session and the panel will include patients. The webinar will be held on Zoom and is free to attend. Book your place.
-
Content ArticleThis report aims to understand the NHS response to racism, what trusts and healthcare organisations do about it and how effective they are at addressing it. It brings together key learning from a number of significant tribunal cases and responses from 1,327 people to a survey about their experiences of raising allegations of racism within their organisations.
-
Content ArticlePatient engagement technologies (PETs) are tools used to guide patients through the perioperative period. This study in the American Journal of Surgery aimed to investigate the levels of patient engagement with PETs through the perioperative period and its impact on clinical outcomes. The authors found that use of PETs improves patient outcomes and experiences in the perioperative period. Patients who engage more frequently with PETs have shorter length of stay (LOS) with lower readmission and post-operative complication rates.
-
Content ArticleIn this letter to Health Secretary Steve Brine MP, members of the All Party Parliamentary Group (APPG) on Pandemic Response and Recovery raise serious concerns about the approach of the Medicines and Healthcare Products Regulatory Agency (MHRA) to patient safety. They outline problems within the MHRA that continue to put patients at serious risk of harm. The letter also highlights the role of the Independent Medicines and Medical Devices Safety Review (IMMDS), in its thorough investigation of Primodos, sodium valproate and pelvic mesh in bringing some of these concerns to the fore. It points to recent evidence presented to the APPG that indicates that the MHRA is at the heart of wider endemic failings, with issues uncovered so far being "the tip of a sizeable iceberg of failure." The letter outlines concerns about the following areas: The Yellow Card Scheme Conflicts of interest and transparency History of regulatory failures in the MHRA It calls on the Health and Social Care Select Committee to investigate these issues and make recommendations to the government on: legislative changes as to who is obligated to report adverse drug reactions. funding changes to the MHRA. separation of regulatory approval duties from post marketing pharmacovigilance. more inclusion of patients. greater transparency across the board. proper enforcement of Part 14 of the Human Medicines Regulations 2012.
-
Content ArticleIn this interview, Professor Martin Marshall, former GP and Chair of the Royal College of General Practitioners, shares his concerns for the future of general practice in the UK. He outlines the danger that more of the workforce will turn to private practice due to current pressures facing NHS GPs.
-
Content ArticleA growing awareness of sex and gender bias in evidence has resulted in the development of new tools to address this concern. The Sex and Gender Equity in Research (SAGER) guidelines and the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) are two initiatives designed to foster more transparent research and reporting practices that bridge the gender evidence gap. These tools enable researchers to unravel the complexities that underpin health risks and outcomes and generate more accurate and relevant findings that can inform effective and equitable policies for better health outcomes. This Lancet article looks at the World Health Organization's (WHO's) adoption of GATHER and the SAGER guidelines to tackle sporadic and suboptimal reporting of sex and gender data. The authors argue that this move is pivotal within WHO's broader strategic agenda, which it outlined in the Roadmap to Advance Gender Equality, Human Rights and Health Equity 2023–2030, launched in December 2023.
-
Content ArticleThis animation aims to help staff and employers across health and social care understand Oliver's Training and why it is so vitally important. It was co-designed and co-produced with autistic people and people with a learning disability. Oliver McGowan died aged 18 in 2017 after being given antipsychotic medication to which he had a fatal reaction. He was given the medication despite his own and his family's assertions that he could not be given antipsychotics, and the fact that this was recorded in his medical records. The animation tells his story and highlights the increased risks facing people with learning disabilities and autism when accessing healthcare.
-
Content ArticleIncorporating parental values in complex medical decisions for young children is important but challenging. This review in The Lancet Child & Adolescent Health explores what it means to incorporate parental values in complex paediatric and perinatal decisions. It provides a narrative overview of the paediatric, ethics and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences.
