Patient-Safety-Learning
PSL ModeratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleThis report by Richard Norrie, director of the Statistics and Policy Research Programme at Civitas, aims to scrutinise the Race and Health Observatory (RHO) rapid evidence review into ethnic inequalities in healthcare published in February 2022. The report highlights inconsistencies in the review's use of research and data and argues that its conclusions do not reflect the full body of evidence available concerning race and health outcomes. The author suggests that the review makes a false assumption that the needs of all ethnic groups are the same, which leads to its potentially inaccurate conclusions about the prevalence and causes of health inequalities.
-
Content ArticleIn this episode of the Driving Insights to Action podcast, patient safety advocates Soojin Jun and Sue Sheridan talk about the role of the World Health Organization's Global Patient Safety Action Plan in helping reduce medication errors in healthcare. They also share their personal experiences of family members' deaths as a result of avoidable harm in healthcare.
-
Content ArticleThis NCEPOD report looks at the quality of care provided to patients with Parkinson’s disease (PD) aged 16 years and over who were admitted to hospital when acutely unwell. It highlights the findings of a review into the pathway of care for patients with Parkinson’s disease (PD) which explored multidisciplinary care and organisational factors in the process of identifying, screening, assessing, treating and monitoring their ability to swallow. You can view and download the following diagrams related to the report: Full report Summary report Summary sheet Recommendation checklist Infographic Slide set Commissioners' guide Fishbone diagram Recommendations Audit toolkit
-
Content ArticleVideo and telephone consultations have, through the course of the pandemic, become a central of daily operations across the NHS. In this blog, Ben Gadd and Amanda Nash of University Hospitals Plymouth NHS Trust share their experiences about how they are being received and the potential lessons we can learn.
-
Content ArticleThis article published by The Conversation looks at the pressures faced by ambulance services and emergency departments across Australia as a result of Covid-19. There has been an increase in 'ramping', where ambulances queue up outside hospitals. Ramping is a sign that the whole health system is under immense pressure. The article looks at the large amounts of funding Australian local governments are putting into ambulance services and emergency departments (EDs), but highlight that this will not solve the issues face by the health system if issues discharging patients into community and social care remain. It highlights a model developed in Leeds, UK, that has been adopted by the health service in Victoria, Australia, focused on solving more systemic issues. The Leeds model aims to improve patient flow in and out of the hospital and ensure that patients are quickly transferred from ambulances into EDs. Discharge coordinators organise the care patients need in the community after an ED or hospital stay. The authors also look at the role of community paramedics in keeping patients out of hospital and their potential to reduce financial and capacity pressure on health systems worldwide.
-
Content ArticleThe Care Quality Commission (CQC) has introduced a new assessment framework that it will use to set out its view of quality and make judgements about health services. The framework is being introduced in phases, and the CQC has published it before it comes into use so that providers and other stakeholders can start to become familiar with it.
-
Content ArticleThe Personalised Care Group at NHS England aims to help improve the choice and control that patients have over their health, as part of its NHS Long Term Plan commitments. These decision support tools will help people discuss their treatment choices with their healthcare professionals through shared decision making. The eight new tools cover the following conditions: Dupuytren’s contracture Carpal tunnel syndrome Hip osteoarthritis Knee osteoarthritis Further treatment for atrial fibrillation Cataracts Glaucoma Wet age-related macular degeneration
-
Content ArticleRecent data shows that people aged 10–25 in the poorest areas of the UK will die earlier than those in richer areas. It’s also predicted that people aged 10–14 living in the most deprived areas will live 18 more years in ill health than their peers in the least deprived areas. In this blog for The Health Foundation, Association for Young People's Health (AYPH) policy fellow Rachael McKeown outlines data recently published by AYPH that shows the scale and complexity of young people’s health inequalities, and the need for action.
-
Content ArticleDuring the Covid-19 pandemic, intensive Care Units (ICUs) all came under severe pressure, resulting in higher than usual mortality and complications rates, and longer stays. However, there was variation in outcomes among ICUs and this editorial in the journal Annals of Intensive Care discusses the concept of a resilient ICU. It looks at which metrics can be used to address the capacity to respond, sustain results and incorporate new practices that lead to improvement.
-
Content ArticleClinical governance can be defined as ‘the framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high quality of care’. This article aims to provide an introduction to clinical governance based on UK practice. The article defines and examines how UK health systems priorities safe care, effective care, person-centred care and assured care.
-
Content Article
PRSB - 111 referral standard (August 2022)
Patient-Safety-Learning posted an article in Processes
The Professional Record Standards Body (PRSB) has published the final draft standard for 111 referral, which defines the information that should be shared from 111 or 999 services when a person is referred on to another service. The standard applies to: all 111 and 999 service referrals to wherever the person goes next. referrals through 111 online, call handler or clinical assessment services and 999 services, and is not specific to any triage system. all age groups including children. The standard is UK-wide and was developed in consultation with a wide range of professionals from all four nations, including from 111 services, receiving services, IT suppliers and people who use services. It does not apply to transfers between 111 services (e.g. across a country border) or between 111 and 999 services. -
Content ArticleIn spring 2021, YouTube asked the National Academy of Medicine to bring together experts to develop principles for elevating credible health information online. In this interview with The Commonwealth Fund, Garth Graham, YouTube’s director and global head of health care and public health partnerships talks about how YouTube—which reaches two billion people each month—has been working with health systems in the US to create high-quality, engaging health content.
-
Content ArticleThis article outlines the results of a recent investigation by the Parliamentary and Health Service Ombudsman (PHSO) which found that a 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray. The patient, known as Mr B, was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019 after being unwell for several days with abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities. The following day Mr B's condition deteriorated and he suffered a heart attack and died. The PHSO investigation found that the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life.
-
Content ArticlePatient safety culture is the foundation of patient safety and refers to a healthcare organisation’s shared values, norms and beliefs that influence staff’s behaviour and actions. This study in BMJ Open Quality aimed to assess nurses’ reporting on the predictors and outcomes of patient safety culture and the differences between patient safety grades and the number of events reported. It aimed to fill a gap in research by looking at patient safety culture in terms of both predictors and outcomes. The author developed a cross-sectional comparative research design and recruited 300 registered nurses to take part in a survey on patient safety culture. The author found that nurses generally perceived patient safety culture as 'moderate', and identified areas that should be prioritised to improve patient safety culture. They concluded that assessing patient safety culture is the first step in improving hospitals’ overall performance and quality of services, and that improving patient safety practices is essential to improving culture and clinical outcomes.
-
Content ArticleThe health and care system in the UK is under intense pressure and as a result, patient and public satisfaction with services has dropped significantly, prompting debate and discussion about the future of health and care services. In this article, Charlotte Wickens, Policy Adviser at The King's Fund, looks at five 'myths' perpetuated about the NHS by politicians and the media. She analyses the extent to which each myth can be backed up or debunked by the available data and evidence. The myths she analyses are: The NHS is a bottomless pit, demanding more and more money The NHS is inefficient GPs aren't working hard enough to meet demand for appointments The government has 'fixed' social care The NHS is being privatised
-
EventuntilThe International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the 6th webinar of the medication without harm webinar series is "Medication Safety in Polypharmacy and Transitions of Care”. Register for the webinar The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm.
-
Content ArticleRestorative justice brings those harmed by crime or conflict and those responsible for causing their harm into contact with each other. In healthcare, this can involve bringing together patients and families of patients who have suffered avoidable harm, and the healthcare professionals who may be responsible for this harm. The aim is to enable everyone affected by an incident to play a part in helping to set right the hurt or injury caused, and hopefully find a positive way forward. This blog outlines the content of a lecture given to staff at the Healthcare Safety Investigation Branch (HSIB) by Jo Wailling, Senior Research Fellow at Te Herenga Waka - Victoria University of Wellington, New Zealand, who is a globally-renowned expert in restorative practice and justice in healthcare. It covers Jo's experience of co-designing and evaluating New Zealand's innovative restorative response to surgical mesh harm, practical examples for patient safety investigations and how HSIB is going to integrate restorative justice principles in its future investigations.
-
Content ArticleThe Commission on Young Lives (COYL) was set up in September 2021, to propose a new settlement to prevent marginalised children and young people from falling into violence, exploitation and the criminal justice system, and to support them to thrive. Its national action plan will include ambitious practical, affordable proposals that government, councils, police, social services and communities can put into place. This detailed report by COYL examines the state of children and young people's mental health, describing the current situation as "a profound crisis." It examines the impact of the pandemic on young people's mental health, as well highlighting the lack of capacity and inequalities present in children and young people's mental health services. It then looks in detail at factors that contribute to mental health issues in children and young people and prevent marginalised groups from accessing mental health support.
-
EventThe Restraint Reduction Network is a movement of people who want to eliminate the use of unnecessary restrictive practices, protect human rights and make a positive difference in people's lives. This webinar is an opportunity to find out more about participating in this project, which goes live in September 2022. The session will help you understand your practice in relation to use of psychotropic medication with children and young people and will give you the opportunity to compare your practice to other inpatient units through a benchmarking dashboard. Register for the webinar
-
Content ArticleThis opinion piece in The BMJ looks at the impact of the government's decision to make the wearing of masks in healthcare settings the decision of local providers, dependent on local risk assessment and prevalence. It highlights reports of patients wearing high-filtration FFP2 or FFP3 respirator—many of who are immunocompromised—being asked to remove and replace them with less effective single-use masks in order to gain entry to NHS facilities for treatment. The authors highlight that Covid-19 is an airborne pathogen and that the likelihood of contracting the virus increases with length of time spent in contaminated air. They argue that downgrading mask use in healthcare settings puts everyone at risk, but that it is a particular issue for patients who are clinically extremely vulnerable due to underlying health conditions or because they are undergoing treatment for cancer. They call on the government to upgrade masks to FFP2 or FFP3 respirators in order to protect staff and patients and reverse the worrying trend of clinically extremely vulnerable patients avoiding attending healthcare services.
-
EventuntilBringing together a community of human factors in patient safety advocates across Ireland and abroad, the annual Human Factors in Patient Safety Conference will offer the opportunity to gain valuable knowledge and insights from human factors experts. The conference will include contributions from: Martin Bromiley OBE, Founder of Clinical Human Factors Group UK – Listening Down to Develop your Safety Behaviours Mr Peter Duffy, Consultant Urologist – Whistle in the Wind: a Personal Exploration of the Consequences of Whistleblowing in Healthcare Professor Eva Doherty (Chair), Director of Human Factors in Patient Safety – The Irish Context, panel discussion Healthcare professionals can register for the event here. For more information, please email mschumanfactors@rcsi.ie.
-
Content ArticleThis National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report highlights the results of a study into quality of care received by people aged 0-24 receiving long-term ventilation (LTV). It aimed to identify remediable factors in the care provided to children and young people who were receiving, or had received, LTV.
-
Content ArticleYoung people from different backgrounds with different lived experiences can have different physical and mental health outcomes. This briefing document by the Association for Young People’s Health (AYPH) offers a definition for health inequalities that is specific to young people, and a conceptual framework to help identify key causes and factors that influence health outcomes. As well as highlighting the impact of Covid-19 on young people's health and wellbeing, the paper focuses on different factors that will affect young people's health outcomes now and in the future, including education, employment, housing, geographical area, development of behaviours and relationships.
-
Content ArticleProven patient safety solutions such as the World Health Organization’s Surgical Safety Checklist can be difficult to implement at scale. This article looks at a voluntary initiative launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that implemented the checklist by 2017 had higher levels of CEO and physician participation than comparison hospitals, and engaged more in activities such as in-person meetings and teamwork skills trainings. The authors suggest three considerations for hospital, state and national policy makers: Successful programs must be designed to engage all stakeholders (CEOs, physicians, nurses, surgical technologists, and others) Offering a variety of program activities—both lower-touch and higher-touch—over the duration of the program allows more hospital and individual participation Change takes time and resources
-
Content ArticleVaginal tapes, slings and meshes are medical devices that are surgically implanted to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women. This report written on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) by York Health Economics Consortium, provides summaries of safety and adverse events related to vaginal tapes for SUI and POP. The summaries were developed using the data reported in systematic reviews of the effects and safety of vaginal tapes published in the 10 years up to 2012.
