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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    There has been an increase in the use of video group consultations (VGCs) by general practice staff, particularly since the beginning of the Covid-19 pandemic, when in-person care was restricted. This qualitative study in the British Journal of General Practice aimed to examine the factors affecting how VGCs are designed and implemented in general practice. Through semi-structured interviews with practice staff and patients, the authors found that: in the first year of the pandemic, VGCs focused on supporting those with long-term conditions or other shared health and social needs. most patients welcomed clinical and peer input, and the opportunity to access their practice remotely during lockdown. not everyone agreed to engage in group-based care or was able to access IT equipment. significant work was needed for practices to deliver VGCs, such as setting up the digital infrastructure, gaining team buy-in, developing new patient-facing online facilitation roles, managing background operational processes, protecting online confidentiality, and ensuring professional indemnity cover. national training was seen as instrumental in capacity building for VGC implementation.
  2. Content Article
    Cancer screening involves testing for early signs of cancer in people without symptoms. It can help spot cancers at an early stage, when treatment is more likely to be successful, or in some cases prevent cancer from developing the first place. The screening test for bowel cancer is the faecal immunochemical test, or FIT, that looks for tiny traces of blood in your poo. These tests are sent to everyone in the eligible population every two years. In this blog Jacob Smith from Cancer Research UK looks at the importance of increasing bowel cancer screening in socioeconomically deprived communities, where there is a higher incidence of bowel cancer and death from bowel cancer. This is partly due to lower levels of participation in screening. The blog highlights the results of a recent study carried out by the University of Sheffield to determine which interventions may be successful in reducing health inequalities related to bowel cancer screening. Modelling found that re-inviting non-participants to take part in screening each year was a highly effective intervention, and it is estimated that this approach would prevent over 11,000 bowel cancer deaths over the lifetime of the current English population aged 50-74.
  3. Content Article
    This report by the All Party Parliamentary Group (APPG) on Muslim Women and the Muslim Women's Network UK aimed to investigate the maternity experiences of Muslim women in the UK, particularly from Black, Asian and other minority ethnic backgrounds. It aimed to better understand the factors that influence the standard of maternity care Muslim women receive, and to determine whether this may be contributing to poorer outcomes for them and their babies. 1,022 women completed surveys and 37 women were interviewed for the research. The study focused on the care given throughout pregnancy in the antenatal, intrapartum and postnatal periods. Experiences of sub-standard care were analysed to find out: whether they were associated with the women’s intersecting identities such as ethnicity, religion and class. whether attitudes were due to unconscious bias (for example, negative stereotypes or assumptions) or conscious action (for example, microaggressions). what role (if any) organisational policies and practices played. Particular attention was paid to how near misses occurred as this information could help to save lives of mothers and babies. To show what good practice looks like, positive experiences were also highlighted.
  4. Content Article
    People with diabetes are increasingly using medical devices to help manage their condition, including devices for monitoring glucose and delivering insulin. However, healthcare professionals are finding that they cannot always access up to date information about a person with diabetes and the data from their medical devices. This makes it harder to provide the best advice and support. The Professional Record Standards Body (PRSB) was commissioned by NHS England and NHS Improvement to produce two standards for sharing diabetes information between people and professionals across all care settings, including self management data from digital apps and medical devices (for example, continuous glucose monitors). The Diabetes Information Record Standard which defines the information needed to support a person’s diabetes management. It includes information that could be recorded by health and care professionals or the person themselves that is relevant to the diabetes care of the person and should be shared between different care providers. The Diabetes Self-Management Standard which defines information that could be recorded by the person (or their carer) at home (either using digital apps or medical devices) and shared with health and care professionals.
  5. Content Article
    In this presentation Paula Goss, the founding member of Rectopexy Mesh Victims and Support, shares her experience of having a mesh implant. She describes the absence of informed consent during the procedure and the pain and complications she experienced following her surgery. This was shared at a Bristol Biomedical Research Centre workshop aimed at improving shared decision making for surgical innovation.
  6. Content Article
    An increasing number of healthcare artificial intelligence (AI) applications are in development or already in use, but the safety impact of using AI in healthcare is largely unknown. This qualitative study in the journal Safety Science aimed to explore how different stakeholders (patients, hospital staff, technology developers and regulators) think about safety and the safety assurance of healthcare AI. Through a series of interviews, the authors assessed stakeholder perceptions of an AI-based infusion pump in the intensive care unit. Participants expressed perceptions about: the potential impact of healthcare AI requirements for human-AI interaction safety assurance practices and regulatory frameworks for AI and the gaps that exist how incidents involving AI should be managed. The authors concluded that there is currently a technology-centric focus on AI safety, and a wider systems approach is needed. They also identified a need for greater awareness of existing standards and best practice among technology developers.
  7. Content Article
    This guide developed by the AHSN Network, the University of Plymouth and the pharma company Boehringer Ingelheim sets out four key principles to involve and engage patients and the public in digital health innovation: Engage – map out your strategy and motivations, identify a representative cohort and develop inclusive engagement practices. Acknowledge, value & support – show you value patients’ and the public’s contribution to ongoing and transparent communication, any necessary training and potential financial reimbursement. Communicate – tailored external communication and open feedback channels are crucial to maintaining engagement and accountability by all parties. Trust and transparency – In order to gain patients’ trust, organisations conducting PPIE should be trustworthy and transparent about potential risks.
  8. Content Article
    In this briefing paper for the Social Market Foundation, Lord Norman Warner sets out a radical change programme that could reverse the decline in NHS services. It examines long-term issues that have been exacerbated by the impact of Brexit and the Covid-19 pandemic—the care backlog, workforce issues and loss of public confidence.
  9. Content Article
    It is important that patients understand the risks, benefits and alternatives associated with their treatment, but there is often a gap in patients' actual understanding of these issues. There is now substantial evidence showing that patient decision aids (PDAs) and shared decision making can bridge the gap between the theory and practice of informed consent. However, in spite of the evidence, PDAs are still rarely used in clinical settings. This article in the journal Maine Law Review looks at how the monetary incentive of a professional liability insurance premium reduction could encourage doctors in the USA to increase the use of PDAs.
  10. Content Article
    Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. This systematic review in BMJ Quality & Safety aimed to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.
  11. Content Article
    Healthcare is traditionally a hierarchical industry. This structure can foster a culture of division amongst staff that is sometimes made worse by significant differences in background and training. However, in order to make sure care is safe and of a high quality, healthcare teams must develop good teamwork and communication. This is only possible if every member of the team feels respected and is free to speak up when they think something is wrong. In this podcast, host David Feldman speaks to Michael Brodman, Professor and Chair Emeritus in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai in the US. They discuss how mutual respect is essential for any institution developing a culture of safety and how the problems presented by medical hierarchy can be overcome.
  12. Content Article
    This blog by doctors Clare Rayner and Amali Lokugamage argues that Long Covid rehabilitation needs a wider focus that goes beyond a purely biomedical paradigm to include complementary therapies and methods. The authors—who have both lived with Long Covid for more than two years—argue that although patients were the first to raise concerns about Long Covid, describe its symptoms and patterns and even research the condition, their narratives and voices are not being included in approaches to treatment. While the biomedical evidence surrounding Long Covid is currently limited, they highlight that there is much valuable lived-experience to be found in patient support and campaign groups, and that patients' knowledge should be drawn on to shape policy and guidance about the condition.
  13. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Clive talks to us about the important role of digital technologies in tackling the big issues healthcare faces, the need for digital tools and records to be joined-up and interoperable, and how his experiences as a carer have shaped how he sees patient safety.
  14. Content Article
    This guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.
  15. Content Article
    This blog by the charity Mental Health UK looks at an innovative project that aims to transform the way care and support are delivered to people living with severe mental illness in Grimsby and Bridgend. It aims to meet people’s mental health needs by providing tailored support, signposting them to specialist services to improve their quality of life, prevent the need for emergency crisis care and reduce pressure on acute medical services. The project is being run in conjunction with healthcare company Johnson & Johnson UK, with the support of the local NHS. The project involves Community Mental Health Navigators supporting the non-medical needs of people living with severe mental illness, such as bipolar disorder, schizophrenia and borderline personality disorder. They provide support with aspects of people’s lives which can drive poor mental health, such as housing, money problems, employment, physical wellbeing and lack of social connections.
  16. Content Article
    This online community has been set up by the Care Quality Commission (CQC) to engage with members of the public on a range of topics related to the CQC's work as regulator of health and social care services in the UK. The site invites people to get involved in different ways, for example: by sharing expertise, experience and thoughts through discussions. by reviewing documents. by taking part in polls and surveys. by contributing to idea boards. When signing up, you can either use your own name or your organisation’s name, and you'll be asked to choose what groups you represent and what sectors you work in or use.
  17. Content Article
    In this blog, Dr Chloe Stewart, health psychologist and national clinical advisor in personalised care for NHS England, looks at the role of personalised care in helping overcome the care backlog and addressing health inequalities in people with musculoskeletal conditions (MSKs). She looks at examples of coproduction in MSK services and highlights the need to give patients better information and training about how to manage their condition.
  18. Event
    until
    Entrenched health inequalities have come to the fore over the past couple of years and we have seen some of the sharpest declines in health and wellbeing for our children, young people and their families. Never has there been a more urgent need to address the link between wider social, economic and environmental causes to the increased risk of poor public health and mental health. These are best understood and addressed at a local level by people and organisations that have relationships and knowledge of the nuances and cultures of individuals and communities. The formation of Integrated Care Systems (ICSs) represents a significant opportunity for Boards to engage the voluntary, community and social enterprise (VCSE) sector in order to enable a truly integrated Health and Social Care System to be delivered. These new arrangements which will bring together local system partners should serve to strengthen relationships between the NHS and VCSE sector and promote greater equity. This free webinar, co-produced and sponsored by Barnardo’s, brings together an esteemed panel of experts to discuss how we make the most of these opportunities at this critical time, as well as showcasing innovative VCSE projects that are delivering improved outcomes for children, young people and their families. Register for the webinar
  19. Content Article
    This study in the journal Current Problems in Diagnostic Radiology aimed to explore the perspectives of radiology and internal medicine residents on the desire for personal contact between radiologists and referring doctors, and the effect of improved contact on clinical practice. A radiology round was implemented, in which radiology residents travel to the internal medicine teaching service teams to discuss their inpatients and review ordered imaging. Surveys were given to both groups following nine months of implementation. The vast majority of both diagnostic radiology residents and internal medicine residents reported benefits in patient management from direct contact with the other group, leading the authors to conclude that this generation of doctors is already aware of the value of radiologists who play an active, in-person role in making clinical decisions.
  20. Content Article
    Medication errors are a common issue within the care home sector, impacting on the health and wellbeing of residents as well as creating challenges for care home staff and managers. This report addresses the issue of medication safety in care homes in England. Through intense engagement with a representative sample of care homes and stakeholders involving an electronic survey, workshops and conversations, Patient Safety Collaboratives have sought to understand the reasons for medication errors and how these could be avoided in the future.
  21. Content Article
    This realist evaluation aimed to explore and explain the ways in which a programme initiated by the Scottish Government, Keeping Childbirth Natural and Dynamic (KCND), worked or did not work in different maternity care contexts. KCND was a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm.
  22. Content Article
    This mixed methods study in the BMJ Open aimed to investigate possible barriers and facilitators for venous thromboembolism (VTE) risk assessment in medical patients and evaluate the impact of local and national initiatives. The authors identified the following barriers to risk assessment: involvement of multiple staff in individual admissions interruptions lack of policy awareness time pressure complexity of tools They concluded that national financial sanctions appear effective in implementing guidance, where other local measures have failed.
  23. Content Article
    This study presents the findings of ‘The concept of seriousness in fitness to practise’ project commissioned by the General Dental Council (GDC) and the Nursing and Midwifery Council (NMC). The project took place between December 2019 and September 2021 and investigated how seriousness in Fitness to Practise (FtP) cases is understood and applied by health professions regulators. The research aimed to: develop an understanding of how the concept of seriousness in relation to misconduct is defined and applied by professional regulators, and to identify the considerations that influence that application. achieve a clearer understanding of the similarities and differences in approaches across regulation and reasons for these. describe the relationship between professional misconduct, enforcement actions and the statutory objectives of healthcare regulation.
  24. Content Article
    This paper in the journal Learning Health Systems examines what would be needed to develop learning health systems (LHS) in the United Kingdom, considering national policy implications and actions which local organisations and health systems could take. It identifies opportunities for local NHS organisations to make better use of health data and ways that national policy could promote greater use of collaboration and analytics.
  25. Content Article
    In this article for US magazine Consumer Reports, Rachel Rabkin Peachman looks at the incidence and impact of malfunctions and design flaws in continuous blood glucose monitors, insulin pumps and other diabetes equipment. She highlights the case of Pamela, a 64-year-old with diabetes who died when her insulin pump unintentionally gave her a massive dose of insulin overnight. The numbers of adverse events and deaths reported to the FDA regarding diabetes devices is far greater than for any other type of medical device—between January 2019 and July 2020, almost 400 deaths and 66,000 injuries in the US were linked to commonly used diabetes devices. Reports are spread across the different device manufacturers and demonstrate the complexities of trying to determine the exact cause of each adverse event. The article also includes information on how people with diabetes can protect themselves from device malfunctions and errors.
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