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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Lack of capacity in social care is having a severe effect on NHS services as hospitals are unable to discharge patients without appropriate care arrangements in place. This is causing delays right across the healthcare system. In this report, NHS Confederation highlights the risks to patient safety caused by the workforce crisis affecting social care in England. In the Confederation's latest survey, 99% of healthcare leaders agreed that there is a social care workforce crisis in their local area, and almost all agreed that it is worse than a year ago and expect it to deteriorate into this winter. The report recommends the government focus on the following key priorities to deal with the crisis: Increase pay in the social care sector, starting by immediately implementing a national care worker minimum wage Publish a long-term, properly funded plan to develop the care workforce and offer career progression opportunities Commit to increasing overall investment to increase access to care to those who need it, meet future demand and pay more for care
  2. Content Article
    Patient choice has been a feature of the NHS in England for the last two decades, but patients' knowledge about what choices they have in accessing their NHS healthcare is variable. This report by the Patients Association and the Independent Healthcare Providers Network (IHPN) looks at the role patient choice can play in tackling the elective care backlog. The report found that: there are significant variations in waiting times across the country. patients do not need to travel long distances to access care more quickly. On average, a patient would need to travel just 13.2 miles to go from one of the worst performing providers to one of the top performers. the potential for reducing waiting times by accessing care through an alternative provider was backed up by both polling and focus group work, which found the public is enthusiastic about patient choice. people's awareness of their rights around where they receive their NHS treatment is low, suggesting the Government and NHS England need to do more to promote choice and make it easier for patients to understand the options available to them.
  3. Content Article
    In this letter to the Secretary of State for Health and Social Care, Rachel Power, Chief Executive of the Patients Association, calls on Steve Barclay to ask the Government to develop a long-term workforce strategy for the NHS. She also requests that the government urgently fund social care and calls on Steve Barclay to take action to remedy the threat to patient safety caused by staff shortages.
  4. Content Article
    Depression is one of the most common mental health issues and GPs often diagnose and treat patients with the condition. In this blog, Dr Ed Beveridge offers his top tips for the assessment, management and treatment of adults with depression in primary care. It provides information on: assessing and screening people with depression for underlying conditions. pharmacological and nonpharmacological treatment options. when to refer to secondary care or seek specialist advice.
  5. Content Article
    This video examines the crisis facing NHS ambulance services in the UK and looks at the impact of delays and lack of capacity on patient safety. Paul Brand, UK Editor at ITV News, speaks to ambulance crews, patients and a recently bereaved family about their experiences, and highlights the increased stress levels ambulance staff are reporting. Note: The video contains footage of a 999 call that some viewers might find distressing.
  6. Content Article
    This practical guide was commissioned by The Health Foundation and NHS England to support NHS systems to tackle health inequalities. Co-written by the Yorkshire and Humber Academic Health Science Network and a reference group of national experts, stakeholders, service providers and people with lived experience of inequalities, the guide suggests practical action that systems can take to ensure equitable access, excellent experience and optimal outcomes for all. The guide covers four key areas for action and features good practice examples which systems and providers can adapt and apply to their local context. There are also checklists to assist system leaders, managers, clinicians, and operational staff, to design new models of care and embed sustainable action to drive down healthcare inequalities. The guide supports the national Core20plus5 approach to reduce healthcare inequalities which focuses on a population group of the core 20% most deprived nationally and those from inclusion health groups; outlining five clinical areas of focus.
  7. Content Article
    This guide from The Patient Revolution aims to help healthcare activists contribute to an international movement for care. It summarises the foundations of The Patient Revolution's collective work towards the goal of careful and kind care for all. Underpinning these foundations is the idea that industrialised healthcare undermines compassionate, individualised care and costs more, both in terms of patient safety and financial cost. The guide provides tools and principles to help activists transform the way care is offered and promote genuine patient-healthcare collaboration.
  8. Content Article
    The Accessible Information Standard gives disabled people and people with sensory loss the right to get healthcare information they can understand and communications support if needed. A survey conducted by HealthWatch between February and May 2022 aimed to investigate whether the standard is being delivered by health services, and whether it offers enough support to patients. While the survey participants were self-selected, their views are likely to reflect those of a significant group of people who need communications support. HealthWatch hopes that the survey's findings will help NHS and social care decision-makers hear what is working and what could be better from the public's perspective.
  9. Content Article
    This document outlines the UK Government's response to the Health and Social Care Select Committee report on the treatment of autistic people and people with learning disabilities, published in July 2021. It contains responses to three main areas of interest raised by the Committee's report: Community support: reducing the number of autistic people and people with learning disabilities in inpatient facilities, and the benefits of the Trieste model The use of restrictive practices in inpatient facilities and wider concerns relating to the appropriateness and continued use of such facilities The wellbeing of and accountability for autistic people and people with learning disabilities including the creation of a new role: the Intellectual Disability Physician, and the need for independent reviews into the deaths of autistic people and people with learning disabilities
  10. Content Article
    Each year, 7,000 to 9,000 people die as a result of a medication errors in the US, and the total cost of looking after patients with medication-associated errors exceeds $40 billion. Alongside this financial cost, adverse events caused by medication errors also cause patients significant psychological and physical pain and suffering. The article aims to: identify the most common medication errors. review some of the critical points at which medication errors are most likely to occur. outline strategies to prevent medication errors occurring. summarise multidisciplinary team strategies for decreasing medication errors.
  11. Content Article
    This is the website of the independent public statutory Inquiry established to examine the circumstances in which patients in the UK were given infected blood and blood products, in particular since 1970. The Inquiry is Chaired by barrister Keith Langstaff, who has experience of health-related public inquiries. The website contains information on: public hearings and meetings evidence latest news on the Inquiry how to get support if you have been affected by infected blood products. The Inquiry team is also inviting patients and family members of patients who received infected blood or infected blood products to give evidence to the Inquiry, either as a written statement or by speaking to an intermediary. Evidence given to the Inquiry will contribute to its findings and recommendations.
  12. Content Article
    Over the few years, the Royal Air Force (RAF) has been going through a cultural evolution. In this episode of the Human Factors podcast, Ian James and Avril Webb give an insight into how the implementation of Human Factors and attitudes to safety have evolved in the RAF, and the positive impact this has had on the organisation.
  13. Content Article
    In this opinion piece for The Guardian, Professor Devi Sridhar, chair of global public health at the University of Edinburgh discusses the global threat of monkeypox—a virus that causes fever, swollen lymph nodes and distinctive rashes on the face, palms, the soles of the feet and genitalia. The World Health Organization (WHO) has designated the recent outbreak of monkeypox a public health emergency of international concern. Professor Sridhar highlights the need to take a collaborative approach across borders to ensure the outbreak is brought under control. She outlines that the most effective strategy in preventing the virus spreading further is to protect the group most at risk from the virus—men who have sex with men (MSM)—through vaccination.
  14. Content Article
    The Birth Injury Help Center is a US-based online resource centre that provides information on birth injuries, as well pregnancy and childbirth. This article provides information for pregnant women about foods, drinks, medications and activities to avoid during pregnancy.
  15. Content Article
    This briefing paper by thinktank The Centre for Mental Health explores evidence about the links between factors that worsen mental health, showing that living in poverty increases people’s risk of mental health difficulties, and that more unequal societies have higher overall levels of mental ill health. It also demonstrates that poverty and economic inequality intersect with structural racism to undermine the mental health of racialised and marginalised groups in society. Among other things, it highlights inequalities in access to primary care and mental health services across the UK.
  16. Content Article
    This article in DIA Global Forum examines a new collaboration between the European Commission, the European Medicines Agency (EMA) EU Member States Belgium, France, and Germany, the Bill & Melinda Gates Foundation and the recently established African Medicines Agency (AMA). The group will mobilise more than €100 million over the next five years to support the AMA and other African medicines regulatory initiatives at regional and national levels. The initiative will foster collaboration and sharing of technical expertise by European regulators with AMA. It also aims to assist African national regulatory authorities (NRAs) in achieving the minimum World Health Organization (WHO) requirements for effective regulatory oversight of quality-assured, safe, local production of medicines and vaccines.
  17. Content Article
    This report draws on data from the National Child Mortality Database (NCMD) to investigate how illness around the time of birth affects the health of children up to the age of 10, and to draw out learning and recommendations for service providers and policymakers. This report aims to understand patterns and trends in child deaths where an event before, or around, the time of birth had a significant impact on life, and the risk of dying in childhood.
  18. Content Article
    The Northern Ireland Department of Health's Mental Health Strategy Delivery Plan for 2022/23 sets out the prioritised workstreams under the 2021-31 Mental Health Strategy, which was published in June 2021, alongside a ten-year Funding Plan. It outlines governance and monitoring arrangements, actions currently in progress and actions that will be delivered at a later date. The Delivery Plan is published alongside Mental Health Strategy Co-Production/Design Principles, designed to give structure and meaning to the Department’s desire to ensure continued co-production throughout the implementation of the ten-year Strategy.
  19. Content Article
    Rather than measuring how safe care is, the focus is often on measuring levels of harm in healthcare systems. This report by Healthcare Excellence Canada outlines findings from a research study which aimed to answer, “How safe is care from the perspective of patients, families, care partners, and care providers?” Through a literature review, interviews, focus groups and a World Café wthe study aimed to increase understanding of how patients and their care partners view safety. The Measuring and Monitoring of Safety Framework (MMSF) (Vincent et al., 2013b) was used to guide the study. The MMSF offers a broader, more comprehensive and real-time view of patient safety and helps shift away from a focus on past cases of harm towards current performance, future risks and organisational resilience. The report concludes that the MMSF represents a critical shift in how patients can enable safer care. Inviting patients and care partners to contribute meaningfully to safety will enhance healthcare providers’ view of harm and understanding of what it means to feel safe.
  20. 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. Annie talks to us about her work training teams in safety behaviours, why productivity and safety must go hand-in-hand, and how working on patient safety is like running a marathon.
  21. Content Article
    In this blog, Chris Day, Director of Engagement at the Care Quality Commission (CQC) sets out more detail on the CQC’s role in the assessment of Integrated Care Systems (ICSs). He highlights the importance of developing regulation that earns the trust of both people using services and those working in them. He outlines how the CQC will use its new responsibilities under the Health and Care Act 2022 to assess the extent to which each ICS understands the needs of its local population and whether it is working effectively in collaboration, with valued input from all health and care partners.
  22. Community Post
    These comments were made by people with diabetes in response to a Twitter thread asking "Why is a hospital stay scary if you have diabetes?" If you have diabetes, or care for someone who does, please share your experience with us by adding a comment to this community thread, “I was in ICU after a car accident—none of the staff knew how to work my CGM and/or my insulin pump. I had to manage my own care” “For me it was when I went into hospital for surgery and the nurse said 'Type 1... so do you take insulin for that?'... that's not a reassuring thing to hear minutes before you're taken into the theatre!” “Lucky to get out alive.” “DKA 10 years ago, once back in normal range the consultant insisted I didn't need anymore insulin & refused to let me have any. Obvs within 3 hours I was back in DKA, he wouldn't come see me but had a convo with my husband on the ward phone where hubs explained how T1 works.” “I've been given a full day's bolus, through my iv and then told I was wrong when I said that I only bolused when I ate. Massive hypo followed quickly. I was then told it was my fault and I should have said something.” “After being admitted as an emergency, my own insulin ran out. I was given 2 (2!) of the wrong types of insulin and told that 'it would be okay'.” “They were often confused about T2 versus T1 - lots of emphasis about low fat foods and only being allowed a low fat yoghurt for puddings even though I was on a pump! I had a bag of snacks though as it was a planned hospital stay” “After a major medical issue I was denied insulin in the ICU for over 24 hours but was told I could have some pills to treat my type 1 diabetes” “Last time I went to the hospital, they took my pump (forcefully) and refused to give it back. When I protested, they sedated me. I was in and out of sedation having a panic attack bc I couldn’t breathe. They sedated me again and put me on DKA protocol, even tho I wasn’t in DKA.” “it’s so scary right like you know that you’re the expert on your condition and your needs but that power gets totally taken away” “Handing over your care over to a group of nurses who have no idea what they are doing. It’s super scary. I hate it when they lock it all away and you can’t get to it.” “I didn’t feel safe either. Told them on a few occasions I felt ‘low’. Finally Lucozade got wheeled out but it was almost an inconvenience” “Totally understand why they don’t know much about it if it’s not their specialism BUT some are so arrogant that what they were told one afternoon 10yrs ago is the absolutely way to deal with, and that the person living with it doesn’t know what they’re talking about!” Sarcastic responses “You seem to know a lot about it!” “The neurologist told me I am a terrible diabetic.” “I never feel safe because they don’t allow me to dose my own insulin and last time dropped me from 600 to 40 in three hours and then shot me back up so fast when i specifically told them that i would go low and high from that much insulin” Report of being diagnosed with type 1 diabetes while in hospital, despite telling every healthcare professional she had T1. “I smuggled in my own tester and meds and took care of myself.” “I think the biggest thing for me is them not understanding insulin dose when they’re writing up your chart and how you don’t really have a “typical” insulin dose that fits neatly into their charts because of carb counting or correction doses/reduction dose. It’s strange, when I’ve had DKA admissions and I’m on the sliding scale IV it’s fine because there’s clear guidelines but for just day to day injection management it’s soooo difficult.” "Daughter had food and insulin withheld in a mental hospital." “the ward nurses didn’t even know I had T1 until the more mobile lady opposite me went and fetched a nurse who had been ignoring my call button. I was hypo and couldn’t reach my treatment.” "Taken off insulin for two days as no doctor to prescribe." “Particularly bad experience when a nurse left the glucose drip on but turned off the insulin. It terrifies me to think how bad this could have been.”
  23. Event
    until
    Digital has been an area of focus in the NHS for a number of years, and is a key feature of the NHS Long Term Plan. The Government's new plan for digital health and social care further recognises its role in transforming the NHS, building on the What Good Looks Like Framework. But do members of the UK public want digital tools as part of their support from the NHS? To better understand the nation’s true opinions, ORCHA has again this year commissioned independent research to ask 2,000 UK residents what they think. In this webinar, ORCHA's Director of Research, Dr Simon Leigh, and Clinical Director, Dr Tom Micklewright, will discuss this research in detail. We'll also hear from industry experts including Helen Hughes, Chief Executive at Patient Safety Learning, Richard Stubbs, CEO at Yorkshire and Humber AHSN, and Miles Sibley, Director at Patient Experience Library. Discover: What are patient attitudes towards digital health in the UK? How is digital health usage changing? Are people finding digital health helpful? Which regions are most activated in terms of digital health? How does the NHS influence the public's digital health choices? Register for the webinar
  24. Content Article
    Fracture liaison services (FLSs) check if people who have recently broken a bone after falling from a standing height or less (a fragility fracture) might also have osteoporosis – a disease that weakens bones. They then advise on treatments to reduce the risk of another fracture, helping to improve patient outcomes. The Royal College of Physicians (RCP) estimates that at least 90,000 patients in England and Wales who should have anti-osteoporosis therapy are not receiving it. This guide by the RCP's Fracture Liaison Service Database (FLS-DB) aims to help patients and their families and carers understand what to expect following a fragility fracture. It outlines three key findings and the actions that individuals can take to ensure they receive the care and treatment they need from health services.
  25. Content Article
    David Oliver is a consultant in geriatrics and acute general medicine who has worked in the NHS for 33 years. In this blog, he talks about his personal experience of running covid 'hot' wards during the different waves of the pandemic, describing the toll working in these conditions has taken on the health of him and many of his colleagues. He highlights the impact of looking after dying patients without adequate PPE, informing family members of patients' death over the phone, being responsible for many more patients than usual and witnessing colleagues die from Covid-19. The result has been burnout, mental health issues and low morale for a workforce that was already stretched before the pandemic hit the UK. David finally caught Covid-19 himself in March 2022 and he talks about how the virus—plus the cumulative effect of working under such strain for over two years—has meant he is not able to work and has been signed-off sick since mid-May.
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