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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The use of pelvic mesh was paused in the UK in 2018 after some patients developed complications and severe pain following the treatment. In this report for CNA, a Singapore-based news channel, Kath Sansom, founder of campaign group Sling The Mesh, talks about the severe pain and life-changing side effects she experienced after pelvic mesh surgery. The report highlights the risks associated with mesh removal surgery, the fact that women harmed by mesh have been dismissed and ignored by the healthcare system, and concerns that the number of patients who experience complications from pelvic mesh has been underestimated. It also outlines the need for stronger medical device regulation in the UK, and looks at issues with compensation and redress for patients harmed by mesh.
  2. Content Article
    This article in The BMJ examines the risks and benefits of current prostate cancer screening methods in the UK. It highlights issues that prevent early diagnosis including great variation in how prostate cancers behave and the poor performance of prostate specific antigen (PSA) testing in identifying disease that requires treatment. As a result of the limited benefits of screening for prostate cancer, routine screening is not recommended by the UK’s National Screening Committee or the US Preventive Service Task Force. The authors highlight that a bid by NHS England to find an estimated 14,000 men who have not yet started treatment for prostate cancer due to the pandemic, seems to contradict this recommendation. The NHS campaign warns that people shouldn’t wait for symptoms and encourages men to use a risk checker which informs patients of risk factors including family history, age and ethnicity. The authors express concern that the campaign implies there is great benefit in detecting asymptomatic disease, which could lead people to believe that the NHS is promoting screening. They argue that the NHS needs to be clearer and more consistent in its messaging, making sure that information aimed at the public emphasises that although PSA testing is available on request for men older than 50, it is not currently recommended, and why.
  3. Content Article
    This report by the Access to Medicine Foundation looks at how the pharmaceuticals industry can help tackle antimicrobial resistance (AMR) by improving access to medicines. It sets out how the unstable antibiotic market, with its fragile supply chains and tough market conditions, hinders the development of robust models that would allow medications to be more easily distributed and accessed. It features six case studies where companies and their partners are using a combination of access strategies to cut through the complexity and address access at a local level.
  4. Content Article
    This literature review in The Operating Theatre Journal looks at 'How industry has helped healthcare better understand human factors'. The author, Nigel Roberts, Theatre Lead at the University Hospitals of Derby and Burton, looks at this question in relation to teamwork, leadership, situational awareness, communication and culture.
  5. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment. HSIB has published an interim report outlining early investigation findings, and recommends a national response to tackle this urgent issue. Findings so far emphasise that an effective response should consider the interactions of the whole system: an end-to-end approach that does not just focus on one area of healthcare and prioritises patient safety. For its reference case, the investigation looks at the case of a patient who was found unconscious at home and taken to hospital by ambulance. The patient was then held in the ambulance at the emergency department for 3 hours and 20 minutes, and during this wait their condition did not improve. They were taken directly to the intensive care unit where they remained for nine days before being transferred to a specialist centre for further treatment.
  6. Content Article
    Midwives and other healthcare professionals are an integral part of many bereaved parents’ birth story and can play an important role in caring for parents when their baby dies. In this blog, Clare Worgan, Head of Training and Education at the charity Sands, talks about the importance of bereavement care to parents, and how training helps healthcare professionals to better provide this care. She outlines five principles of bereavement care and talks about why Sands is calling for bereavement care training to be provided to all staff who come into contact with bereaved parents.
  7. Content Article
    This retrospective cohort study in the British Journal of General Practice aimed to identify opportunities for timely investigations or referrals in patients presenting with potential symptoms of colon and rectal cancer, or abnormal blood tests. The study found evidence that patients with these cancers presented with low haemoglobin, high platelets and high inflammatory markers as early as nine months pre-diagnosis, and the authors suggest that starting cancer-specific investigations or referrals earlier may be beneficial in patients with some of these diagnostic markers.
  8. Event
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    This online study day from the East of England Neonatal Operational Delivery Network will be led by Sara Davis, Neonatal Practice Development Lead. Using a blend of theory and guided workshops, you will have the opportunity to see worked examples, ask questions, share ideas and receive support in the first stages of planning your own project. It will include: Action planning for learning and improvement using human factor science and QI methodologies, Audit as a tool for assurance and improvement and team effectiveness. The cost of this study day is: £10.00 per person for delegates attending from within the East of England Network £20.00 per person for delegates attending from outside of the East of England Network. Book a place
  9. 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. Mark talks to us about how he came to work in healthcare, the vital role of safety scientists and human factors specialists in improving patient safety, and the challenges involved in integrating new technologies into the health system.
  10. Content Article
    This article in the Journal of Interprofessional Care highlights the challenges experienced by programme leaders and healthcare professionals as they work to improve patient safety. It discusses the complexities of translating organisation-wide speaking-up policies to local practices and settings.
  11. Content Article
    In this article for The Guardian, Dr Kara Thompson, an obstetrician and gynaecologist working in the public hospital system in Geelong and Melbourne, Australia, argues that women must be given clear and unbiased information in order to make informed decisions about their birth preferences. She highlights the case of an information brochure about caesarean birth published on the website of a hospital in New South Wales, which presented incorrect claims about the relative risks presented by vaginal and caesarean birth. She outlines how the leaflet indicates that the way women are informed about birth choices is still subject to fear-mongering and shaming, and highlights the need for healthcare workers to respect maternal choice and autonomy.
  12. Content Article
    This ITV documentary tells the story of how surgeon Ian Paterson duped his patients into believing they had cancer and performed unnecessary surgeries on them, before he was caught and jailed for 20 years in 2017. It features personal accounts of patients who were harmed by Paterson while he worked in NHS and private practice. Further reading: Report of the independent Inquiry into the issues raised by Paterson (4 February 2020) Patient Safety Learning’s response to the Paterson Inquiry (11 February 2020) Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson (16 December 2021)
  13. Content Article
    Several accidents have shown that crew members’ failure to speak up can have devastating consequences. Despite decades of crew resource management (CRM) training, this problem persists and still poses a risk to flight safety. This study aimed to understand why crew members choose silence over speaking up. The authors explored past speaking up behaviour and the reasons for silence in 1,751 crew members, who reported to have remained silent in half of all speaking up episodes they had experienced. Reasons for silence mainly concerned fear of damaging relationships, fear of punishment and operational pressures. The study identified significant group differences in the frequencies and reasons for silence and recommends interventions to specifically and effectively foster speaking up.
  14. Content Article
    This report outlines the results of a survey of 10,000 nursing staff in the UK carried out by the Royal College of Nursing (RCN). The survey highlighted stark differences in career progression and treatment in the workplace between White nurses and those from a mixed ethnic background, and Black and Asian nurses. In the 35-44 age group, 66% of White and 64% of respondents from mixed ethnic backgrounds said they’d been promoted. This dropped to just 38% of Asian and 35% of Black respondents. Black respondents working in both hospital (39%) and community (32%) settings are more likely to report having experienced physical abuse than respondents of other ethnic backgrounds. In response to these findings, the RCN is calling on the UK Government to reform human rights law to help tackle workplace racism, including introducing a legal requirement to eliminate disparities in recruitment, retention and career progression. They also want employers to have greater responsibility to protect minority ethnic groups from racism in all its forms.
  15. Content Article
    The King’s Fund was commissioned by NHS England to undertake a review of the leadership and culture of the Healthcare Safety Investigation Branch (HSIB), including the culture and leadership needed for success as the organisation moves towards a steady state of independence. This report contains the authors' findings, obtained from individual interviews, focus groups and staff survey results, previous reports and other relevant information. It also contains HSIB staff members' responses to the findings, reflections from The King’s Fund review team about what needs to change, and a plan for the future.
  16. Content Article
    In this podcast for The Guardian, Madeleine Finlay speaks to Michael Marmot, Professor of Epidemiology and Director of the Institute of Health Equity at University College London, about the impact of the cost of living crisis on people's health. They talk about the ways that poverty makes people sicker and why falling income is so bad for the country’s health.
  17. Content Article
    This long read by The King's Fund aims to explain the reforms brought about by The Health and Care Act 2022, and what these changes will mean in practice. it gives short and long answers to the following questions: What are the main changes brought about by the Act? Is this an unnecessary top-down reorganisation? Will the Act lead to greater involvement of the private sector? Does the Act give ministers more power over the day-to-day running of the NHS? Will the Act make any difference to patients? Does the Act tackle the big challenges the health and care system currently faces?
  18. Content Article
    The Arthritis and Musculoskeletal Alliance (ARMA) has compiled relevant and useful resources and information specifically about musculoskeletal health inequalities. The resources include research studies, reports and reviews, and cover these areas: Social deprivation Ethnicity Sex, gender and sexual orientation Health literacy and education level Multiple factors Children and young people Webinars
  19. Content Article
    Handover in healthcare settings can be a time when the risk of error and harm is increased. This blog summarises the results of global survey that asked the opinions of healthcare workers on the safety of handover. It highlights ten key points raised by the results: Handover causes frequent errors and patient safety incidents Handover errors can cause serious harm to patients Most people think they are better than average at handover The longer you’ve been around, the scarier handover appears  Different types of handovers have a similar safety profile The safety of handover is a problem all over the world  Most practitioners use manual or informal systems to support handover EPR systems are not up to the job of supporting handover Staff need more training, and we need more time Healthcare leaders want better electronic systems The results of the survey have been published in Preprints.
  20. Content Article
    Handover is a critical process for ensuring quality and safety in healthcare, and research suggests that poor handover results in significant morbidity, mortality, dissatisfaction and increased financial costs. However, the safety of handover has not received much research attention to date. This study aimed to measure the perceived risk, degree of patient harm and the systems used to support handover, and to understand how this varied by care setting, type of clinical practice, location and level of experience. The authors suggest that the results of the study indicate that action needs to be taken to improve communication and reduce risk during all types of handovers. Clinical leaders should find ways to train and support handover with effective systems, particularly focusing on training less experienced staff. More research is needed to demonstrate which interventions improve the safety of handover.
  21. Event
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    Collaboration to deliver NHS Long Term Plan goals on CVD and Population Health Management A novel injectable treatment for people at risk of cardiovascular disease is being made available to patients more quickly, thanks to a three-way agreement between NHS England and NHS Improvement, the AHSN Network and the pharmaceutical company, Novartis. Inclisiran is the first of a new type of cholesterol-lowering therapy, which uses RNA interference (RNAi) to boost the liver’s ability to remove harmful cholesterol from the blood. It can be given to people with high cholesterol who have already had a previous cardiovascular event to reduce the chances of them having another. This webinar will introduce this innovative injectable therapy, explore it’s its place on the treatment pathway, and how it can support both the NHS Long Term Plan dual ambitions of reducing cardiovascular disease and through Population Health Management. Register for the webinar
  22. Event
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    The 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 4th webinar of the medication without harm webinar series is scheduled on June 18th, 2022, from 11:30 to 12:30 GMT. The theme is "Importance of Systems and Safe Medication Practices for patient safety”. This webinar will emphasize on the "Importance of Systems and Safe Medication Practices for patient safety ", within WHO’s Global Patient Safety Challenge: Medication Without Harm, to improve medication safety. 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. Register for the webinar
  23. Content Article
    Krista Haugen is National Director of Patient Safety for US-based emergency and patient relocation services provider Global Medical Response. In this interview, she describes how her 25-year career as an emergency medicine nurse has influenced her approach to safety and patient care. She discusses her personal experience of being involved in an accident as an air-ambulance flight nurse, and how this caused her to look at safety and risk management from a systems perspective, focussing on building a just culture where safety is optimised through organisational reflection and learning.
  24. Content Article
    In 2020, the Independent Medicines and Medical Devices Safety (IMMDS) Review made specific recommendations that the government provide justice and redress to thousands of women who have been harmed by surgical mesh implants. Surgical mesh, also known as transvaginal tape, is a medical device surgically implanted to support organs and tissue. It is primarily used to treat urinary incontinence in women, but is also used to treat hernias and to reinforce abdominal areas where women have had tissue removed to reconstruct their breasts after mastectomy. In this article for the Mail Online, John Naish highlights that two years after the IMMDS, none of its recommendations have been implemented properly and surgical mesh is still being used. He examines the case of Kelly Cook, a 37 year-old mother who has been left with constant pain, nerve issues and incontinence after mesh surgery in 2018. In spite of the impact the mesh is having on her life, she has been told she may not be seen at one of the new specialist mesh centres for two years due to the length of the waiting list. The article also highlights the fact that no financial redress has yet been offered to mesh victims, that women's pain is still not being seen as a serious issue, and that there is a concerning lack of research into the safety of mesh devices.
  25. Content Article
    This study in the British Journal of General Practice aimed to examine the impact of Covid-19 on GP contacts with children and young people in England. The authors conducted a longitudinal trends analysis using electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum database. The study found that: GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1-14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15–24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1-14 years (>90%). Remote contacts more than doubled, increasing most in infants. Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%).
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