Patient-Safety-Learning
PSL ModeratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleCollectively, allied health professionals (AHPs) are the third largest clinical workforce in the NHS: there are 185,000 AHPs working in 14 professions across the spectrum of health and care, education, academia, research, the criminal justice system and the voluntary and private sectors. This NHS England strategy is for the whole AHP community, including support workers, assistant practitioners, registered professionals, pre-registration apprentices and students. It aims to reflect how AHPs work in multidisciplinary teams, so that the AHP community working in a variety of health and care sectors can use it to continually improve and redesign services.
-
Content ArticleMany people with Long Covid experience varying levels of long-term cognitive impairment, but the causes of this are not well understood. This preprint longitudinal observational study aimed to identify links between cognitive impairment and different biomarkers in people with Long Covid. The authors reported the findings of 128 prospectively studied patients who had tested positive for Covid. They looked at: lung function, physical and mental health at two months post diagnosis. blood cytokines, neuro-biomarkers and kynurenine pathway (KP) metabolites at 2-, 4-, 8- and 12-months post diagnosis. The study identified that KP metabolites were significantly associated with cognitive decline and could therefore offer a potential therapeutic target for treating cognitive impairment related to Long Covid.
-
EventuntilUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. Ensuring medication safety in polypharmacy is one of the critical challenges in medication safety. Inappropriate polypharmacy has been described as a significant public health challenge, as it increases the likelihood of adverse effects, considerably impacting health outcomes and expenditure on health care resources. Countries need to prioritize raising awareness of the problems associated with inappropriate polypharmacy and the need to address this issue. All stakeholders have a vital role in driving change for the management of polypharmacy. At this webinar, we will introduce the WHO technical report on “Medication Safety in Polypharmacy”, and experiences from different countries and organizations will be shared on the proper management of polypharmacy and the factors that influence appropriate polypharmacy. The session will be available in English, French and Spanish. Register for the webinar
-
Content ArticleSince the Covid-19 pandemic, staff shortages have worsened in health systems around the world, with an increasing number of healthcare workers leaving the workforce coinciding with increased patient demand. In this blog, Jens Hooiveld, International Marketing Manager at the Patient Safety Company, examines the patient safety issues caused by staffing shortages. He highlights tools that can help nurses manage patient safety in this pressured climate by decreasing the burden of admin associated with reporting adverse incidents.
-
EventuntilThe Faculty of Clinical Radiology has developed guidance on the duty of candour with the aim of providing radiologists with guidance and real-world examples on the implementation of the duty of candour. The document recognises the unique circumstances faced by radiologists and all who work in imaging. It is not possible to provide guidance for every situation, but the aim is to provide an approach which will help colleagues navigate an unfamiliar process in the best possible way for our patients and the professionals who care for them. The Royal College of Radiologists is hosting a webinar to discuss this new guidance and answer any queries. Please submit any questions in advance to guidance@rcr.ac.uk by Friday 24th June to ensure we are able to answer as many as possible. Register for the webinar
-
Content ArticleThis guidance from The Royal College of Radiologists aims to provide radiologists with guidance on how to implement the duty of candour, recognising the unique circumstances they face. It includes real-world examples and provides an approach which will help radiologists navigate an unfamiliar process in the best possible way. The guidance covers: The principles of candour Why this can be difficult in a radiological context Candour in different situations (reactive and proactive candour) and departmental disclosure policies Candour processes in practice The difference between discrepancy assessment and education/Radiology Events and Learning Meetings (REALM) Specific considerations (interventional radiology and remote reporting within an imaging network).
-
Content ArticleStaying in hospital can be a frightening experience for people with diabetes. In 2017, an estimated 9,600 people required rescue treatment after falling into a coma following a severe hypoglycaemic attack in hospital and 2,200 people suffered from Diabetic Ketoacidosis (DKA) due to under treatment with insulin. This report by Diabetes UK outlines the patient safety issues and suggests the following measures are needed to make hospitals safer for people with diabetes: multidisciplinary diabetes inpatient teams in all hospitals better support in hospitals for people to take ownership of their diabetes better access to systems and technology more support to help hospitals learn from mistakes strong clinical leadership from diabetes inpatient teams knowledgeable healthcare professionals who understand diabetes.
-
Content ArticleThis report by NHS Confederation looks at the lived experience of senior black and minority ethnic leaders in the NHS. It is based on the findings of a survey and series of roundtables conducted by the BME Leadership Network in spring 2022, which focused on the challenges BME leaders face in relation to racism and discrimination as they move through their careers. The report highlights that: More than half of surveyed BME NHS leaders considered leaving the health service in the last three years because of their experience of racist treatment while performing their role as an NHS leader. Colleagues, leaders and managers seemed to be a particular source of racist treatment, more so than members of the public. This is concerning, given that the NHS has been prioritising equality, diversity and inclusion activities in recent years. This suggests that more focused efforts are required at every level to reduce the incidence of racist behaviour and to improve awareness among all staff of the impact of this type of discrimination. Only 10 per cent of leaders surveyed were confident that the NHS is delivering its commitment to combat institutional racism and reduce health inequalities. Senior BME staff reported low levels of confidence in their own organisations’ abilities to manage and support a pipeline of diverse talent and in the ability of the system to achieve this at a national level. Only a minority were confident they could rely on the support of colleagues to challenge racial discrimination, and a smaller minority believed they would be supported by NHS England and NHS Improvement if challenging prejudice or discrimination locally. Leaders described how structural and cultural issues within the NHS led to a situation where BME leaders were not present in sufficient numbers to generate a climate of inclusivity and were sometimes siloed in particular types of role. This helped to create a situation where career progression was felt to be unduly challenging and where neither succession planning nor talent development were occurring at sufficient scale to support the next generation of diverse leaders. Some leaders reported policing their own behaviour in the workplace and compromising their values in order to fit in. Being able to represent their own cultures and be themselves at work was a critically important goal for many. The report outlines that it is essential that BME leaders are able to see effective development programmes to support diverse talent, and that they are provided with the right support to feel secure in calling out unacceptable behaviour. It highlights that the NHS needs to do more to tackle cultures of discriminatory behaviour, provide personal support to current and aspiring leaders, and develop succession planning and talent development schemes.
-
Content ArticleWith waiting lists for gynaecology having grown by 60% since before the pandemic, many women are being left to cope with conditions like endometriosis, fibroids and prolapse on their own while waiting for NHS care. In this article, four women describe how NHS waiting lists and attitudes to gynaecological symptoms have left them living with severe pain and feeling like their health is not being taken seriously.
-
Content ArticleThe 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.
-
Content ArticleThis 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.
-
Content ArticleThis 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.
-
Content Article
Human factors - Safer surgery checklist (June 2022)
Patient-Safety-Learning posted an article in Surgery
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. -
Content ArticleThis 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.
-
Content ArticleMidwives 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.
-
Content ArticleThis 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.
-
Event
Neonatal Quality Improvement study day
Patient-Safety-Learning posted an event in Community Calendar
untilThis 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 -
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. -
Content ArticleThis 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.
-
Content ArticleIn 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.
-
Content ArticleThis 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)
-
Content ArticleSeveral 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.
-
Content ArticleThis 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.
-
Content ArticleThe 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.
-
Content ArticleIn 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.
