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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Event
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    This webinar will look at how integration between different parts of the health system can provide solutions to some of challenges that mental health services face. Why attend? We often hear of the challenges in providing great mental health support. However, we hear less about the innovative solutions that the health and care system is implementing to meet the challenges, and how these can be replicated. This webinar will focus on how integration between different parts of the health system can provide solutions to some of challenges that mental health services face. Who will I hear from? Sonya Mclean, Crisis Care Commissioning Manager at Hampshire, Southampton and Isle of Wight CCG Dr Adam Cox, Clinical Director at Southampton CCG Beth Ford, User Involvement Manager for Mental Health, Learning Disabilities and Specialities Services, Service User/Patient and Carer Feedback Lead for Hampshire, Southampton and Isle of Wight CCG Discover: how a collaboration between Hampshire, Southampton and Isle of Wight CCG and numerous partners including patients, ambulance services, police, and voluntary sector organisations has reduced 999 mental health contacts by 26 per cent through a NHS 111 mental health triage services. how Doncaster CCG worked with their local authority, CAMHS services, police, education, and other partners to accelerated improvements to children and young people’s services around suicide prevention and self-harm, improving assessments, planning and service delivery. what the key enablers and challenges to innovation are in the mental health sector and how barriers to innovation can be overcome. what supports and drives better partnership working between different parts of the system. other inspiring solutions that being crafted across the sector and what networking/cross-working can take place. greater awareness of the sector and how different parts are innovating or integrating their services then adapting these solutions to benefit your local area. More information and register
  2. Content Article
    Preventable harm continues to occur to critically ill premature babies, despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. This article in the Journal for Healthcare Quality describes the introduction of a robust process improvement (RPI) program at a NICU in a US children's hospital. Leaders, staff, and parents were trained in RPI concepts and tools and given regular mentoring for their improvement initiatives, which focused on central line blood stream infections, very low birth weight infant nutrition and unplanned extubations. The authors conclude that implementing the RPI program resulted in significant and sustainable improvements to reduce harm in the NICU.
  3. Content Article
    Older generations are becoming more diverse than ever, but also more unequal. Tackling these inequalities is important to ensure that everyone is able to live a good later life. This set of downloadable 'evidence cards' by the Centre for Ageing Better highlights the severe inequalities experienced by Black, Asian and Minority Ethnic groups approaching retirement age, and what causes these inequalities. The evidence cards are available to download as both PDF and image files.
  4. Content Article
    The Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.
  5. Content Article
    Remote, at-home patient monitoring was widely used during the Covid-19 pandemic due to lack of hospital beds. This article in JAMA Network looks at the benefits of remote monitoring and how it can be used safely. Studies have shown that the use of remote telemonitoring reduced length of hospitalisation for Covid patients requiring oxygen, and the number of patient visits to emergency departments. The authors look at how the combined use of telehealth, home health and remote monitoring could bring hospital-level–monitoring services to patients in their home, and what barriers need to be overcome to achieve this.
  6. Content Article
    These online resources are designed to help healthcare professionals improve conversations with their patients about suicidal ideation, self-harm and other common mental health problems. The resources are based on a field of research known as Conversation Analysis, which micro-analyses verbal and non-verbal communication to study the consequences of different ways of communicating.  Resources include research findings and real examples from video-recorded psychosocial assessments with mental health nurses, social workers and other healthcare professionals. To access the resources, you need to be a healthcare professional and will need to create an account.
  7. Content Article
    Positive defensive medicine describes an approach to healthcare that involves excessive testing, over-diagnosing and overtreatment. Negative defensive medicine, on the contrary, describes an approach where doctors avoid, refer or transfer high risk patients. This article in Patient Safety in Surgery examines how both defensive medicine approaches can contribute to medical errors.
  8. Content Article
    This case report in the journal Cureus examines the use of dalfampridine, a drug used to improve walking in multiple sclerosis (MS) patients. Dalfampridine can have serious side effects including inducing seizures. Although the US Food and Drug Administration (FDA) recommends stopping the medication permanently after a single seizure episode, this recommendation is not widely known by health care professionals. The authors argue that there is a need to raise awareness of the FDA recommendation and the potential for dalfampridine to cause seizures amongst primary and secondary care doctors and patients.
  9. Content Article
    This report represents the views of organisations and experts who responded to the Department of Health & Social Care's call for evidence on its Women's Health Strategy. The call for evidence was released in March 2021. This report focuses on submissions received from 436 organisations and individuals with expertise in women’s health, including the charity sector (34%), academia (22%), industry (10%), clinicians (7%), professional bodies (7%), pressure groups (7%), NHS organisations (3%), parliamentary groups (2%), royal colleges (1%), local government (1%), think tanks (1%) and others (6%).
  10. Content Article
    Young people with type 1 diabetes experience higher rates of psychological distress, periods of burnout and feelings of being unable to cope with the daily burden of living with diabetes, than those who are diagnosed as adults. This article in The BMJ considers approaches to reduce anxiety and stress in young people with diabetes including: family, peer, and psychological support and education on living with diabetes. psychological screening assessment tools at diagnosis and annually. ensuring there are adequate local mental health support pathways. psychological and behavioural interventions, such as solution focused therapy, coping skills training, motivational interviewing and cognitive behavioural therapy.
  11. Content Article
    The National Paediatric Diabetes Audit (NPDA) is performed annually in England and Wales and aims to provide information that leads to improved quality care for children and young people affected by diabetes. The audit is funded by the Department of Health through the Healthcare Quality Improvement Partnership (HQIP). Key messages in this 2020-21 annual report on care processes and outcomes include: There was an increase of an increase of 20.7% in the number of children aged 0-15 diagnosed with type 1 diabetes compared with 2019-20. Completion rates on recommended health checks were lower than in previous years due to the impact of the Covid-19 pandemic. There was wide variation between paediatric diabetes units in the completion rates of all key annual health checks. A smaller percentage of newly-diagnosed children and young people started insulin pump therapy compared to previous years. The national median HbA1c (a measure of blood glucose control) reduced from 61.5 mmol/mol to 61.0mmol/mol between 2019/20 and 2020/21, following several years of year on year decreases (improvement) in the national median. Children from ethnic minorities were less likely to be using insulin pumps and continuous glucose monitors (CGMs) than white children. However, the highest percentage increase between audit years in the use of CGMs was seen in black children and young people with type 1 diabetes.
  12. Content Article
    New data from the Office for National Statistics demonstrates that people with severe and potentially terminal health conditions are more than twice as likely to take their own lives than the general population. This press release by the Campaign for Dignity in Dying highlights the patient safety issues caused by current laws around assisted dying in the UK, including patients dying alone by suicide, without loved ones to support them.
  13. Content Article
    Epistemic injustice occurs when a person is not given authority and credibility as a 'knower' in a conversation, due to negative stereotypes associated with their identity. These stereotypes might relate to their age, gender, ethnicity, social class, education, sexual orientation or health. Young people with unusual experiences and beliefs are particularly at risk of experiencing epistemic injustice, and this can have a negative impact on their health outcomes. In this blog Joe Houlders, Matthew Broome and Lisa Bortolotti from the University of Birmingham talk about the risks of young people with unusual experiences and beliefs experiencing epistemic injustice in clinical encounters. This is the first in a series of blogs reporting outcomes from a project on Agency in Youth Mental Health, led by Rose McCabe at City University.
  14. Content Article
    The article in the Journal of Global Health examines the unique patient safety risks that can arise in fragile, conflict-affected and vulnerable settings (FCV), including humanitarian crises, conflict, extreme adversity, services disruption and immediate or protracted emergencies. Recent estimates suggest a large proportion of the total number of preventable deaths take place in FCV settings, including 60% of preventable maternal deaths, 53% of deaths in children under five years, and 45% of neonatal deaths. The authors highlight a gap in knowledge and research about healthcare in FCV settings, which prevents researchers from being able to effectively assess interventions for quality, safety and sustainability. They suggest that more academic research is urgently needed in order to make policy and practice more effective in improving patient safety in these settings.
  15. Content Article
    In this blog for The Health Foundation, the authors make five recommendations for strengthening NHS management and leadership: Support providers and systems to tackle variation in management practice Improve access to training and development opportunities Ensure training equips managers and leaders with the skills they need today Tackle the reporting burden and 'priority thickets' facing managers Ensure the role of managers and leaders is better understood and valued
  16. Content Article
    This article in the Journal of Global Health aimed to consider which patient safety interventions are the most effective and appropriate in fragile, conflict-affected, and vulnerable (FCV) settings. The authors examined available literature published between 2003 and 2020, using an evidence-scanning approach. They found that the existing literature is dominated by infection prevention and control interventions for multiple reasons, including strength of evidence, acceptability, feasibility and impact on patient and healthcare worker wellbeing. They identified an urgent need to further develop the evidence base, specialist knowledge and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions and risk management.
  17. Content Article
    This analysis in the Financial Times highlights that in early April 2022, the number of vacant NHS hospital beds in England was 5.4%, the lowest figure since the start of the Covid-19 pandemic. The joint pressures of dealing with the backlog of elective care and ongoing high rates of Covid-19 infections are leaving the health service dangerously close to capacity. The authors highlight that this is likely to cause longer waits in accident and emergency and the potential for patients to be sent to wards that cannot effectively cater for their needs.
  18. Content Article
    This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Ehi talks to us about how building a connection with patients makes their care safer, the safety issues caused by lack of regulation, accountability and transparency, and the moral responsibility each of us has to speak up when we spot safety risks or see a patient harmed.
  19. Content Article
    This report by the charity Maternity Action looked at the lived experience of pregnant women seeking asylum in the UK. It highlights that pregnant women face barriers in accessing appropriate housing and nutrition during pregnancy, and that midwives and voluntary sector organisations play an important role in supporting pregnant women seeking asylum.
  20. Content Article
    This visual guide by the UK Health Security Agency shows photographs of different vaccines used in the UK routine immunisation schedule and their packaging. It includes information on trade names and abbreviations, diseases each vaccine protects against and the age at which it should be administered.
  21. Content Article
    This article examines the lasting impact of the tragic case of Daksha Emson, a 34-year old psychiatrist who took her own life and that of her baby daughter in an episode of postpartum psychosis. Daksha had a history of bipolar disorder and had attempted suicide before, and the inquiry into her death found that she received “significantly poorer standard of care than that which her own patients might have expected.” The authors highlight the impact of her story on the development in the UK of both specialist perinatal mental health services and specialised confidential services for health professionals, which remove some of the stigma attached to help-seeking.
  22. Content Article
    These resources by the Royal College of Nursing provide practical and clinical guidance for vaccine administration. All information supports guidance in The Green Book - Immunisation against infectious disease published by the UK Health Security Agency.
  23. Content Article
    This article in the journal Patient Safety describes a state-wide, population-based study into tracheostomy- and laryngectomy-related airway safety events. The Pennsylvania-based study aimed to assess the relationship of these events with associated factors, interventions and outcomes, to identify potential areas for improvement. The authors queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between 1 January 2018, and 31 December 2020.
  24. Content Article
    Sally Percival is Co-Chair of the National Co-production Advisory Group at the organisation Think Local Act Personal (TLAP). In this blog, she reflects on what has changed in co-production over the past 12 years, including the increased desire from policy makers to listen to patients' lived experience. She also talks about the importance of creating the right environment for co-production to take place and TLAP's 'Making it Real' approach.
  25. Content Article
    This guidance from the Department of Health and Social Care (DHSC) should be used to help reduce the spread of Covid-19 in adult social care settings. It applies from 4 April 2022 and should be read in conjunction with: the infection prevention and control (IPC) resource for adult social care, which should be used as a basis for any infection prevention and control response the adult social care testing guidance, which details the testing regimes for all staff, as well as any resident and outbreak testing where applicable.
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