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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This analysis by Paul Gallagher, Health Correspondent at i News discusses the prevalence of maternity scandals in the NHS, in light of the publication of the Ockenden Review into failings in maternity services at Shrewsbury and Telford NHS Trust. He highlights the importance of implementing the findings of the review, particularly focusing on the need for a comprehensive plan to tackle workforce shortages. He also highlights the continued existence in some trusts of a culture of covering up harm, evidenced by staff at Shrewsbury being pressured not to talk to investigators, right up until the report's publication.
  2. Content Article
    This is the report of Professor Ben Goldacre’s review into how the efficient and safe use of health data for research and analysis can benefit patients and the healthcare sector. It sets out a practical vision of how the Department of Health and the NHS can curate, manage and analyse the huge volume of health data available in the UK, and then communicate and use that data to improve the quality, safety and efficiency of health services.
  3. Content Article
    This analysis by the King's Fund looks at the latest British Social Attitudes (BSA) survey, which revealed that public satisfaction with the NHS fell by 17 percent between 2020 and 2021. It discusses the 'halo effect' that affected public attitudes to the NHS at the beginning of the pandemic, and why this has faded since 2021. The article highlights the importance of addressing workforce issues, but states that returning the NHS to an 'even keel' will take a long period of time. In the meantime, the Government should prioritise managing public expectations of the NHS. It also highlights that although the survey shows great dissatisfaction with the care currently provided, the public appears to have upheld its faith in the core principles of the NHS.
  4. Content Article
    'Cautious Tortoise' is an easy to follow flow chart that aims to guide parents and caregivers through the early steps of their child's recovery from Covid-19 and Long Covid, while supporting them to preserve energy to aid ongoing recovery. Alongside an infographic flow-chart, this webpage contains frequently asked questions about Covid-19 and Long Covid in children, including: What does the government advise?  Long Covid Kids urge families to proceed cautiously  When can a child be referred to a Long Covid Paediatric Hub?  How many children get Long Covid?  Long Covid Symptoms In Children  What is post exertional malaise/post exertional symptom exacerbation?  When is the right time to return to school?
  5. Content Article
    This article in the journal Archives of Disease in Childhood examines patient safety theories and suggests principles to tackle safety challenges specific to paediatric care. The authors provide an overview of the evolution of patient safety theories and tools such as huddles and electronic prescribing. They look at the example of Paediatric Early Warning Systems (PEWS), highlighting that the organisational context and culture in which PEWS is used will dramatically affect its effectiveness as a tool. They conclude that approaches to patient safety must see it as a complex interconnected whole, rooted in the culture and environment in which safety interventions act. They also argue that paediatricians must take a lead in improving the safety of the care they deliver on a systems basis.
  6. Content Article
    In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report. This article contains a summary of the report, which can be read in full here.
  7. Content Article
    Falls are the most commonly reported patient safety incident in healthcare, with nearly 250,000 reported from hospitals in England and Wales each year. As well as causing injury to patients, the cost of treating falls is estimated to be around £630 million each year in England. This eLearning course is designed to help healthcare workers prevent patient falls in hospital. There are two modules available: Module 1 is aimed at hospital-based nurses. Module 2 is aimed at foundation level doctors and includes interactive information about patient and environmental falls risk factors, the patient assessment and post fall management. Both modules have been designed to complement, not replace, local falls prevention policies and processes.
  8. Event
    until
    Patient Academy for Innovation and Research (PAIR Academy) and the International Alliance of Patients’ Organizations (IAPO) are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the second webinar of the medication without harm webinar series is "Role of Healthcare Professionals in Ensuring Medication Safety”. Register for the webinar
  9. Content Article
    This report by the Health and Social Care Commons Select Committee examines why cancer outcomes in England remain behind other comparable countries. For example, 58.9% of people in England diagnosed with colon cancer will live for five years or more, compared to 66.8% in Canada and 70.8% in Australia. The report identifies key issues in early diagnosis, access to treatment, variation in services and research and innovation, and makes recommendations aimed at improving cancer survival rates in England.
  10. Content Article
    Out-of-hours discharge from the intensive care unit (ICU) to the ward is associated with increased in-hospital mortality and ICU readmission. This study in the journal Critical Care Medicine was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. It aimed to map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night. The study identified significant limitations in out-of-hours care provision following overnight discharge from ICU. The authors recommend changes to help make daytime discharge more likely, and new systems to ensure patient safety where night time discharge is unavoidable.
  11. Content Article
    This article in the British Journal of General Practice aimed to develop a safety-netting intervention to reduce delays in cancer diagnosis in primary care. To develop the tool, patient representatives, GPs and nurse practitioners were invited to a series of co-design workshops. These workshops suggested the intervention format and content should incorporate visual and written communication specifying clear timelines for monitoring symptoms and when to present back. Participants also agreed that they needed to be available in paper and electronic forms, be linked to existing computer systems and be able to be delivered within a 10-minute consultation. The output of this process was the Shared Safety Net Action Plan (SSNAP), a safety-netting intervention to assist the timely diagnosis of cancer in primary care.
  12. Content Article
    Since the Covid-19 pandemic began, a disproportionate number of BAME patients have reported not having their Long-Covid symptoms taking seriously. In this blog, Sheeva Azma looks at the impact of racial profiling on patient safety in the US, highlighting how health inequalities have worsened during the pandemic. She interviews Chimére Smith, who developed Long Covid after catching the virus in March 2020 and was left unable to work. Smith talks about the importance of representation in medicine, sharing how black doctors listened to her and took her seriously, when every white doctor she had seen dismissed her symptoms.
  13. Content Article
    Potassium permanganate is routinely used in the NHS as a dilute solution to treat weeping and blistering skin conditions, such as acute  weeping/infected eczema and leg ulcers. It is not licensed as a medicine. Supplied in concentrated forms, either as a ‘tablet’ or a solution, it  requires dilution before it is used as a soak or in the bath. These concentrated forms resemble an oral tablet or juice drink and if ingested are highly toxic; causing rapid swelling and bleeding of the lips and tongue, gross oropharyngeal oedema, local tissue necrosis, stridor, and gastrointestinal ulceration. Ingestion can be fatal due to gastrointestinal haemorrhage, acute respiratory distress syndrome and/or multiorgan failure. Even dilute solutions can be toxic if swallowed. A Patient Safety Alert issued in 20142 highlighted incidents where patients had inadvertently ingested the concentrated form, and the risks in relation to terminology and presenting tablets or solution in receptacles that imply they are for oral ingestion, such as plastic cups or jugs. A review of the National Reporting and Learning System over a two-year period identified that incidents of ingestion are still occurring. One  report described an older patient dying from aspiration pneumonia and extensive laryngeal swelling after ingesting potassium permanganate tablets left by her bedside. Review of the other 34 incidents identified key themes: healthcare staff administering potassium permanganate orally patients taking potassium permanganate orally at home, or when left on a bedside locker potassium permanganate incorrectly prescribed as oral medication. The British Association of Dermatologists (BAD) ‘Recommendations to minimise risk of harm from potassium permanganate soaks’ includes advice on formulary management, prescribing, dispensing, storage, preparation and use, and waste.
  14. Content Article
    Public satisfaction with the NHS is currently at a 25-year low, and lack of effective communication and engagement with patients has contributed to this dissatisfaction. In this blog, Lucy Watson, Chair, and Rachel Power, Chief Executive of The Patients Association, reflect on the findings of the Ockenden Report and the implications for patient trust in the NHS. They highlight the immense damage to trust caused by the combination of the hospital's substandard clinical care, lack of compassion, tendency to blame mothers and unwillingness to respond to concerns. The authors argue that listening to and better engaging with patients is essential to create the culture change the NHS needs to rebuild public trust and improve safety. They call for honest and transparency about how the NHS is coping, and for more action to tackle low staff morale.
  15. Content Article
    This report by Save the Children's Global Medical Team (GMT) shares the results of independent audits conducted in 2021. The audits aimed to assess the safety and quality of clinical and pharmacy services delivered by the organisation across seven countries. The team strategically focused on higher-risk programmes where Save the Children staff deliver services directly, with an aim to ensure that services remain safe and fully assured.
  16. 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. Roohil talks to us about the vital role of pharmacists in making sure medications help patients, rather than causing harm. She highlights the global threat of substandard and counterfeit medicines, the need to improve access to medicines and the importance of having pharmacists 'on the ground' to help patients understand how to take them.
  17. Content Article
    Health literacy describes "the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health." The National Health Literacy Community of Practice provides resources for healthcare staff about health literacy. On this online platform, the community shares research and best practice, offers support for training and discusses ideas about health literacy. Resources include a Health Literacy GeoData tool which provides an estimate of the percentage of a local authority population with low health literacy and numeracy.
  18. Content Article
    This guidance from the Department of Health and Social Care (DHSC) outlines infection prevention and control (IPC) principles for adult social care settings in England, to be used with guidance on managing specific infections. It applies from 4 April 2022. This should be read in conjunction with DHSC's Covid-19 supplement to the infection prevention and control resource for adult social care.
  19. Content Article
    The Schools for Health in Europe network foundation (SHE) aims to improve the health of children and young people in Europe, including reducing health inequalities, through a specific setting focus on schools. This factsheet by SHE provides an overview of current evidence on health literacy with a specific focus on schools, pupils, and educational staff. It contains information and data on: Health literacy among school-aged children The interplay between health literacy, health and education Health literacy in schools in the WHO European Region A future avenue for health literacy in schools
  20. Content Article
    This video introduces the SingHealth Patient Advocacy Network (SPAN), a patient-led collaborative that encourages patients and caregivers to be actively involved in their care. SPAN is co-chaired by two patients and aims to rethink traditional models of care. The network wants to improve the quality and design of healthcare so that it encompasses the needs and desires of patients and their caregivers.
  21. Content Article
    A large proportion of avoidable harm and adverse events occur in fragile, conflict-affected and vulnerable (FCV) settings. This article in the BMJ Open outlines the online Delphi study approach that will be taken to generate a consensus on the most relevant patient safety interventions for FCV settings. The results of this study will create a list of the most relevant patient safety interventions, based on the consensus reached among a range of experts including frontline clinicians and administrators, non-governmental organisations, policymakers and researchers. The study aims to increase awareness of the issues in this area, and identify priority interventions as well as areas for further evaluation and research.
  22. Content Article
    Serious pathology as a cause of musculoskeletal (MSK) conditions is considered rare, but it needs to be managed either as an emergency or as urgent onward referral as directed by local pathways. This guidance supports primary and community care practitioners in recognising serious pathology which requires emergency or urgent referral to secondary care in a patient who present with new or worsening MSK symptoms.
  23. Content Article
    Sharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this article, Sharon reflects on the significant impact of the harm caused by Primodos, a widely used hormone pregnancy test prescribed to women in the UK between 1958 and 1970. Primodos is now known to cause miscarriage, stillbirth and birth defects, and this article examines the culture of denial and an absence of state and corporate pharmaceutical accountability that allowed patients to continue to be harmed over decades.
  24. Content Article
    This long read by the Health Foundation examines the challenges of discharging people from hospital, and looks at 'discharge to assess' (D2A) an approach to reducing the incidence of delayed discharge. It outlines priorities for policymakers and the NHS and suggests next steps for managing hospital discharge.
  25. Content Article
    This statement from Hugh Alderwick, Director of Policy, outlines the Health Foundation's response to the House of Commons votes on the Health and Care Bill on 30 March 2022. He highlights the potential for the policies voted through to increase health inequalities, and to stall attempts to improve health and care workforce planning.
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