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EventuntilPatient 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
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Content ArticleThis 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.
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Content ArticleOut-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.
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Content ArticleThis 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.
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Content ArticleSince 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.
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Content ArticlePotassium 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.
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Content ArticlePublic 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.
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Content ArticleThis 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.
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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. -
Content ArticleHealth 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.
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Content ArticleThis 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.
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Content ArticleThe 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
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Content ArticleThis 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.
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Content ArticleA 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.
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Content ArticleSerious 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.
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Content ArticleSharon 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.
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Content ArticleThis 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.
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Content ArticleThis 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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Content ArticleThis report published by the National Guardian’s Office shows the experience of Freedom to Speak Up Guardians amid the continued pressure of the pandemic on the healthcare sector. Although the majority of guardians who responded to the survey were positive about the culture of their organisation, the results highlight a decline in factors that make it easy for staff to speak up, including support from leadership.
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Content Article
NHS Staff Survey Results 2021 (30 March 2022)
Patient-Safety-Learning posted an article in Culture
The NHS Staff Survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. 648,594 staff responded to the survey this year. The full results of the 2021 NHS Staff Survey are published on the NHS Staff Survey website. -
Content ArticleWhen people already negatively affected by unfavourable social determinants of health seek care, healthcare itself may make health inequalities worse, rather than tackling them. This is seen in certain demographic groups experiencing disproportionate levels of harm. This article in The BMJ argues that focusing on patient safety in terms of specific health inequalities will help make healthcare more equally safe. It looks at interpersonal and structural factors that shape care experiences for people from marginalised backgrounds, including poor communication, basing treatment on models built around majority norms and healthcare worker bias. It highlights the importance of having a clear line of accountability for unequal harms so that individuals and organisations are given responsibility for taking action to overcome issues.
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Content ArticleThe concept of woman-centred care is at the core of midwifery care and midwives have a key role as advocates and facilitators of women’s choices. This briefing from the Royal College of Midwives provides guiding principles and support for midwives in facilitating personalised care and women’s choices, including when those fall outside clinical recommendations.
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Content ArticleThis blog provides an overview of a roundtable webinar organised by the European Biosafety Network (EBN), which focused on the need to prevent exposure to hazardous medicinal products (HMPs) and other substances. It was chaired by Gitta Vanpeborgh, Belgian Federal Deputy, and included attendees from across Europe.
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Content ArticleThis study in the British Journal of General Practice aimed to identify cardiovascular disease-related Prevention of Future Deaths reports (PFDs) involving anticoagulants, and to highlight issues raised and responses received. The authors highlight that nearly two-thirds (60%) of PFDs had not received responses from the organisations they were sent to, including NHS trusts, hospitals and general practices. They call for national organisations, healthcare professionals and prescribers to take actions that address concerns raised by coroners in PFDs, in order to improve the safe use of anticoagulants in treating cardiovascular disease.
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Content ArticleIn this article in the journal Health Expectations, the authors explore how current investigative responses can increase the harm for all those affected by failing to acknowledge and respond to the human impacts. They argue that when investigations respond to the need for healing alongside learning, it can reduce the level of harm for everyone involved, including including patients, families, health professionals and organisations.
