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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This report by the Patients Association analyses the opinions and experiences of diagnostic testing services of more than 1,000 NHS patients. It highlights that patients view diagnostics as a fundamental part of the NHS—and one that should be prioritised. Most respondents (93%) want testing capacity to be invested in over the coming years so that patients can receive tests and diagnosis more quickly. Patients place such importance on diagnostics that 60% would consider paying for the tests they need if they faced a long wait on the NHS.
  2. Content Article
    In this Lancet article, Lioba Hirsch shares her experience of labour and birth as a Black woman. She describes dismissive behaviours and blaming comments from several healthcare professionals that left her feeling unable to ask questions and advocate for herself and her baby. She suggests that the lack of compassion and dignity she was shown are a risk to patient safety: "I am so glad that my child was safe that day, but many children and their birthing parents are not and the slope from disrespect and disregard to dismissal and its consequences is a slippery one."
  3. Content Article
    The Government plans to expand physician associate (PA) and anaesthesia associate (AA) roles and to establish the General Medical Council (GMC) as their statutory regulator. There has been concerted opposition to the plans by groups including the Doctors’ Association UK (DAUK) and the British Medical Association (BMA). Earlier this month, the House of Lords sent the draft legislation to the main chamber for proper scrutiny, stating that this was the procedure when an issue "is politically or legally important or gives rise to issues of public policy". In this Medscape article, Dr Sheena Meredith outlines the Government's proposals and why the issue has become so contentious.
  4. Content Article
    Primary care appointments may provide an opportunity to identify patients at higher risk of suicide. This study in the British Journal of General Practice aimed to explore primary care consultation patterns in the five years before suicide to identify suicide high-risk groups and common reasons for seeing a healthcare professional. The authors found that frequent consultations (more than once per month in the final year) were associated with increased suicide risk. The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation, including females, patients experiencing less socioeconomic deprivation and those with psychiatric conditions. The commonest reasons that patients who went on to commit suicide requested consultations in the year before their death, were medication review, depression and pain.
  5. Content Article
    Infection Control Matters is a podcast in which infection control professionals discuss new research and issues on the topic of infection prevention and control. In this episode, Martin Kiernan and Phil Russo talk to Professor Michael Borg from the Faculty of Medicine & Surgery at the University of Malta They discuss a recent paper describing the stages that brought about a 90% reduction in MRSA bloodstream infections over a ten-year period.
  6. Event
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    This webinar hosted by the Patients Association provides an opportunity to hear about the new Pharmacy First Service. Speakers include: David Webb, Chief Pharmaceutical Officer for England Pallavi Dawda, Head of Delivery, Clinical Strategy Community Pharmacy, NHS England Leighton Colegrave, member of Hertfordshire and West Essex ICB's Patient Engagement Forum Tunde Sokoya, community pharmacist, Essex Lindsey Fairbrother, community pharmacist, Derbyshire. The Patients Association Chief Executive Rachel Power will chair the webinar. Register for free.
  7. Event
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    This webinar will explore the findings from the Patients Association's Patient Experience of Diagnostics report and consider its recommendations. The panellists are: Professor Sir Mike Richards, who was the first National Cancer Director at the Department of Health Karen Stalbow, Head of Diagnostic Policy at NHS England Dr Ashton Harper, Head of Medical Affairs at Roche Diagnostics Ltd. Patients Association Chief Executive Rachel Power will chair the session and the panel will include patients. The webinar will be held on Zoom and is free to attend. Book your place.
  8. Content Article
    This report aims to understand the NHS response to racism, what trusts and healthcare organisations do about it and how effective they are at addressing it. It brings together key learning from a number of significant tribunal cases and responses from 1,327 people to a survey about their experiences of raising allegations of racism within their organisations.
  9. Content Article
    Patient engagement technologies (PETs) are tools used to guide patients through the perioperative period. This study in the American Journal of Surgery aimed to investigate the levels of patient engagement with PETs through the perioperative period and its impact on clinical outcomes. The authors found that use of PETs improves patient outcomes and experiences in the perioperative period. Patients who engage more frequently with PETs have shorter length of stay (LOS) with lower readmission and post-operative complication rates.
  10. Content Article
    In this letter to Health Secretary Steve Brine MP, members of the All Party Parliamentary Group (APPG) on Pandemic Response and Recovery raise serious concerns about the approach of the Medicines and Healthcare Products Regulatory Agency (MHRA) to patient safety. They outline problems within the MHRA that continue to put patients at serious risk of harm. The letter also highlights the role of the Independent Medicines and Medical Devices Safety Review (IMMDS), in its thorough investigation of Primodos, sodium valproate and pelvic mesh in bringing some of these concerns to the fore. It points to recent evidence presented to the APPG that indicates that the MHRA is at the heart of wider endemic failings, with issues uncovered so far being "the tip of a sizeable iceberg of failure." The letter outlines concerns about the following areas: The Yellow Card Scheme Conflicts of interest and transparency History of regulatory failures in the MHRA It calls on the Health and Social Care Select Committee to investigate these issues and make recommendations to the government on: legislative changes as to who is obligated to report adverse drug reactions. funding changes to the MHRA. separation of regulatory approval duties from post marketing pharmacovigilance. more inclusion of patients. greater transparency across the board. proper enforcement of Part 14 of the Human Medicines Regulations 2012.
  11. Content Article
    In this interview, Professor Martin Marshall, former GP and Chair of the Royal College of General Practitioners, shares his concerns for the future of general practice in the UK. He outlines the danger that more of the workforce will turn to private practice due to current pressures facing NHS GPs.
  12. Content Article
    A growing awareness of sex and gender bias in evidence has resulted in the development of new tools to address this concern. The Sex and Gender Equity in Research (SAGER) guidelines and the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) are two initiatives designed to foster more transparent research and reporting practices that bridge the gender evidence gap. These tools enable researchers to unravel the complexities that underpin health risks and outcomes and generate more accurate and relevant findings that can inform effective and equitable policies for better health outcomes. This Lancet article looks at the World Health Organization's (WHO's) adoption of GATHER and the SAGER guidelines to tackle sporadic and suboptimal reporting of sex and gender data. The authors argue that this move is pivotal within WHO's broader strategic agenda, which it outlined in the Roadmap to Advance Gender Equality, Human Rights and Health Equity 2023–2030, launched in December 2023.
  13. Content Article
    This animation aims to help staff and employers across health and social care understand Oliver's Training and why it is so vitally important. It was co-designed and co-produced with autistic people and people with a learning disability. Oliver McGowan died aged 18 in 2017 after being given antipsychotic medication to which he had a fatal reaction. He was given the medication despite his own and his family's assertions that he could not be given antipsychotics, and the fact that this was recorded in his medical records. The animation tells his story and highlights the increased risks facing people with learning disabilities and autism when accessing healthcare.
  14. Content Article
    Incorporating parental values in complex medical decisions for young children is important but challenging. This review in The Lancet Child & Adolescent Health explores what it means to incorporate parental values in complex paediatric and perinatal decisions. It provides a narrative overview of the paediatric, ethics and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. 
  15. 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. Kevin talks to us about the role research plays in improving staff and patient safety. He explains how his own research has uncovered the extent of violence experienced by student nurses and the underreporting of sharps injuries among healthcare students. He also highlights how research can help universities improve awareness of issues facing students across all healthcare courses and provide more effective support.
  16. Content Article
    Healthcare students are at high risk of sharps injuries, which can negatively impact their confidence and wellbeing. This study audited three clinical skills simulation wards at a UK university to determine the incidence of sharps injuries in this educational setting. The authors found that sharps injuries were the most common type of incident in clinical skills simulation wards, with student nurses being at highest risk. They suggest that intervention is needed to improve safety in this educational setting, including sharps handling training, with greater focus on existing regulations.
  17. Content Article
    Preventable conditions are costing the NHS and wider society hundreds of billions of pounds and leading to reduced quality of life for large numbers of people. This paper from the Tony Blair Institute for Global Change proposes ways in which the NHS can use existing tools for screening and preventing ill health, to make the UK healthier and more productive and reduce pressure on the health system. It suggests a prevention programme that uses AI to highlight risk factors and screen individuals most likely to develop chronic health conditions.
  18. Content Article
    Studies have reported evidence on sharps injuries among nursing, medical and dental students but little is known about the amount, type and causes of sharps injuries affecting other healthcare students. This narrative review aimed to identify the extent, type and causes of sharps injuries sustained by healthcare students, especially those not in nursing, medicine or dentistry. The review highlights that some groups of healthcare students, including those studying pharmacy, physiotherapy and radiography, sustain sharps injuries from similar devices as reported in research on such injuries in nursing, medical and nursing students. Sharps injuries happen in a range of healthcare environments, and many were not reported by students. The main cause of a sharps injury identified was a lack of knowledge.
  19. Content Article
    The National Institute for Health and Care Excellence (NICE) pioneered the Health Technology Assessment (HTA) processes and methodologies. Technology appraisals (TAs) focus on pharmaceutical products and clinical and economic data, which are presented by the product manufacturers to the NICE appraisal committee for decision-making. Uncertainty in data reduces the chance of a positive outcome from the HTA process or requires a higher discount. This study in the BMJ Open aimed to investigate the quality of clinical data submitted by product manufacturers to NICE. The authors found that the primary components of clinical evidence influencing NICE’s decision-making framework were of poor quality. They argue that there is a need to generate robust clinical data for premarket and postmarket introduction of medicines into clinical practice, to ensure they deliver benefits to patients.
  20. Content Article
    Nontechnical skills (NTS) are the behaviours and thought processes used by surgeons to make decisions, maintain awareness of the operating environment, communicate with and lead team members with the view to producing reliably safe outcomes. This qualitative research explored how surgeons deploy NTS to facilitate safe and effective outcomes from surgical interventions. The authors conclude that successfully understanding and engaging NTS is potentially more proactively useful to surgeons than feedback from more invasive techniques used by some approaches to safe operator assurance.
  21. Content Article
    The adrenal glands are found in the fatty tissue at the back of the abdomen above each kidney, and produce steroid and adrenaline hormones. Surgery on tumours of the adrenal gland is uncommon compared with surgery for other tumours such as those of the breast, bowel, kidney and lung. Research has shown that the more adrenal operations a surgeon undertakes per year, the better the overall outcomes for patients undergoing that type of surgery. In this study, the outcomes from adrenal operations recorded over 18 years in the national adrenal surgical registry were analysed. The results confirmed previous findings showing that postoperative complications and length of hospital stay were reduced for patients operated by surgeons who did more adrenal operations per year. Operations done by keyhole surgery had better outcomes. Operations done either in older patients, or for the rare adrenal cancer tumours had worse outcomes, as did operations in which both adrenal glands were removed. The authors recommended that all surgeons performing adrenal surgery should monitor the outcomes of their operations, ideally in a national registry, and discuss these with patients before surgery; and undertake a minimum of six adrenal operations per year, but a minimum of 12 per year if doing surgery for adrenal cancer or surgery to remove both adrenal glands.
  22. Content Article
    Concerns have been voiced about the possibility of health risks to operating room staff from exposure to surgical smoke generated from electrocautery. This study reviewed available literature to try and assess this risk. The authors concluded that: Regulations on Surgical Smoke that supersede the best judgement of the surgeon are not warranted. The extent of particulate pollution from surgical smoke has been overstated and drawing parallels between exposure to surgical smoke and cigarette smoking is not justified. Numerous studies consistently report negligible levels of pollutants associated with surgical smoke within the operating room's breathable air. While transmission of HPV through surgical smoke is a theoretical concern, conclusive evidence supporting the claim is yet to be established.
  23. Content Article
    This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC). The authors identified patients with MTC from the National Cancer Database and assessed differences in disease presentation and likelihood of guideline-concordant surgical management by sex and race/ethnicity. The results showed that male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.
  24. Content Article
    NHS England’s Worry and Concern Collaborative is looking into how hospitals can make sure the worries and concerns of patients, their family and friends about a patient in hospital are taken into account by doctors, nurses and other health professionals.  This webinar, hosted by the Patients Association explored: The role of the National Worry and Concern Collaborative and its seven pilot sites the experiences of both clinicians and patients how these services need to be designed and delivered.
  25. Content Article
    This systematic review and meta-analysis in JAMA Internal Medicine aimed to explore whether there is an association between daily toothbrushing among hospitalised patients and prevention of hospital-acquired pneumonia. The authors found that hospital-acquired pneumonia rates were lower among patients randomised to daily toothbrushing, particularly among patients receiving invasive mechanical ventilation. Toothbrushing was also associated with shorter duration of mechanical ventilation, shorter intensive care unit (ICU) length of stay and lower ICU mortality, whereas hospital length of stay and use of antibiotics showed no differences.
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