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Patient-Safety-Learning

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  1. Event
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    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. This is the first webinar of the series and will take place at 17.00 IST (11.30 GMT). The theme is "An approach towards medication safety for patients and family." Register for the webinar
  2. Content Article
    The theme for World Patient Safety Day 2022 is Medication Safety. It will take place on 17 September 2022. Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare across the world. Medication errors occur when weak medication systems, and human factors such as fatigue, poor environmental conditions or staff shortages, affect prescribing, transcribing, dispensing, administration and monitoring practices. This can result in severe patient harm, disability and even death. The ongoing Covid-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm. The theme builds on the ongoing WHO Global Patient Safety Challenge: Medication Without Harm. It also provides much-needed impetus to take urgent action for reducing medication-related harm through strengthening systems and practices of medication use.
  3. Content Article
    This is the third in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Deinniol tells us about how his role at the Healthcare Safety Investigation Branch (HSIB) helps make healthcare services in the UK safer for both patients and staff. He explains the importance of understanding the complexity of healthcare systems and the pressures that staff within the NHS face. He highlights the need build trust with patients, staff and other stakeholders to find ways forward in improving patient safety.
  4. Content Article
    This study in Nature Medicine aimed to characterise post-acute cardiovascular manifestations of Covid-19 that had not yet been comprehensively researched. The authors used national healthcare databases from the US Department of Veterans Affairs to build a cohort of 153,760 individuals with Covid-19, as well as two sets of control cohorts with 5,637,647 (contemporary controls) and 5,859,411 (historical controls) individuals, to estimate risks and one-year burdens of a set of pre-specified cardiovascular outcomes. The study demonstrated that, following the initial 30 days after infection, individuals with Covid-19 are at increased risk of incident cardiovascular disease, including cerebrovascular disorders, dysrhythmias, ischemic and non-ischemic heart disease, pericarditis, myocarditis, heart failure and thromboembolic disease. These risks were evident even among individuals who were not hospitalised during the acute phase of the infection and increased in a graded fashion according to the care setting during the acute phase (non-hospitalised, hospitalised and admitted to intensive care). The authors conclude the risk and one-year burden of cardiovascular disease in survivors of acute Covid-19 are substantial, and that pathways should include attention to cardiovascular health and disease.
  5. Content Article
    In this blog, we take a look at why women have been historically underrepresented in clinical trials and medical research, and the ongoing implications this has on medication safety for women.
  6. Content Article
    Speaking to patients about what matters to them helps healthcare teams understand individuals' priorities, leading to better care partnerships and improved patient experience. This toolkit developed by the Montefiore Medical Center in New York provides an outline of how to implement "what matters to you?" (WMTY) conversations in healthcare settings.
  7. Content Article
    This article in the journal IJQHC Communications examines how looking at the ‘Head’, ‘Heart’ and ‘Hands’ aspects of quality improvement can accelerate adoption of change, optimise the use of resources and maximise the impact and sustainability of interventions. It defines the different elements of Head, Heart and Hands approaches and looks at how these could be applied to rapidly changing environments such as healthcare systems during the Covid-19 pandemic.
  8. Content Article
    Sky Rollings had been diagnosed with Emotionally Unstable Personality Disorder (EUPD) and was sectioned under the Mental Health Act. She was transferred from a Children and Adolescent Mental Health Hospital to the Acute Adult Unit at the Harplands Hospital on 4 November 2019. She died on 9 November at the Royal Stoke University Hospital.
  9. Content Article
    This thesis explores different aspects of risk and safety in healthcare, adding to previous research by studying patient safety in first-contact care, primary care and the emergency department. The author investigated preventable harm and serious safety incidents in primary health care and emergency departments, and found that diagnostic error was the most common type or error. The thesis makes recommendations for safety improvements at all levels of a healthcare system.
  10. Content Article
    This guidance from the British Medical Association (BMA) covers frequently asked questions around prescribing in primary care and informs GPs of the BMA general practice committee’s policies in prescribing.
  11. Content Article
    The World Health Organization has released a mobile application for patients and their families and caregivers as part of its Global Patient Safety Challenge: 'Medication Without Harm'. The app is designed to guide patients through the five key moments where action can reduce the risk of medication-related harm, and to facilitate patients to ask their healthcare professional important questions about their medications. The app is available from Google Play and the Apple App Store.
  12. Content Article
    This literature review in the Journal of Patient Safety aimed to assess lessons learned on patient safety in Organization for Economic Cooperation and Development (OECD) countries, and to assess whether they can be applied to humanitarian medicine. The authors concluded that safety culture and strategies will need to be adapted to address different intervention contexts and to respond to the concerns and expectations of humanitarian staff. As there is no overarching authority for the sector, medical humanitarian organisations, have a major responsibility in the development of a general patient safety policy in all their operations.
  13. Content Article
    The Covid-19 pandemic has rapidly accelerated a trend of decline in access to and outcomes in healthcare. This situation means that people who have the means to do so are opting for faster, private care, creating a two-tier healthcare system. However, IPPR polling shows that near-universal public support remains for retaining a universal, free, comprehensive and tax-funded NHS. The public highly values the principles of the NHS as a system that universalises the benefits of the best healthcare and shares the cost across the population. This report by The Institute for Public Policy Research (IPPR) think tank proposes policies based on three aims: recovery, building back better and increased sustainability facing an uncertain future.
  14. Content Article
    This study in PLOS Medicine looked at the uptake of the Covid-19 vaccine in different ethnic groups in Manchester between 1 December 2020 and 18 April 2021. Covid-19 vaccine uptake is lower amongst most minority ethnic groups compared to the White British group in England, despite higher Covid-19 mortality rates. This study adds to existing evidence by estimating inequalities for 16 minority ethnic groups, examining ethnic inequalities within population subgroups, and comparing the scale of ethnic inequalities in Covid-19 vaccine uptake to those for routine seasonal influenza vaccine uptake. The authors of the study found that ethnic inequalities in Covid-19 vaccine uptake exceeded those for influenza vaccine uptake. existed amongst those recently vaccinated against influenza. were widest amongst those with greatest Covid-19 risk. This suggests the Covid-19 vaccination programme has created additional, different health inequalities. They suggest that further research and policy action is needed to understand and remove barriers to vaccine uptake, and to build trust and confidence amongst minority ethnic communities.
  15. Content Article
    In this blog, Clare Rayner, an occupational physician, describes how an international collaboration to help understand Long Covid was established by harnessing the power of technology and social media. This collective, between a group of UK doctors experiencing prolonged health problems after Covid-19 infection and a globally renowned rehabilitation clinic at Mount Sinai Hospital in New York, aims to help both patients and healthcare professionals by disseminating learning about Long Covid from both sides of the Atlantic.
  16. Content Article
    In this blog, Aimee Robson, Deputy Director of Personalised Care at NHS England, talks about how healthcare workers can introduce one simple question into their communication with patients: “What matters to you?” She highlights that facilitating dialogue with patients about their own priorities is the first step in achieving personalised care, a key commitment outlined in the NHS Long Term Plan.
  17. Content Article
    'Deep End’ general practices serve communities in the most socioeconomically disadvantaged areas. The analogy of the deep end of the swimming pool to describe how a one size fits all funding model for NHS GP practices regardless of area-based differences in patient needs leaves health professionals in high-deprivation places treading water to stay afloat. Lincolnshire’s East Coast is now amongst the most deprived communities in the UK. This in-depth article in BJGP Life reports on an event for local healthcare professionals and academic researchers hosted by First Coastal Primary Care Network (FCPCN) in November 2021, in Skegness, Lincolnshire. The aim of the event was to discuss the challenges that health professionals working within the FCPCN face with a focus on inequities and the experiences of the healthcare workforce.
  18. Event
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    The Safety for All campaign has organised this webinar in partnership with NHS Supply Chain and Patient Safety Learning. It will look at the challenges in healthcare supply chain and patient and staff safety. As we emerge from Covid restrictions, it is timely to look back and forward at the challenges facing the supply chain in healthcare, but also to ensure that safety for both patients and staff are prioritised amongst the other challenges facing the NHS and social care in the future. The webinar will be chaired by Jonathan Hazan, Chair of Patient Safety Learning, and will feature a keynote speech from the Chair of NHS Supply Chain, Heather Tierney-Moore. Heather will discuss Supply Chain’s role in supporting the NHS to deliver safe and excellent patient care, safety, sustainability, resilience and efficiency. This will be followed by a panel discussion with representatives from supply chain, patient safety, industry and the MHRA and a further session on how human factors need to be integrated into the process of delivering safety in healthcare. Finally, there will be a case study on a patient and staff safety issue in perioperative care and how better procurement can help deliver better care and safety in infection prevention. The webinar will be hosted on Microsoft Teams, join the webinar using this link. Full Webinar Programme
  19. Content Article
    This webpage from the British Medical Association (BMA) contains analysis of NHS data and is updated monthly. It highlights the growing backlogs across the NHS and includes operations data and information on the cancer waiting list, GP referrals and A&E waiting times.
  20. Content Article
    Promoting a ‘just culture’ is a key theme in patient safety research and policy, reflecting a growing understanding that patients, their families and healthcare staff involved in safety events can experience feelings of sadness, guilt and anger, and need to be treated fairly and sensitively. There is also growing recognition that a ‘blame culture’ discourages openness and learning. However, there are still significant difficulties in listening to and involving patients and families in organisations' responses to safety incidents, and for healthcare staff, a blame culture often persists. This can lead to a sense of sustained unfairness, unresponsiveness and secondary harm. The authors of this article in BMJ Quality & Safety argue that confusion about safety cultures comes in part from a lack of focused attention on the nature and implications of justice in the field of patient safety. They make suggestions about how to open up a conversation about justice in research and practice.
  21. Content Article
    General practice has always been the foundation and gateway to the NHS, but this part of the healthcare system is now under strain due to greater demand from an increasingly complex patient profile, and a stretched workforce. Lack of staff and coherent planning means that the current model is not fit for purpose, and this has resulted in a recent decrease in patient satisfaction. This proposal by the think tank Policy Exchange outlines the reforms that could help the NHS develop a model of general practice to better meet the needs and interests of patients and healthcare workers.
  22. Content Article
    Medical research is progressing to clarify the full range of sub-acute and long-term effects of post-COVID-19 syndrome (Long Covid), but most manuscripts published to date only analyse the effects in patients discharged from hospital, which may induce significant bias. This Spanish study in the journal Scientific Reports aimed to analyse the single and multiple associations between post-COVID-19 characteristics with up to six months of follow-up in hospitalised and non-hospitalised Covid-19 patients. Key findings include: At six months follow-up, fatigue, arthralgia, fever, breathlessness, emotional disturbance, depression, cognitive deficit, haemoglobin, total bilirubin, and ferritin are correlated with the gender of the patient Patients with previous respiratory diseases and abnormal body mass index, ex-smoker, and dyspnoea had a robust statistically significant association. Non-hospitalised patients may suffer more severe thromboembolic events and fatigue than hospitalised patients. Functional lung tests are good predictors of chest CT imaging abnormalities in elderly patients with Long Covid.
  23. Content Article
    The Perfect Patient Information Journey is Patient Information Forum's long-running project investigating how high-quality information can be provided throughout a person’s journey with a long-term condition.
  24. Event
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    This webinar is part of the HSJ Elective Care Recovery Virtual Series. To clear the waiting list backlog, hospitals will need to drive more elective activity within capacity and resource constraints. It demands the need to think differently and to work differently, questioning assumptions about the ‘normal’ ways of doing things. In this session we’ll explore innovative ideas, digital interventions and transformation programmes designed to free up time in elective pathways. Key topics include: Patient-initiated follow-ups Reducing outpatient appointments Pre-operative transformation / digitisation Investing in digital tools to improve efficiency in elective care pathways Register
  25. Event
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    In the first of the Health Services Journal (HSJ) Elective Care Recovery Virtual Series, we’ll be exploring the requirements of the Elective Recovery Plan – which was published in February - and the role that digital innovations can play in tackling long waiting lists and ensuring patients are prioritised by clinical need. We will start by hearing from Sir Jim Mackey, chief executive, Northumbria Healthcare Trust and national director for elective care recovery about the broad direction of the plan and its key asks of NHS organisations. Then we will look at the role that digital innovations can play in supporting patients and clinicians and hear from some examples where this has been put into practice. Viewers will be able to pose questions to the panellists during the discussion. Speakers include: Sir James Mackey, national director of elective recovery and chief executive, Northumbria Healthcare Foundation Trust Viki Jenkins, heart failure advanced nurse practitioner and echocardiographer, Betsi Cadwaladr University Health Board James Illman (Chair) Register
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