Claire Cox
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Everything posted by Claire Cox
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Content ArticleThis guidance is intended for doctors, nurses and allied healthcare professionals looking after children. It is therefore written in a manner to be accessible to all groups. It is intended to improve the care of children at risk of, or with, Acute Kidney Injury (AKI).
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Content ArticleHuman factors affect paramedic practice and training. However, although there are frequent references to human factors in the literature, little evidence on this is available on those that influence student paramedic development. In this article, published by the Journal of Paramedic Practice, looks at a case study which highlighted certain human factors unique to the role, most notably how interactions between students and mentors can affect a student's practice. Following this, the awareness and effect of human factors within the student paramedic role were investigated.
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Community PostOh Alice, I bet you feel scared stiff. I know there are many women on this forum who may be able to offer some words of advice/comfort to you. @Katharine Tylko I am glad you have found our site as this will put you in touch with women around the UK who understand your anxieties and are battling for a safer hysteroscopy.
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Community PostE57c52aefe1c97dd028637d8fd24b0adThanks Jonathan! The narrative of a datix is so important. I am new to the patient safety manager role, so I have limited experience in dealing with the 'back end' of datix. From the small amount that I have seen - you get many (tonnes actually) that are no harm, and you can tell that 'I am going to datix you' type reports. Datix may not be the best place to report these type of incidents - but where else can you log them? When reading the narrative you can get a sense of what is going on and the theme of it - communication, frustration with current systems/processes. These reports should not be ignored as, if looked at and themed with others, tell a powerful story about what is happening in that area. It may highlight risk hot spots or a poor culture of speaking up in certain areas, it may be an indicator of a deeper problem at play. Reporting systems are process driven. What you do with that information is not always process driven. The serious incidents are a process - but the no harm incidents often don't follow a process, so are often left aside. These small, seemingly insignificant events with a narrative are important. I am not sure what other patient safety managers do , but I am collecting the themes of all no harm events that happen in my directorates and will be looking at them on a monthly basis to spot trends and hotspots. We have a process to capture incidents. This is not the problem. The problem is with what we are doing with the information captured. How we interpret the data, who we involve, how we feed back and how we share actions and how we change practice - this is the hard work. It is easy to complain about Datix or any other incident reporting system and its functionality - its not so easy to act on the information it is giving us. As I mention, I am new to this area - 1 month in. Naive? Possibly, wanting the best for patients and staff? DefinitelyCommunity PostHi , I am new to patient safety management, after 25 years working clinically it has been a learning curve. I have seen RCA reports, some poor reports that need to be re written and many good ones too. This takes up a huge amount of time by many different people of differing roles. Co-ordinating meeting, feedback and discussion can take time and hold up actions for dissemination. There is much effort put into severe and moderate harm, internal RCAs where it is not a serious incident but it doesn't warrant a serious incident investigation. However, the very low/no harm incidents don't get much of a look in (there are tonnes of them!) If you take a look at the 'accident triangle ' (which I am sure you will be aware of ) - near misses and no harm happen the most frequent and may often lead to the more serious incidents if left. I would suggest much more emphasis, effort needs to be directed into the no harm/near miss incidents. They may seem petty and not sexy, like an SI - but they are great indicators of when the next SI may appear. An over sight of all no/low harm incidents with thematic problems highlighted and then fed into either a local (ward, department) or Trust wide QI project would be a fantastic way of changing practice from the 'ground up'. Capability of ALL staff trained in QI is happening in Trusts but not all Trusts. It would be a fabulous question for the CQC lines of enquiry 'how many staff are trained in QI?' This can be linked to well led and safety, but thats a whole other subject! As I mentioned, I am new to this role, but these are my observations so far. ClaireContent ArticleAs the colourful rainbows in people's windows are beginning to fade, is the public support for our frontline workers also fading? Has gratitude and thank you's been replaced with frustration and anger from the public? In her latest blog, critical care outreach nurse Claire reflects on the impact this is having on the wellbeing of already exhausted frontline staff.Content ArticleConnection, inclusion and compassion are certain, unchanging, and provide a safe refuge to deal with what feels frightening and isolating for so many. The challenge set by the Francis Inquiry Report – to create a compassionate, inclusive organisational culture – is now amplified in the COVID-19 era, which the NHS entered with pre-existing record levels of staff stress and chronic excessive workloads. This workshop from the University of Manchester, explores the problems and opportunities associated with changing healthcare organisation cultures.Content ArticleThis communication skills guide to practice, developed by Ausmed, explores several common communication scenarios that you may find yourself in as a health professional, and help you navigate and master each interaction you have in your day-to-day practice.Content ArticleA two minute video on COVID-19 and systemic inequality by David Nabarro, Special Envoy of WHO Director-General on COVID-19. COVID is the great revealer. It reveals inequality and issues around wealth, gender, race and climate. "You want to get on top of this disease? You've got to address systemic inequality". David gives advice on what you can do.Content ArticleDespite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. This short video by the University of Michigan Health System explains more.Content ArticleIn this short film, Nadine Montgomery presents her story that led to the landmark ruling on consent (Montgomery v Lanarkshire Health Board, 2015)Content ArticleNorthampton General Hospital NHS Trust has produced this leaflet to help keep patients safe in hospital.Content ArticleDespite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient-and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. The aim of this review, published in Systemic Reviews, is to explore patients’, relatives’ and healthcare professionals’ experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.Content ArticleNear miss events are much more common than events where harm actually reaches a patient, as much as 7-100 times more frequent. However, reporting systems for such events are much less common. At Faulkner Hospital, over 75% of the safety event reports the hospital captures in RL6 are near misses.Content ArticleThe Imperial Simulation Team, led by Dr Malik, filmed this Immersive Simulation of a SARS-CoV2 patient with COVID-19 disease who had a cardiac arrest. Filmed at Imperial College Healthcare NHS Trust/Imperial College London.Content ArticleMouth Care Matters have launched a video – Supporting Patients in Hospital Who Are Resistant to Mouth Care. As part of their work with trusts in England, care resistant behaviour was the number one barrier to providing mouth care. They have developed a video is to explain why a patient may be resistant towards mouth care, and some ways that may help manage this. This video is aimed at all healthcare professionals. Covering techniques, use of distraction and products, we hope after watching this video you will have picked up many new tips towards delivering better care, to a patient who may at first be resistant to mouth care.Content ArticleIn everyday life and in health care environments, distractions and interruptions are threats to human performance and safety. A distraction may occur when a driver is texting while in traffic or when a health care professional is interrupted during a high-risk task such as prescribing or administering a medication. Interruptions—ringing telephones, active alarms or computerized alerts, or even being asked a question – are ubiquitous in society, and health care is no exception. This article by nurse, Suzanne Beyea, discusses how mindfulness can reduced distraction and improve patient safety. Published by the Patient Safety Safety Network.Content ArticleThis resource, from NHS Education for Scotland, has been designed for acute general hospital staff to help them develop their abilities in supporting people with dementia, their families and carers. It will help you develop the knowledge and skills set out at the ‘Dementia Skilled Practice Level’ of Promoting Excellence: a framework for all health and social services staff working with people with dementia, their families and carers.Content ArticleDementia is a cause of disability and dependency associated with high demands for health services and expected to have a significant impact on resources. Care policies worldwide increasingly rely on family caregivers to contribute to service delivery for older people, and the general direction of health care policy internationally is to provide care in the community, meaning most people will receive services there. Patient safety in primary care is therefore important for future care, but not yet investigated sufficiently when services are carried out in patients’ homes. In particular, we know little about how family carers experience patient safety of older people with dementia in the community.Content ArticleLack of transparency helped Ian Paterson to operate unchecked for years, according to inquiry The recent report of the Paterson Inquiry identified multiple levels of dysfunction across England’s health system. These allowed surgeon Ian Paterson to practise unchecked for many years, causing serious harm to thousands of patients. Among the less surprising of the failings is the lack of transparency in reporting activity and outcomes by the private hospitals where he worked. As the report notes, transparency is no panacea, but it is essential for protecting patients from harm. This BMJ editorial argues that urgent action is now needed to improve reporting by independent sector providers to bring them in line with standards in the NHS.Content ArticleThe Acute Data Alignment Programme (ADAPt) is a joint programme between NHS Digital and the Private Healthcare Information Network (PHIN) which is looking to adopt common standards for data collections and performance measures across both the NHS and private healthcare. This will ensure that relevant information is consistently recorded and available so it can be more easily analysed and compared.Content ArticleThis report by the Center for Health and the Public Interest, brings together what is known about patient safety in private hospitals. It offers insights into the number of patient safety incidents in private hospitals, analyses the potential risks inherent in the way that these services operate, and makes recommendations to improve transparency in the private sector.Content ArticleKate and Jenny Sanger’s 'Communication Passport' gives a voice to the voiceless and enables those being supported and those providing that support to have the two-way conversation that leads to a happy and positive relationship. The passport is a powerful support tool for staff, giving them confidence and job satisfaction that they are doing their best for the person they support. Kate and Jenny Sanger created the communication passport originally for Kate’s daughter, Laura. The aim of the passport is to enable a range of professionals and specialists access important information so that care can be delivered more holistically. The communication passport has now been shared widely to help other families and individuals with complex needs. Kate and Jenny Sanger speak in this webinar about building a communication passport.Content ArticleWhat does good end of life care planning look like? What should you talk about, how and when should you talk about it? Big questions. It’s hard enough for any of us to plan for our time of declining health and dying. Much harder, still, for people with learning disabilities. And much, much harder still at this time of COVID-19. There is a danger that we talk about it at an unhelpful time or in an unhelpful way. This danger is greatest if there is a tick-box approach to “end of life care planning” (or, as it is often called, “advance care planning”), where the focus is on completed paperwork rather than on communication. In this webinar, Professor Irene Tuffrey-Wijne talks about what end of life care planning is (and what it isn’t), and talks through her top tips on how to approach this with people with learning disabilities. She will also discuss some of the particular challenges we face now, during COVID-19, in relation to end of life care planning.
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