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Claire Cox

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Everything posted by Claire Cox

  1. Content Article
    Speaking at the Domain Driven Design conference in 2018, Sidney Dekker talks about the complexity of pursuing and averting drift into failure.
  2. Content Article
    This leaflet, produced by the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy, is for individuals who have been offered hysteroscopy as an outpatient. It may also be helpful if you are a partner, relative or friend of someone who has been offered this procedure. Key points: Outpatient hysteroscopy (OPH) is a procedure carried out in the outpatient clinic that involves examination of the inside of your uterus (womb) with a thin telescope. There are many reasons why you may be referred for OPH, such as to investigate and/or treat abnormal bleeding, to remove a polyp seen on a scan or to remove a coil with missing threads. The actual procedure usually takes 10-15 minutes. It can take longer if you are having any additional procedures. You may feel pain or discomfort during OPH. It is recommended that you take pain relief 1-2 hours before the appointment. If it is too painful, it is important to let your healthcare professional know as the procedure can be stopped at any time. You may choose to have the hysteroscopy under general anaesthetic. This will be done in an operating theatre, usually as a day case procedure. Possible risks with hysteroscopy include pain, feeling faint or sick, bleeding, infection and rarely uterine perforation (damage to the wall of the uterus). The risk of uterine perforation is lower during OPH than during hysteroscopy under general anaesthesia. Join the conversation on the hub about hysteroscopies.
  3. Content Article
    In the light of the current national guidance to reduce the number of inpatient learning disability beds, a review was completed of the quality of lives of the people who had been former inpatients in Cornwall at the time of closure of the learning disability inpatient facilities almost 10 years before transforming care. This study highlights that people with complex concerns with a history of placement breakdowns and past institutionalisation can be settled successfully and safely in local communities. However, it is difficult for many of them to achieve a satisfactory quality of life long term. The obligation for this lies with service providers to provide adequate support to overcome that difficulty.
  4. Content Article
    The safe management of a patient’s airway is one of the most challenging and complex tasks undertaken by a health professional - complications can result in devastating outcomes. How can anaesthetists improve safety, prevent complications, and be prepared to manage difficulties when they arise? How, in a crisis, can we ensure that human and technical resources are best utilised? This free course from Future Learn, endorsed by the Difficult Airway Society, will provide answers to these key questions and help you develop strategies to improve patient safety in your area of practice, discussing safe airway management in patient groups and multidisciplinary clinical settings. This course, is for all members of the multidisciplinary team who provide airway support to patients, or care for patients with a compromised airway. This includes anaesthetists, anaesthesia associates, operating department practitioners, nurses, physiotherapists, adult and paediatric intensivists, prehospital and emergency medicine physicians, paramedics, head and neck surgeons and members of the cardiac arrest team. By the end of the course, you'll be able to: improve your strategies to deal with the unexpected difficult airway and explore guidelines to use in special circumstances. identify the key learning points and recommendations from the 4th National Audit Project (NAP4) on major complications of airway management in the UK. apply the principles of multidisciplinary planning, communication and teamwork in shared airways interventions. describe the technical and non-technical aspects of safe airway management for patients undergoing elective or emergency surgery, and the critically ill. engage in a global discussion on airway matters with health professionals from around the world.
  5. Content Article
    Elisabeth Poorman argues that becoming a doctor means learning that mistakes are not acceptable. From study through to practice, doctors are told in ways big and small, the only way to be a good doctor is to be a perfect doctor. The pressure only intensifies when real harm is on the line. The encouraged response is to study harder, sleep less, and never admit fear.  In this film from the 2019 Boston Moth Grand Slam, Poorman tells her own story and argues that it's not perfection, but humanity and compassion that patients need.
  6. Content Article
    The need for effective teamwork and improved communication amongst caregivers is increasingly recognised in healthcare policy worldwide. As healthcare organisations navigate in highly complex contexts, they are largely dependent on thorough collaboration and sharing of information between staff at all levels. Promoting high‐quality teamwork based on effective and frequent communication is therefore essential for developing well‐functioning healthcare organisations This article from Nursing Open, published here by Wiley Online Library, aims to investigate whether nurse reported teamwork with physicians was associated with patient perceived consistency in staff‐to‐patient communication.
  7. Content Article
    In 2018/19, ten people died each week following release from prison. Every two days, someone took their own life. In the same year, one woman died every week, and half of these deaths were self-inflicted.  This report, co-authored by Dr Jake Phillips of Sheffield Hallam University and Rebecca Roberts of INQUEST, provides an overview of what is known about the deaths of people on post custody supervision following release from prison. It highlights the lack of visibility and policy attention given to this growing problem and calls for immediate action to ensure greater scrutiny, learning and prevention. The report makes the following recommendations: National review: the government should proceed with its national review of deaths of people on post-release supervision in the community following a custodial sentence to establish the scale, nature and cause of the problem. Data: more detailed and accurate data should be made available along with regular reporting to the Minister responsible and Parliament alongside the publication of an annual report. Investigations: deaths of people on post custody supervision should be investigated by an independent body with adequate resources allocated to allow this to happen. There needs to be a threshold for this with a range of factors taken into account. Improve scrutiny and learning: the Government needs to confirm oversight at a local and national level.
  8. Content Article
    Significant changes in how autistic people with a learning disability access and experience healthcare can and should be informed by stakeholders, including the patient and their family. This article, published by the University of Hertfordshire, provides different examples and suggestions from experts by parental experience. Small differences can lead to big changes which can escalate if carried out by many people on numerous occasions. Big changes in how autistic people with a learning disability access and experience healthcare can and should be informed by stakeholders, including the patient and their family. Blair et al identified the following simple steps: Take time to be with the person and their families to understand their lived experiences. Pick up not only on what is said, but also what is not said, and avoid hurrying the interaction. It is essential to remember that every interaction counts and each contact matters. Health professionals only spend a fraction of time with a person, so it is vital to gain as much insight as possible from the person and those who know them best, and to consider all that is being relayed, verbally and non-verbally. In doing so, healthcare practitioners can refocus how they interpret what they see and develop their understanding that what is seen superficially is not all that there is.
  9. Content Article Comment
    Thank you to the Dr that sent this blog in to us, powerful and moving. What needs to change in order for this care to happen every time. Not just by chance that a clinician has lived experience?
  10. Content Article
    This blog written by Adams mum gives praise to the domestic staff that work with in our hospitals. She explains how the domestic staff were a source of support and company for Adam and the family when he was admitted. Adams mum is a mother an academic, lawyer and lay advisor.
  11. Content Article
    Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. We tend to regard excellence as something to gratefully accept, rather than something to study and understand. Our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation. In this video, Senior Paediatric Intensivist, Adrian Plunkett from Birmingham Childrens Hospital UK, discusses positive reporting (as opposed to incident reporting) in improving morale and outcome in sepsis.
  12. Content Article
    Reflecting current best practice, the Oxford Handbook of Critical Care Nursing, Second Edition, is a practical, concise, easily accessible, and evidence-based guide for all levels of nursing staff working in critical care environments. It aims to provide a quick, easy-to-follow overview of critical care nursing, and is not intended as a specialist text. Rather it provides both the novice and the experienced nurse at the bedside with the answers to day-to-day problems experienced when caring for critically ill patients, and is also a guide to some of the less commonly encountered issues. The second edition has been updated to reflect recent significant changes in the management of the critically ill adult. Current guidance from organisations such as the National Institute for Health and Care Excellence (NICE), the British Association of Critical Care Nurses (BACCN), and the Intensive Care Society (ICS) has been included. In addition to the updating of clinical guidance, an emphasis has now been placed on nursing management, and the book is designed to help to facilitate systematic nursing assessment of the critically ill adult. New chapters focusing on changes in the delivery of critical care, systematic assessment, and end-of-life care have also been added.
  13. Content Article
    Episode 1 in this podcast series from the Care Quality Commission talks about the work they have been doing to collect people's experiences of care through the development of their 'Give Feedback on Care' service, their public campaigns work and the work of their national contact centre.
  14. Content Article
    In The Silo Effect, the author uses an anthropological lens to explore how individuals, teams and whole organisations often work in silos of thought, process and product. With examples drawn from a range of fascinating areas - the New York Fire Department and Facebook to the Bank of England and Sony - these narratives illustrate not just how foolishly people can behave when they are mastered by silos but also how the brightest institutions and individuals can master them.
  15. Content Article
    Safety-I is defined as the freedom from unacceptable harm. The purpose of traditional safety management is therefore to find ways to ensure this ‘freedom’. But as socio-technical systems steadily have become larger and less tractable, this has become harder to do. Resilience engineering pointed out from the very beginning that resilient performance – an organisation’s ability to function as required under expected and unexpected conditions alike – required more than the prevention of incidents and accidents. This developed into a new interpretation of safety (Safety-II) and consequently a new form of safety management. Safety-II changes safety management from protective safety and a focus on how things can go wrong, to productive safety and a focus on how things can and do go well. For Safety-II, the aim is not just the elimination of hazards and the prevention of failures and malfunctions but also how best to develop an organisation’s potentials for resilient performance – the way it responds, monitors, learns, and anticipates. That requires models and methods that go beyond the Safety-I toolbox. This book introduces a comprehensive approach for the management of Safety-II, called the Resilience Assessment Grid (RAG). It explains the principles of the RAG and how it can be used to develop the resilience potentials. The RAG provides four sets of diagnostic and formative questions that can be tailored to any organisation. The questions are based on the principles of resilience engineering and backed by practical experience from several domains. Safety-II in Practice is for both the safety professional and academic reader. For the professional, it presents a workable method (RAG) for the management of Safety-II, with a proven track record. For academic and student readers, the book is a concise and practical presentation of resilience engineering.
  16. Content Article
    In 1991, the Institute of Medicine released a landmark report revealing that as many as 98,000 patients a year were dying due to avoidable medical error. But even more recent research indicates that estimate was, if anything, a drastic understatement of the patient-safety crisis in the US healthcare system. In Malpractice, neurosurgeon and attorney Dr. Larry Schlachter demonstrates how most patients enter the system without any idea of the risks they face due to a medical culture that avoids transparency, perpetuates an atmosphere of blind deference to doctors, and protects dangerous doctors from any accountability. Drawing on twenty-three years of experience, Dr. Schlachter recounts unbelievable stories that illustrate the host of risks patients face whenever they seek diagnostic evaluation or go under the knife. This book brings readers inside the healthcare citadel, exposing the flawed culture that can fuel egos and outlining the steps every patent should take to protect himself or herself in “a bitter pill for an industry that for many years has avoided the hardest conversations about patient safety.”—Dr. Michael Dogali, MDCM, FACS, president of Pacific Neurosurgery
  17. Content Article
    This book is an account of the life of a surgeon: what it is like to cut into people's bodies and the life and death decisions that have to be made. 
  18. Content Article
    Helping patients and their families cope during a terminal illness is fundamental to good health care and that depends on professionals and the people in their care having access to the right information at the right time to support them. The Professional Record Standards Body (PRSB) has published the crisis care standard to support better coordination of treatment in primary,acute and community care, as well as hospices, care homes, and social services. The standard will also help patients to avoid unnecessary admissions and procedures.
  19. Content Article Comment
    Hi @HelenH Yes. I have been in contact with the brilliant @Paul Harris he will have more information.
  20. Content Article
    Referrals to hospital are increasing as more people continue to live longer with a range of complex conditions. The Professional Records Standards Body (PRSB) recognise that good information sharing is integral to ensuring that patients can receive the ongoing care that they need. Currently there are differences between GP systems and GP practices in the clinical content of referrals, with multiple templates in use. The clinical referral information standard is designed to improve the exchange of referral information from GPs to hospital consultants and other health care professionals providing outpatient services. Working with clinicians and patients, the PRSB have published this standard along with implementation guidance for digital referrals from GPs to hospitals. Once implemented, it will ensure that clinicians have the right information they need to provide the best care for patients. The standard was produced in collaboration with the Royal College of Physicians Health Informatics Unit and input from the Royal College of General Practitioners. By using the standard professionals will have access to all relevant information in a timely manner results in safer and more consistent care for people using health and care services. The information will include data about medication, previous history, allergies and current symptoms, as well as a patient’s concerns and expectations. This standard has now been updated to version 1.1. Detailed release notes are available outlining the changes. These can be found in the supporting documents link above. The standard has been updated in-line with new PRSB digital medications information assurance. The PRSB has worked in partnership with the Health Informatics Unit at the Royal College of Physicians to produce these standards.
  21. Content Article
    BAPEN’s web-based self-screening tool is designed for people who are worried about their weight or the weight of somebody they care about to quickly and easily work out if there is a risk of malnutrition. To use the tool, you just need to enter your height and weight into the online calculator, along with your height and weight 3-6 months ago. You will be given a rating that will tell you if you are at high, medium or low risk of malnutrition. You will then be able to download a dietary advice sheet that gives basic information and suggestions for improving nutritional intake. If you are worried about your weight or having difficulty eating, make sure you talk to your GP or a healthcare professional. The dietary advice sheet was developed in partnership with a number of professional organisations. NB this site is intended for adult self-screening only.
  22. Content Article
    I-Hydrate was a collaborative research project, which used service improvement methodology, and was undertaken at two privately operated North West London care homes in partnership with care home staff, residents and their carers and families. I-Hydrate aimed to optimise the hydration of residents in nursing homes, improve the quality and safety of care and decrease dehydration and the morbidity associated with it.  The study used quality improvement methods to develop and test interventions to extend drinking opportunities and choice in two care homes. Initial activity included observation of the systems for delivering fluids and involving staff, residents and carers in describing and mapping the organisation of care. An interactive training programme was indicated by staff as an important priority and was therefore introduced as a first step to improve hydration care. Subsequent interventions were co-designed with care staff and tested using Plan Do Study Act (PDSA) cycles. Their efficacy was measured through data captured on the amount of fluids served and consumed, and staff and resident feedback. The long-term impact of the interventions was assessed by measuring daily laxative and antibiotic consumption, weekly incidence of adverse health events, and average fluid intake of a random sample of six residents captured monthly. The link below shows the I-Hydrate presentation which summarises the project and its findings.
  23. Content Article
    Follow Lyns story, an animation highlighting the challenge of malnutrition in later life. The Malnutrition Task Force (MTF) are united to combat preventable and avoidable malnutrition and dehydration among older people in the UK. Established in 2012, they believe that good nutrition and hydration is fundamental to delivering dignified care, and enabling older people to live fulfilling and independent lives.  Tackling malnutrition is everybody’s business. The MTF works with partners across sectors and settings to raise awareness of undernutrition in later life and its causes, provide information and guidance, and spread best practice and innovation to improve the lives of older people in the UK.
  24. Content Article
    The aim of the Airway Device Evaluation Project Team (ADEPT) is to establish a process by which the airway-management community within the profession could lead a process of formal device/equipment evaluation. There is increasing number of airway management devices being introduced into clinical practice with little or no evidence of their clinical efficacy or safety. While there are several national and international regulations governing which products can come on to the market and be legitimately sold, there has hitherto been no formal professional guidance relating to how products should be selected (purchased). ADEPT has formulated such advice, emphasising evidence based principles and defined a minimum level of evidence needed to make a pragmatic decision about the purchase or selection of an airway device. ADEPT advises that this definition should form the basis of a professional standard, guiding those with responsibility for selecting airway devices. This paper, published by Anaesthesia journal, describes how widespread adoption of this professional standard can act as a driver to create an infrastructure in which the required evidence can be obtained.
  25. Content Article
    The Difficult Airway Society (DAS) is a UK based medical specialist society formed to enhance and promote safe airway management of patients by anaesthetists and other healthcare practitioners. DAS is actively involved in training healthcare professionals in the safe and competent practice of advanced airway management. DAS has produced guidelines for airway management of patient undergoing anaesthetic. These guidelines are highly valued and widely followed not only in the UK but also worldwide. With nearly 3000 members (most of whom are anaesthetists based in UK and worldwide ) DAS is also the largest specialist society in the UK. The links below lead you to patient information leaflets produced by DAS about how anaesthetist manage your airway (breathing passage) during an anaesthetic.

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