Everything posted by Claire Cox
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Transforming care in Cornwall: A review of the quality of the lives of people with learning disabilities a decade post‐discharge from hospital
Content ArticleIn 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.
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Develop safe airway management strategies for your patients: a free course from FutureLearn
Content ArticleThe 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.
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It's not perfection, but humanity that patients need: a short talk by Dr Poorman
Content ArticleElisabeth 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.
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Patient experience of communication consistency amongst staff is related to nurse–physician teamwork in hospitals (January 2010)
Content ArticleThe 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
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Deaths of people following release from prison (INQUEST, November 2019)
Content ArticleIn 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.
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Refocusing: what you see isn’t all there is – getting healthcare right in hospitals for autistic and learning disabled people
Content ArticleSignificant 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.
- Walk on by...
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In praise of NHS domestics: a blog by Adam's mum
Content ArticleThis 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.
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Learning from excellence (2017)
Content ArticleSafety 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.
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Oxford Handbook of Critical Care Nursing 2nd Edition
Content ArticleReflecting 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.
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CQC Podcast: Give feedback on care (14 January 2020)
Content ArticleEpisode 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.
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The Silo Effect: Why every organisation needs to disrupt itself to survive
Content ArticleIn 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.
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Safety-II in practice (June 2017)
Content ArticleSafety-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 resil
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Malpractice: A neurosurgeon reveals how our health care system harms patients and protects dangerous doctors
Content ArticleIn 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
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Complications: A surgeon's notes on an imperfect science (March 2008)
Content ArticleThis 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.
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Crisis care summary 2.1- Professional Record Standards Body
Content ArticleHelping 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.
- The SPA experience: NHS Wales Award winner 2016
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Clinical referral information v 1.1 - Professional Records Standards Body
Content ArticleReferrals 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.
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The BAPEN self-screening tool for malnutrition
Content ArticleBAPEN’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.
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I-Hydrate: Quality Improvement project around hydration in care homes (July 2018)
Content ArticleI-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.
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Malnutrition Task Force case study: Lyn's story
Content ArticleFollow 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.
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Airway Device Evaluation Project Team (ADEPT)
Content ArticleThe 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.
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Patient education and information: difficult airway
Content ArticleThe 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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Airway alert card and difficult airway database
Content ArticleThe Difficult Airway Society (DAS) has produced a difficult airway card for patients to carry in their wallet. This is to alert the anaesthetist that this patient has a 'difficult airway' before they find out the hard way. This website also holds the database for patients with difficult airways. This is for clinicians to use to help assess risk in patients undergoing sedation or general anaesthetic.
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Learning from Excellence
Content ArticleEmma Plunkett, Consultant Anaesthetist and Adrian Plunkett, Paediatric Incentivist, talk about what inspired them to establish the Learning from Excellence approach to patient safety and care, how it has made an impact in the West Midlands and why it won a coveted HSJ Patient Safety Award.