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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing PSIRF resources, tools and templates to support one another as the approach is implemented. In this ‘Top picks’, we’ve selected some to share with you.* 
  2. Content Article
    This study, published by BMC Pregnancy and Childbirth, explored minority ethnic women's experiences of access to and engagement with perinatal mental health care.
  3. Content Article
    This study aims to explore minority ethnic women’s experiences of perinatal mental health services during COVID-19 in London. Methods: Eighteen women from ethnic minority backgrounds were interviewed, and data were subject to a thematic analysis. Results: Three main themes were identified, each with two sub-themes: ‘Difficulties and Disruptions to Access’ (Access to Appointments; Pandemic Restrictions and Disruption), ‘Experiences of Remote Delivery’ (Preference for Face-to-Face Contact; Advantages of Remote Support); ‘Psychosocial Experiences’ linked to COVID-19 (Heightened Anxiety; Social Isolation). Conclusions: Women from ethnic minority backgrounds experienced disrupted perinatal mental health care and COVID-19 restrictions compounding their mental health difficulties. Services should take women’s circumstances into account and provide flexibility regarding remote delivery of care.
  4. Content Article
    Through personalised care, people have the opportunity to be actively involved in the decision-making process around their treatment options and care by speaking up on things that feel most important to them. There is increasing evidence to show that involving people in decisions about their healthcare leads to improvements in the quality of care, higher patient satisfaction and improved health outcomes, all of which lead to the more effective use of healthcare services. Find out more about the evidence for personalised care, including links to related research, on the Personalised Care Institute website via the link below.
  5. Content Article Comment
    A recent report added to the hub, produced by the Patient Experience Library, highlights the same issue with PPI toolkits. And they identified some key gaps in among the mountain.
  6. Content Article
    The Personalised Care Institute (PCI) helps to empower patients with the knowledge, skills and confidence to feel more in control of their mental and physical health. They do this by educating and inspiring health and care professionals to deliver universal personalised care that takes into account an individual’s strengths, needs and expectations, in order to deliver the right care for them. They set the standards for evidence-based personalised care training, providing a robust quality-assurance and accreditation framework for training providers and commissioners along with a central learning hub for health and care professional learners.
  7. Content Article
    In this opinion piece for the BMJ, Rammya Mathew talks about the limits of a no blame culture in identifying where harm is being caused by a clinician. "The Letby case is an extreme example of the shortcomings of a “no blame” culture. When things go wrong we’re encouraged to always support staff and ensure that no one feels implicated. It’s as though only systems and processes can be criticised, and discussing the possibility of individual accountability is considered “off grounds.”
  8. Content Article
    This paywalled article, published in Advanced Critical Care, notes that ten years after the publication of a landmark article in AACN Advanced Critical Care, alarm fatigue continues to be an issue that researchers, clinicians, and organisations aim to remediate. 
  9. Content Article
    Researchers at the University of Hertfordshire are carrying out a study to better understand women’s negative experiences of IUD procedures. They hope this research will be used to develop new guidance for patients and professionals that reduces the risk of coil procedures being experienced as distressing. If you are aged 16+, have had a coil fitting/removal in the last 2 years in a UK health settings (GPs, sexual health clinics, gynaecologist, and any other medical setting) that you found distressing, and are able to provide a valid UK phone number (mobile or landline), then you are eligible to participate. Full details of the research and how to take part can be found via the link below or by contacting Sabrina at s.pilav@herts.ac.uk.
  10. Community Post
    Hi @Sabrinapsychologist Thank you for reaching out via the forum. Capturing lived experience will be an important part of understanding the issues and how improvements can be made. We will also add your information about the study to the main 'Learn' library so we can share your research request via our other channels.
  11. Content Article
    Most pharmaceutical products can cause adverse consequences of varying severity and frequency. Authors of this article, published by Drug Safety, look at issues relating to the monitoring the safety of over the counter medicines.
  12. Content Article
    Patient and public involvement (PPI) is, these days, a given in healthcare policy and practice. Providers, commissioners, policymakers and researchers all state the importance of hearing from service users about what matters to them. This "involvement imperative" has given rise to a plethora of guidance notes, checklists, frameworks and toolkits, all purporting to show what good practice in PPI looks like. The Patient Experience Library decided to carry out a mapping exercise, to see how much guidance there is, and to see if they could make sense of it all.
  13. Content Article
    Healthcare can be confusing. This book, published by the US-based Patient Safety Authority, is a tool to help patients communicate their wants and needs in a way their care team can understand. The Patient’s Companion covers common healthcare topics like what to do if you’re told you have a chronic (long-term, often incurable) disease or when and how to get a second opinion. The book is available in English and also a Spanish version.
  14. Content Article
    The Disability Royal Commission held Public hearing 33 in Brisbane from 8 to 10 May 2023. Public hearing 33 was a case study about two young men, brothers Kaleb and Jonathon. Their names have been changed to protect their identity. The brothers have disability and the hearing examined their experience of violence, abuse, neglect and deprivation of human rights. They held the hearing to ask why and how it happened. In total 13 witnesses gave evidence. This video is a summary of the report.
  15. Content Article
    Patient harm due to unsafe care is the 14th leading cause of death and disability globally. In this paywalled blog, Dr Georgia Richards from the Preventable Deaths Tracker, looks at patient safety through the lens of avoidable deaths.
  16. Content Article
    A reflective blog by Sue Strudwick, Patient Safety Partner at Kingston Hospital Foundation Trust about her medical career and new role advocating the patient voice.
  17. Content Article
    Falls have a significant negative impact on the health and well-being of people with dementia and increase service costs related to staff time, paramedic visits, and accident and emergency (A&E) admissions. The author of this study, published in the Journal of Patient Safety, examined whether a remote digital vision-based monitoring and management system had an impact on the prevention of falls.
  18. News Article
    One of the most serious complications of a DVT is when a part of the clot breaks off and travels through the bloodstream to the lungs, leading to a blockage called a pulmonary embolism — this can cause chest pain, breathing difficulties, a faster heartbeat, coughing up blood, and can be life-threatening if not treated quickly. Worryingly, research suggests 40 per cent of patients who die from a pulmonary embolism complained of nagging symptoms for weeks before their death. For every pulmonary embolism diagnosed in time, there are at least another two where the diagnosis was missed and resulted in sudden death, according to the charity Thrombosis UK. Read full story Source: Daily Mail, 25 September 2023
  19. Content Article
    The Patient Association have identified the six key principles of patient partnership. They have engaged extensively with patients in developing these principles, as well as a network of national and local organisations and health and care thought leaders. The principles they have identified are: Treating patients as equals: Patients are treated as equals, with their views recognised as equally valid and having an equal say in decisions. Patients who are fully informed: Services and systems make sure patients are fully informed, in a way that patients can access and understand, and patients use as much information as they wish to. Shared decision making and patient partnership: Shared decision making, and patient partnership approaches are used as a matter of routine. Recognising inequalities: Inequalities are recognised, and appropriate approaches adopted for different patient groups and communities, identifying and meeting their specific needs. Seeking patient input: Patient input is actively sought, genuinely valued, and meaningfully acted on. Joining services around patients: Services join up around patients, working with them to identify their needs, and responding to them in a way that make things as easy as possible for the patient. Find out more on The Patient Association website via the link below.
  20. Content Article
    The well-being of Black mothers during and after pregnancy has been disproportionately affected by cultural barriers that hinder access to adequate mental health care. Addressing and breaking these barriers is essential to ensuring the well-being of Black mothers and promoting healthy outcomes for their children. Black Maternal Mental Health Week is led by The Motherhood Group and the theme for 2023 is Breaking Cultural Barriers.
  21. Content Article
    The Speak Up™ Campaign includes a large selection of resources produced by The Joint Commission (US-based) to encourage patients to speak up and be active participants in their healthcare. These resources are free and can be used by stakeholders that want to promote the Speak Up message. You will find resources about speaking up: about your care against discrimination at your telehealth visit for new parents for safe surgery for your mental health to prevent serious illness. The Joint Commission website also includes information about using Speak Up in your organisation.
  22. Content Article
    In this chart of the week from the Nuffield Trust, Ose Ogbebor looks at how the numbers of recommendations from 111 for further dental care have changed over the past four years. NHS 111 data indicates that demand for dental care is still at higher levels than before the pandemic, providing further evidence for the need for urgent NHS dental reform.
  23. Content Article
    In this article, published by the Institute for Government, Sam Freedman looks at the state of the NHS pre and post pandemic and how staffing, bed shortages, staff churn and other issues have had an impact.  Sam argues we are drifting further into crisis due to a stubborn refusal by the government to to engage properly with these issues.
  24. Content Article
    This review, published in Nature Reviews Immunology, looks at the research and data relating to long-Covid. Subsections include: Symptoms Possible mechanisms of long COVID Long-term disease risk following COVID-19 Therapeutics and outlook
  25. Content Article
    Workplace-based knowledge exchange programmes (WKEPs), such as job shadowing or secondments, offer potential for health and care providers, academics, and policy-makers to foster partnerships, develop local solutions and overcome key differences in practices. Yet opportunities for exchange can be hard to find and are poorly reported in the literature. This study, published in BMJ Leader, aimed to understand the views of providers, academics and policy-makers regarding WKEPs, in particular, their motivations to participate in such exchanges and the perceived barriers and facilitators to participation. Results showed WKEPs were reported to be valuable experiences but required significant organisational buy-in and cooperation to arrange and sustain. To benefit emerging partnerships, such as the new integrated care systems in England, more outcomes evaluations of existing WKEPs are needed, and research focused on overcoming barriers to participation, such as time and costs.
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