Jump to content
 View Profile  See their activity

  • Posts

    779

  • Joined

  • Last visited

Patient_Safety_Learning

PSL Moderators

 Content Type 

Everything posted by Patient_Safety_Learning

  1. Content Article
    Chloe, 24, was at high risk for aortic dissection due to her genetic history. Despite presenting alarming symptoms at the A&E department, her condition was misdiagnosed. A subsequent call to the hospital resulted in no further action, and Chloe tragically died four days later. Investigations confirmed that the hospital’s lack of correct diagnosis was a missed opportunity that could have saved her life. In this article, the Aortic Dissection Charitable Trust looks at the case of Chloe, within a framework of four key themes set out by Patient Safety Learning for World Patient Safety Day 2023: Elevating the voice of patients and families. Shared decision-making at the point of care. Engaging patients when things go wrong. Engaging patients for system improvement.
  2. Event
    Join the Aortic Dissection Charitable Trust on Aortic Dissection Awareness Day to discover ground-breaking research, hear from esteemed experts, and learn how you can contribute to aortic dissection research. The Rt Hon Steve Barclay MP, Secretary of State for Health and Social Care, will kick off the event, followed by Professor Lord Kakkar KBE, Chair of the UK Biobank. Lord Kakkar will discuss how the UK Biobank’s large-scale biomedical database can advance research in aortic dissection. It’s a groundbreaking moment for everyone committed to improving lives affected by this condition. The RAG Chair, Dr Colin Bicknell, Consultant Vascular Surgeon and Head of Specialty at the Imperial Vascular Unit, will announce and introduce the 2023 research grant winners. Register here
  3. Content Article
    This opinion piece is by Luke* who suffers from post-SSRI sexual dysfunction (PSSD) after he was prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant.  Luke introduces the condition, drawing on the experiences that others have shared through PSSD communities, to highlight the devastating impact on patients. He calls for widespread recognition, improved risk communication and better support for sufferers.  *Name has been changed
  4. Content Article
    This article by Jesse Lyn Stoner, argues that leading without relying on authority is a higher evolutionary skill. It supports developing adult relationships based on mutual objectives and creates work environments grounded in respect for human dignity. Stoner outlines “The 8 Portals of Influence” – Ways to Influence Without Authority.
  5. Content Article
    In this podcast episode, Rosie, Sean, Carlton, and Emily share their experiences with Post-SSRI Sexual Dysfunction (PSSD), a condition where individuals face persistent sexual side effects and other side effects after taking or discontinuing certain antidepressants. Throughout the conversation, they emphasise the need for increased awareness and research on PSSD, sharing personal stories to shed light on this often-overlooked condition. Despite the challenges they face, they remain determined to advocate for recognition and support for those suffering from PSSD.
  6. Content Article
    Sexual dysfunction is a common side effect of Serotonergic antidepressants (SA) treatment, and persists in some patients despite drug discontinuation, a condition termed post-SSRI sexual dysfunction (PSSD). The risk for PSSD is unknown but is thought to be rare and difficult to assess. This study, published in the Annals of general psychiatry, aims to estimate the risk of erectile dysfunction (ED) and PSSD in males treated with SAs.
  7. Content Article
    A set of enduring conditions have been reported in the literature involving persistent sexual dysfunction after discontinuation of serotonin reuptake inhibiting antidepressants, 5 alpha-reductase inhibitors and isotretinoin. The objective of this study, published by the International Journal of Safety and Risk in Medicine, was to develop diagnostic criteria for post-SSRI sexual dysfunction (PSSD), persistent genital arousal disorder (PGAD) following serotonin reuptake inhibitors, post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction (PRSD).
  8. Content Article
    In August 2022, NHS England launched a new way of responding to safety events, called the Patient Safety Incident Response Framework (PSIRF). The PSIRF policy aims to support NHS organisations to be more flexible in how they respond to safety events.  The Response Study is funded by the National Institute for Health and Care Research (NIHR). The aim of the Response Study is to understand, in real time, how the roll out of this new policy happens across the NHS in England, and what impact it has.  The study is based at the University of Leeds. It began in May 2022 and will end in July 2025. The Response Study are inviting all PSIRF Leads from NHS Trusts and Integrated Care Boards in England to complete a survey by 15 December 2023. To access the survey please contact responsestudy@leeds.ac.uk.
  9. Content Article
    This study, published by Applied Ergonomics, found that employing user experience design (UXD) could help to improve health education materials. Researchers looked at printed information about breast and cervical cancer screening and its perceived usability. 
  10. Content Article
    The model of general practice is changing and, at the core of this, general practice is moving away from a model of 'seeing a GP' to a model that is 'consulting with the multi-disciplinary team'.  National Voices set up a project to understand awareness and experience of multidisciplinary teams across two groups: frequent users of primary care services and those who experience health inequalities.   This report presents those insights and includes recommendations on how to improve experiences of multidisciplinary teams within general practice amongst populations who experience health inequalities and frequent users of primary care services. In particular, the report highlights how primary care teams can build trust and assure people that general practice has oversight of their care.
  11. Community Post
    This case study focuses on a North Staffordshire Combined NHS Trust project. The lead consultant for the service was concerned that the clinical pathways were not optimised and bottlenecks were delaying access, assessment and diagnosis of patients. As a result there were delays to initiating treatment. In addition to potential harm to patients this was resulting in inefficient and wasteful use of resources. Following pathway changes, value and efficiency impact was noted in the following areas: Because head CT scans are provided by a neighbouring acute trust, reducing the number of patients referred had a direct impact on service cost as well as releasing capacity in the wider system. Comparing baseline activity with the review period showed a 30% reduction in CT scan referrals and a £7,800 direct cost saving. The number of patients not attending appointments reduced from 572 in the baseline period to 379 after implementing pathway changes. While not a cash releasing saving this improved overall efficiency and productivity for the service and contributed to a reduction in overall unit price per attendance. At the start of the project, the average unit price for patients attending the memory service was £280.93. Through a combination of direct cost savings and efficiency and productivity gains arising from the revised pathway, this figure had reduced to £205.12 in the review period. Do you have a cost-saving or efficiency case study to share? What were the patient safety implications? Do you have resources or knowledge to share that can help others make positive changes? Comment below (sign in or register here for free first), or get in touch with us at content@pslhub.org to tell your story.
  12. Content Article
    In this video we hear from three people campaigning for patient safety improvements: Sandra Igwe – CEO of the Motherhood Group. Tim Edwards – campaigner for improvements in pulmonary embolism care and diagnosis. Soojin Jun – co-founder of Patients for Patient Safety US. They talk about their experiences of engaging with the system, the challenges they have faced and offer advice for others seeking to campaign for change in healthcare. The insights they share help evidence the need for healthcare organisations and frontline staff to work with patients, their families and campaigners in improving safety and reducing inequalities.
  13. Content Article
    Engagement Value Outcome (EVO) promotes collaborative working between clinical and finance teams to enhance their collective understanding of patient level costing. It provides the NHS with a framework to ensure resources are used in the most effective way possible to provide high-quality care to patients. This clinical transformation case study focuses on the North Staffordshire Combined NHS Trust EVO project. The lead consultant for the service was concerned that the clinical pathways were not optimised and bottlenecks were delaying access, assessment and diagnosis of patients. As a result there were  delays to initiating treatment. In addition to potential harm to patients this was resulting in inefficient and wasteful use of resources
  14. Content Article
    Consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination. This must be done on the basis of an explanation by a clinician. Consent from a patient is needed regardless of the procedure, whether it's a physical examination or something else. The principle of consent is an important part of medical ethics and international human rights law. This webpage from the NHS includes information on: how consent is given and what we mean by consent assessing capacity consent from children and young people assessing capacity when consent is not needed consent and life support.
  15. Content Article
    Shaping Our Lives is a non-profit, user-led group, led by Disabled people and service users. They want to make sure everyone can have their say, especially those from marginalised groups who often face barriers to getting involved. Involvement activities enable people to influence and improve policies and services that affect their lives, like health or social care. Involvement can mean sharing your experiences and opinions in a focus group, a patient involvement forum, or a research study. The My Involvement Profile was designed by Disabled people. It’s made up of two simple template forms. It can help you: Keep a record of your involvement activities. Keep a list of your access and support requirements so you don’t have to keep repeating them. Each section has help notes to assist you in completing it if you need them. Download the profile via the link to the Shaping Our Lives website below.
  16. Content Article
    This recent study published by the Journal of Hospital Infection, evaluated using patients as hand hygiene observers in an outpatient setting. It demonstrated that the implementation of a hand hygiene compliance improvement programme using the patient as the observer can be adopted successfully in the ambulatory setting.
  17. Content Article
    The SAFER Guides are designed to help healthcare organisations conduct self-assessments to optimise the safety and safe use of electronic health records (EHRs). Each of the nine SAFER Guides begins with a Checklist of “recommended practices.” This Patient Identification SAFER Guide identifies recommended safety practices associated with the reliable identification of patients in the EHRs. Accurate patient  identification ensures that the information presented by and entered into the EHR is associated with the correct person. Processes related to patient identification are complex and require careful planning and attention to avoid errors. The SAFER Guides are produced by The Office of The National Coordinator for Health Information Technology.
  18. Content Article
    This digital story produced by Patient Voices, hears from Claudia who reflects on the unexpected death of a baby she helped care for in hospital. Claudia describes her own and her team's emotions as they debriefed and embarked on their serious incident report.
  19. Content Article
    Patient Voices uses reflective digital storytelling to deliver compelling and motivating insight that drives organisational change growth and success. Patient Voices’ methodologies are recognised by the National Audit Office, among many other major institutions, as a valid and uniquely illuminating method of gathering qualitative data.
  20. Content Article
    In 2020, the Independent Medicines and Medical Devices Safety Review (IMMDS), chaired by Baroness Cumberlege, highlighted the avoidable harm caused by both pelvic and sodium valproate. It also set out the devastating impact on people’s lives when patients’ voices go unheard. The Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner (PSC) to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. The work will focus on what a suitable redress scheme for those affected should look like, to meet the needs of those affected. 
  21. Content Article
    The government brought forward an amendment to the Health and Care Act 2022 which gives the Secretary of State for Health and Social Care the power to bring into force a licensing scheme in England for non-surgical cosmetic procedures. The purpose of the scheme is to ensure that consumers who choose to undergo a non-surgical cosmetic procedure can be confident that the treatment they receive is safe and of a high standard. Under the proposed scheme, practitioners will need to be licensed to perform specific procedures and the premises from which they operate will also need to be licensed.
  22. Content Article
    This debate was requested by Barbara Keeley MP of Worsley and Eccles South, following the death of Emily Chesterton, the daughter of her constituents Marion and Brendan Chesterton. Emily died in November 2022 after suffering a pulmonary embolism. She was just 30 years old when she died. The conclusion of the coroner was: “Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”
  23. News Article
    A woman who suffered chronic abdominal pain for 18 months after undergoing a caesarean section was found to have a surgical instrument the size of a dinner plate inside her abdomen. The Alexis retractor, or AWR, was left inside the New Zealand mother after her baby was delivered at Auckland City Hospital in 2020. Following initial investigations into the case, Te Whatu Ora Auckland, formerly Auckland District Health Board, claimed it had not failed to exercise reasonable skill and care towards the patient, who was in her 20s. But on Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland in breach of the code of patient rights. Read full story Source: Guardian, 4 September 2023
  24. News Article
    Campaigners have expressed alarm at new analysis showing a sharp increase in new or expectant mothers waiting for mental health care, with one woman found to have waited 319 days for a first appointment. More than 30,000 women who are pregnant or have newly given birth are on waiting lists for mental health support, according to NHS England data analysed by Labour, with the party saying many of them were being left to “suffer in silence”. Amid rising demand for what are known as perinatal mental health services, during the period from August 2022 to March 2023 the numbers of women waiting rose by 40%. Over that same period, the numbers who accessed support also rose, but only by 8%. Read full story Source: Guardian, 4 September 2023
  25. News Article
    The government could ban unlicensed providers of cosmetic treatments in England, in what industry bodies say would be the biggest shake-up in a generation. Under the plans, anyone carrying out Botox, breast or butt lift injections would have to be trained and licensed, with their premises also inspected. The proposals have been have been opened up for public consultation. At present, healthcare professionals such as doctors, nurses and dentists carrying out non-surgical cosmetic procedures have to be trained and insured to do them as part of the requirements laid down by their regulatory bodies. But there is no set training for beauty therapists and other non-professionals. Read full story Source: BBC News, 3 September 2023
×
×
  • Create New...