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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. News Article
    The parents of a teenager who died in hospital two years ago are calling for patients to be given the right to an urgent second opinion, if they feel their concerns are not being taken seriously by medical staff. Martha Mills, who would have been 16 on Monday, died after failures in treating her sepsis at King's College Hospital. An inquest said she could have survived had her care been better. Martha's mother, Merope, has helped the think tank Demos write a report which is calling on NHS England to urgently put in place Martha's rule. This would "effectively formalise the idea of asking for a second opinion, from a different team outside the team currently looking after you if you feel you are not being listened to", she said. She added that asking for a second opinion when there is a deterioration "shouldn't be a problem and it shouldn't involve confrontation". It might be that a patient or family could escalate to another team over the phone to get an urgent critical care review. Read full story Source: BBC News, 4 September 2023
  2. Content Article
    Martha Mills died from sepsis aged 13 after sustaining a pancreatic injury from a bike accident. The inquest into her death heard that she would likely have survived had consultants made a decision to move her to intensive care sooner. Her mother, Merope, has spoken about the failures in Martha’s care, and how she trusted the clinicians against her own instincts – they didn’t listen to her concerns and instead “managed” her. This report is a response to that call from Martha Mills’ parents to rebalance the power between patients and medics with one purpose only: to improve patient safety. It comes amidst significant evidence that shows that failing to properly listen to patients and their families contributes to safety problems in the NHS.
  3. Content Article
    Recovering services from the covid crisis is the big task for NHS leaders for the foreseeable future. The Recovery Watch newsletter tracks prospects and progress. This week by HSJ bureau chief and performance lead James Illman.
  4. Content Article
    Since February 2020, the elective waiting list has grown by 61% from 4.57 million to 7.47 million. The delivery plan for tackling the COVID-19 backlog of elective care set out the system-wide response to reducing this backlog.
  5. Content Article
    Friends of African Nursing (FoAN) was started as an organisation by Lesley and Kate, who had family contacts in Africa and due to their professional nursing backgrounds, had taken an interest in the health systems in African countries which they had visited whilst on holiday. It was apparent to them both separately, that the privilege of the healthcare environment in which they both worked in the UK - which offered continuing education, ready access to journals, speciality (perioperative) education and a professional association (in which they were closely involved, at home) as a ready made network was indeed a huge privilege which should be shared.  Their primary interest is in supporting nurses and nursing in Africa. FOAN specialises in supporting nurses who work in Operating Theatres particularly and work with the surgical teams. Surgery is often high risk in Africa and their key interest is to update practice, educate on risk management and patient safety as well as infection prevention measures. They have also delivered programmes for ward leaders and other bespoke courses. Visit the FoAN website to find out more via the link below.
  6. Content Article
    This article by Bloomberg Opinion, looks at the number of excess deaths recorded throughout the world during the Covid-19 pandemic and how the different strategies applied by countries impacted those statistics.
  7. Content Article
    Although well-established principles exist for improving the timeliness and efficiency of care, many organisations struggle to achieve more than small-scale, localised gains. Where care processes are complex and include segments under different groups' control, the elegant solutions promised by improvement methodologies remain elusive. This study, published in BMJ Quality and Safety, sought to identify common design flaws that limit the impact of flow initiatives.
  8. News Article
    Racism is a significant issue affecting recruitment, retention, and patient care. With this in mind, the Royal College of Psychiatrists launched the Act Against Racism campaign, offering guidance and actions to combat racism in the workplace for better staff well-being and patient care, writes Adrian James In June, HSJ revealed that mental health trusts in England are among the biggest users of locum doctors in the NHS. With one in seven medical posts in mental health trusts vacant, many providers now rely on locum doctors to deliver essential services to patients. Read full story Source: HSJ, 9 August 2023
  9. News Article
    Coroners have raised multiple warnings about the way a commonly-used medication is being prescribed to at-risk patients, HSJ has found. HSJ has identified at least nine ‘prevention of future deaths’ reports issued by coroners since 2017 which highlighted the way the deceased’s prescription for sertraline was handled, with two of these issued since the start of 2023. It comes as Open Prescribing data suggests sertraline prescriptions have increased by almost 40 per cent since 2019, which has led to concerns that GPs are struggling to meet the growing demand for follow-up checks. Read full story Source: HSJ, 9 August 2023
  10. Community Post
    "One of the best examples I saw involved a case in which a worker was about to move a vehicle and trailer. The keys were in the ignition, but before starting the vehicle, he decided to perform a walkaround and discovered a mechanic was working underneath the trailer. Together, they agreed to take the keys out of the ignition and established a tagging system to ensure nobody else would inadvertently move the equipment while it was being worked on."[1] According to this article by Safety Management Group, just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns an organisation's safety philosophy into a clear reality. Do you use a 'good catch' reporting system in your health and social care setting? Has it made a difference to safety culture or behaviour? How easy was it to implement? Do you recognise and/or celebrate staff for reporting incidents? Or perhaps this is something you'd like to implement. What would you like to ask others who have tried it? Share your experiences and questions in the comments below. You'll need to register for free first. Related reading: Near-Miss and Good-Catch Reporting Promote a culture of safety with good catch reports Using good catches to increase worker ownership of safety 5 Examples of good catches in healthcare and how to implement a near miss campaign [1] SMB. Using good catches to increase worker ownership of safety. Accessed online 9/08/23.
  11. Content Article
    Just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns a company’s safety philosophy into a clear reality. This article, published by Safety Management Group (SMG), looks at the importance of reporting 'good catches' and the positive impact this can have on safety culture and behaviour.
  12. Community Post
    Hi @Lorraine 2 Many thanks for sharing your positive experience of undergoing a hysteroscopy procedure. I am very pleased to hear that you felt supported, informed and that the pain was manageable. Sharing good practice examples is vital, as you say, for improving the quality of care more broadly in this area. Routine collection of pain scores is also important, as you have also highlighted, if we are to understand the prevalence of high levels of pain. If you have not already seen this, the calls to action at the end of this blog may be of interest to you: Thank you again for sharing your experience
  13. Event
    until
    Delivered by the NHS Confederation’s Health and Care Women Leaders Network. Join them on Wednesday, 1 November in Leeds for the network's seventh annual conference. The event will be hosted by the network chair, Samantha Allen, chief executive of North East and North Cumbria Integrated Care Board (ICB). Everyone is welcome. The conference this year will focus on supporting delegates' personal and professional development and provide space for learning and networking. The programme will look at work underway within the sector and the network to progress gender equality, with a focus on women’s safety, women’s health, turning intent into action and channelling your inner activist. On the day, delegates will participate in an interactive programme including opportunities for networking, learning and development. You will listen to inspirational speakers sharing stories and join lively debates and discussions on the issues currently challenging our sector and beyond, including closing the gender health gap and improving women’s safety. Book your place
  14. News Article
    A hospital maternity service has dropped two ratings to ‘inadequate’ after the Care Quality Commission warned of a ‘chaotic environment’, where leaders normalised poor practices and failed to act on safety concerns. The Care Quality Commission inspected Hull Royal Infirmary’s maternity services earlier this year, and imposed urgent conditions on the service, requiring Hull University Teaching Hospitals Trust to make “rapid improvements” to keep people safe. The overall maternity rating fell from “good” to “inadequate”, the CQC announced today, although it only reviewed the “safe” and “well led” domains. The inspection was part of an ongoing national CQC maternity inspection programme, which has downgraded numerous services to “inadequate” over the last year. The regulator said the antenatal day unit and triage department was a “chaotic environment which was not fit for purpose”, and found some staff described “unkindness” from peers. Women and service users waited long periods without an offer of food or water, it said. Significant concerns were raised about safeguarding, with staff unable to identify adults and children suffering or at risk of significant harm. Read full story Source: HSJ, 9 August 2023
  15. News Article
    About one in seven people in the UK now take medication to treat depression but some say they are not being given appropriate advice about the potential side-effects of the drugs they have been prescribed. Seonaid Stallan's son Dylan was a teenager when he began receiving treatment for body dysmorphia and depression. "He was struggling with the way he felt about himself, the way he looked," Seonaid said. "He was extremely anxious. He would be physically sick. He would be unable to leave the house." Dylan, from Glasgow, was treated with the antidepressant Fluoxetine from the age of 16. But when he turned 18, his medication was changed to Sertraline. Within two months of his prescription change he had taken his own life. Read full story Source: BBC, 9 August 2023
  16. News Article
    A ‘disappointingly slow’ transformation of community services means thousands of mental health patients are still presenting at emergency departments within weeks of being discharged from an inpatient facility. Experts said an NHS England-led community transformation programme, launched in 2019 as part of a £2.3bn investment in mental health services, should have helped reduce readmission rates, but internal data seen by HSJ suggests the rates have actually increased since then. The data reveals for the first time the proportion of patients discharged from inpatient care who then present to accident and emergency within two months. The proportion of adult patients was 11 per cent in 2018-19, when the investment programme was launched, and had increased to 12 per cent by 2022-23, representing around 6,000 adult cases. The situation appears worse for children, with an 18 per cent readmission rate within two months, up from 17 per cent in 2018-19. Read full story Source: HSJ, 8 August 2023
  17. Content Article
    In this article, published by Incident Prevention, authors define what a 'near miss' or 'good catch' is and look at why it is so important to report them.
  18. Content Article
    The eDischarge Information Record Standard was first published in 2015. Despite significant investment in programme initiatives, the widespread implementation of the standards has been slow.  In this report from the Professional Record Standard Body, authors identify the challenges that have inhibited the adoption of the standard, make recommendations for improvements and set out the anticipated benefits that this will bring. The aims of this discovery and user-design phase were: To review the current state of adoption of transfer of care messages between secondary care senders and primary care receivers of transfers of care and identify reasons for the low uptake to date. To understand GP’s needs and priorities for computer readable data that can be shared with primary care systems without loss of meaning. To make recommendations for what needs to happen to enable widespread adoption that supports the needs of GPs to deliver safer patient care.
  19. News Article
    Almost three-quarters of babies born with a rare muscle-wasting disease are living longer thanks to advances in NHS treatment. Spinal muscular atrophy (SMA) is a genetic condition that causes muscle weakness, along with progressive loss of movement and paralysis. There are three types of this disease that impact children. SMA1 manifests in babies under the age of six months and is the most severe, while SMA2 and SMA3 are less severe. They develop between the ages of seven and 18 months, and after 18 months of age, respectively. According to the NHS, about 70 babies are born in the UK with SMA each year. The NHS began rolling out new treatments in 2019, starting with injectable drug nurinersen – marketed as Spinraza – which targets the SMN2 gene in patients. Before 2019 there were no effective drugs for this condition. A study by SMA Reach UK claims patients with untreated SMA1 historically had a 50% survival probability at eight to 10 months, reducing to 8% at 20 months of age. However, data from the SMA Reach UK database analysed by NHS England found 73% of babies with SMA1 are now living beyond two years and without permanent ventilatory support. Read full story Source: Independent, 7 August 2023
  20. News Article
    One of the UK's most secretive centres of scientific research - Porton Down - is aiming to stop the next pandemic "in its tracks". James Gallagher, Health and science correspondent, passed through the incredibly tight security at this remote facility to get rare access to its scientists. They are based in the shiny new Vaccine Development and Evaluation Centre. Their work builds on the response to Covid, and aims to save lives and minimise the need for lockdowns when a new disease next emerges. Read full story Source: BBC 7 August 2023
  21. News Article
    Families of people with complex medical needs are warning the NHS system that funds their care at home is struggling to provide sufficient support. Despite recent significant increases in spending on Continuing Healthcare, experts say staff shortages and rising prices mean families are lacking help. Some say at times they are so exhausted from providing care, they worry about the safety of their relatives. The government says it has invested billions into health and social care. The BBC followed 24-year-old Declan Spencer for 10 months, witnessing how the repeated breakdown of his care has left his mother having to provide it by herself, day and night. Read full story Source: BBC 7 August 2023
  22. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Judi talks to us about her experience of managing patient safety for a large healthcare provider, the importance of ensuring implemented safety standards are sustained and how crucial it is to professionalise patient safety.
  23. Content Article
    A good catch in healthcare is recognised as an employee interception of a potential safety event before a patient is harmed. Both near misses and good catches present healthcare organisations with opportunities for learning to reduce harmful events, which is why reporting near misses in healthcare should be a priority for all organisations, regardless of type or size. It is important that all employees can recognise common examples of good catches in healthcare that prevent patient harm before it reaches the patient. This article, published by Performance Health Partners, includes five situations in which harm can likely occur when no action is taken. It also looks at how to establish a good catch program and how to recognise staff for reporting.
  24. Content Article
    Key to the success of the Patient Safety Incident Response Framework (PSIRF) is working collaboratively across organisations utilising the skills of colleagues from different departments This podcast, hosted by Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England, aims to further progress the conversation with special guests: Liz Maddocks-Brown, formerly NHS Horizons Claire Cox, Andy Wilmer and Lorraine Catt from Kings College Hospital Stefan Cantore from Sheffield University Management School.
  25. Content Article
    The Patient Safety Incident Response Framework (PSIRF) supporting guidance “Engaging and involving patients, families and staff following a patient safety incident” presents the moral and logical arguments for engaging with those affected by a patient safety incident and involving them in a learning response. This article builds on the guidance given to describe how After Action Review (AAR) can be used to ensure patients and their families and carers can and do make a significant and meaningful contribution to the learning process.
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