Patient_Safety_Learning
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Content Article
Ron Daniels is a Consultant in Critical Care, Vice President of the Global Sepsis Alliance, Chief Medical Officer of the United Kingdom Sepsis Trust, and a Topic leader for Patient Safety Learning’s hub. In this interview, Ron explains why doctors have to carefully manage the use of antibiotics in order to protect patients, now and in the future. -
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In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology. In her first blog, Harry’s mother Julie told us about Harry and the events that preceded his death, during which he suffered with anxiety, addiction and psychosis. She talked about the inquest and how they learned of gaps in Harry’s care, that led the coroner to deem it an avoidable death. In this second blog, Julie explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. -
Content Article
In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology. Harry’s death was found to be avoidable as carers were not fully aware of this condition associated with acute psychosis. In this blog, Harry’s mother Julie tells us more about Harry and the years that proceeded his death, during which he suffered with anxiety, addiction and psychosis. Julie describes the barriers they faced in getting the right support and care for Harry before he died and highlights the need for healthcare staff to have a greater awareness of ABD and the associated risks of a medical emergency. You can also read a second blog by Julie, where she explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. -
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Community PostA blog has been published today on the hub which talks about the launch of a new network for patients and clinicians to come together to improve gynaecology experiences:
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Community PostHi @Tardisgirl98 I am sorry you're experiencing this level of pain following the procedure. Pain experiences vary hugely in relation to the procedure and the pain felt afterwards and it sounds like you are having a difficult post-procedure experience. I would advise that you make an appointment with your GP to explain your symptoms and the pain you are experiencing as they should be able to assess you properly. In addition to speaking to a GP, if you had the procedure done somewhere outside of your GP practice and a have a contact number, you could also call them to seek follow up advice.
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In this short blog, Stephanie O'Donohue tells us about a brand new network called TIGER UK. Based on the belief that progress lies in collaboration, TIGER UK is open to anyone who is passionate about sharing insights and working together to improve gynaecology experiences. Find out how a personal experience motivated her to start the group, and how you can join. -
Content ArticleThe phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an under recognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. In this article from Cambridge University press, causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.
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Content ArticleAcute behavioural disturbance (ABD) is a term used in law enforcement and healthcare, but there is a lack of clarity regarding its meaning. Common language should be used across staff groups to support the identification, prioritisation and delivery of care to this group of patients. The terminology currently used is inconsistent and confusing. This study, published in the Emergency Medicine Journal, aimed to reach a consensus on the criteria for identification and management of ABD, and to agree when other care pathways or guidelines might be more appropriately used.
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Content ArticleThe objective of this study, published in BMJ Sexual & Reproductive Health, was to explore experiences of pain during medical abortion and provide patient-centred recommendations for improving abortion experience and pain counselling. Authors concluded: Abortion providers should use patient-centred recommendations to better prepare patients for pain during medical abortion. Setting realistic expectations can improve abortion experience and support informed method choice. Further research is needed to develop and test patient-centred counselling materials.
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Content ArticleHarry Vass was a 24yr old, he had a history of ADHD, poor mental health, psychosis, paranoia secondary to recreational drug use and illicit drug dependency including cocaine. Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as “mental health”, he was expressing paranoid thoughts. He had a high heart rate and was sweating. He underwent a physical assessment and was assessed by the Mental Health Team. At some point he took cocaine in the toilet of the hospital after which he became more agitated and there were concerns being raised that others in the department felt threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were called but when they attended Harry was calm from the effects of the medication. The police were called and attended again when Harry’s agitation increased. It was during this discussion that the police officer raised the possibility of Harry having ABD (acute behavioural disturbance). The police officer said that he’d seen close to a dozen cases, that Harry had similar symptoms. The two mental health practitioners said that they knew very little about ABD. After some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was admitted under s136 Mental Health Ac
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Content ArticleA major clinical trial, led by the University of Sheffield, has revealed survival rates for patients with operable bladder cancer are significantly improved by adding an immunotherapy drug to before and after surgery.
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Content ArticleIn this article for Health Service Journal (paywalled), Trust chair Matthew Swindells argues NHS managers must be held accountable for efficiency and quality, but transparency, fair funding allocations, and a balanced performance regime are also key to driving improvements.
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Content ArticleThis document from Avon and Somerset Constabulary outlines a number of improvements initiatives they have put in place to help make sure people with mental health issues get the right care from the right person. This includes: Training five constables to perform a new role which is called the Mental Health Link Officer (MHLO). Right Care Right Person (RCRP) Avon & Somerset principles. Partnership working with Western Ambulance Service Foundation Trust (SWASFT). The positive impact of Mental Health Link Officers. For more detail please see the attached document.
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Content ArticleOn 18 December 2024, the World Health Organization (WHO) prequalified the first diagnostic test for glucose-6-phosphate dehydrogenase (G6PD) deficiency which can help to safely deliver WHO-recommended treatments to prevent relapse of Plasmodium vivax (P. vivax) infection. The prequalification of this G6PD diagnostic test marks a significant milestone in facilitating safe and effective P. vivax malaria treatment, reaffirming WHO’s dedication to ensuring equitable access to life-saving health solutions globally. Some 500 000 people die each year from malaria, most of them children.
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Content ArticleDoctors in Distress focuses on supporting medical staff to prevent worsening of mental health issues. If you feel like you are struggling and want immediate help , please have a look at the support services listed on their website via the link below.
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Content ArticlePatient safety (PS) is a basic principle of healthcare worldwide. In Saudi Arabia, medical colleges have integrated PS modules into their regular curricula. This study investigated undergraduate medical students’ and interns’ attitudes regarding PS at King Abdulaziz University (KAU), Jeddah. The findings highlight that most participants’ attitudes needed to be more positive. Gender disparities were found in PS attitudes among Saudi medical students and interns, while no significant variance was noted between interns’ and medical students’ scores.
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Content ArticleIn the field of healthcare, ensuring patient safety is a critical priority that has garnered global recognition as a pressing public health concern. Despite notable progress in medical treatments and diagnostic technologies, patients continue to be at risk of adverse events and harm during the perioperative period. Anaesthetists hold a pivotal position in this phase of patient care and have the potential to greatly impact safety and outcomes. This research sought to assess the knowledge, attitudes, and influencing factors of anaesthetists concerning patient safety in government referral hospitals situated in Addis Ababa, Ethiopia. The study revealed that over half of the participants had good knowledge (56.7%) and a positive attitude (68.9%). Factors significantly associated with patient safety knowledge included having patient safety information during continuing education [AOR = 4.016; 95% CI: (1.99–8.07)] and having a working experience of more than 15 years [AOR = 3.9; 95% CI: (1.23–12.29)]. Additionally, those who received patient safety training [AOR =2.0; 95% CI: (1.2–3.64)] were more likely to have a positive attitude than those who did not receive such training. The study found that a majority of Ethiopian anaesthetists hold a favourable view toward patient safety, with 56.7% demonstrating good patient safety knowledge and 68.9% exhibiting a favourable attitude toward patient safety. Work experience, continuous education, patient safety training, and s
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"Doctors aren't listening, and it is making us unwell". In her book, 'Unheard: The Medical Practice of Silencing', Dr Rageshri Dhairyawan takes us on a journey to show how not listening to patients has been ingrained in medicine since its inception. Join the Chief Executive of the Patient's Association's, Rachel Power, in a fireside chat with Dr Rageshri Dhairyawan, as they discuss the importance of engaged listening and it's place in the future of Healthcare. This event is free to attend and will take place Thursday 23rd January 2025, beginning at 7pm. Register here -
Content ArticleThis is the second main empirical paper from the NIHR (National Institute for Health and Care Research) funded Learn Together programme, led by Lauren Ramsey. In this open access paper, authors explore the historical experiences of patient safety incident investigations within the English NHS. Importantly. They also explored and contrasted the experience from the perspectives of the three key groups of people affected: patients and families healthcare staff involved in an incident investigation incident investigators.
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Community PostWe are looking for someone with expertise in women's health to join our team of volunteer Topic leaders. Our topic leaders are an integral part of ensuring the value of content on the hub. We want to ensure that quality content is published on the hub and that we have credible experts in specific topic areas to: contribute personal blogs sharing expertise and insights advise us on the validity of posted content suggest areas to develop content in lead and respond to discussions within our communities. If you'd like an informal chat about the role, you can contact the hub team at [email protected].
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The following account has been shared with Patient Safety Learning anonymously. We’d like to thank the patient for sharing their experience to help raise awareness of the patient safety issues surrounding IUD procedures. *Trigger warning: Some people may find the following account distressing to read. Please note that experiences of pain and the care given during gynaecological procedures vary greatly. -
Content ArticleAustralian based health improvement agency, Safer Care Victoria, help health services: prevent and learn from patient harm identify and deliver service improvements engage with consumers. The Safer Care Victoria Quality Improvement Toolkit includes fact sheets, practical tools, templates and resources to help Victorian health services improve the quality of care.
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Content ArticleThis Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents trend statistics on severe maternal morbidity (SMM) overall and for groups of SMM complications by patient characteristics.
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Despite various initiatives to tackle the problem, safety incidents linked to the late administration of medicines, or medicines that have been omitted entirely, have remained stubbornly high for decades. In this article (link at bottom of page) for the Pharmaceutical Journal, David Lipanovic says a national focus may finally deliver a solution. Related reading: HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department (5 December 2024)
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