Patient_Safety_Learning
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Everything posted by Patient_Safety_Learning
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Community PostHi @DeborahANP, thank you for feeling able to share your experience. The comments about HRT and the way in which you were not forewarned about the risks or potential pain of an IUD insertion, are just awful to hear. Sadly these issues are happening far too regularly and women are not being supported to make informed choices. We are also hearing, similarly to you that many women are not being supported or responded to appropriately when the procedure causes extreme pain. I would encourage you to feedback to your provider if you feel able to. The more formal recording of these experiences, the more evidence there should be that change is needed urgently. How do I make a complaint: Sources of help and advice If you are happy for us to share your account more widely, through an individual blog post on the hub we can also help raise awareness in that way. This of course is your personal choice. You can contact us at [email protected] if this is something you'd like to do. In terms of support, I would speak with your GP about the physical and psychological impact and to get advice on any support that is available. It might also be worth asking about women's health hubs and whether any are opening up locally, as these are due to be introduced and may provide better support. At Patient Safety Learning we continue to speak up about the trauma and lack of consent that is too often present during gynaecological procedures. No patient should have to endure what you did, with such little compassion. I am pasting a few links below that may be of interest to you, but please do be aware that may be triggering as some contain other traumatic gynae experiences. Pain experiences during intrauterine device procedures: a thematic analysis of tweets (11 June 2024) Failures of informed consent and the impact on women’s health: a Patient Safety Learning blog Gynecology has a pain problem Our discomfort is routine. What if it didn’t have to be? (1 June 2022) Fitting coils: developing a safe and supportive service The ripples of trauma caused by severe pain during IUD procedures (BMJ Opinion, July 2021)
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Content ArticleThere are many regular yet critical medications that must be given to patients whilst in the Emergency Department. Time is of the essence. This webpage from East Midlands Emergency Medicine Educational Media, includes a downloadable poster to help manage the risk to patients.
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Community PostHi @Ian Fearnley that would be great. If you would like to write a blog about the project, our guide can be found here: Guide to writing a blog - Patient Safety Learning - the hub If you prefer to share the report with just a few sentences to introduce it, we can do it like that too.
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Community PostHi @Ian Fearnley we'd love to hear more about the project and if you are happy to share your learning and findings? You can get in touch with us at [email protected] with more detail if you would like help sharing your work via the hub.
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Content Article
Stephen Heard is a Patient Safety Partner at Norfolk Community Health and Care Trust. He is also, as an RAF veteran himself, employed by Arden and GEM Commissioning Support Unit as one of a small part time team of regional leads for the Royal College of GPs (RCGP) veteran friendly accreditation scheme. In this blog, he explains how GP practices can support veterans and their families in ensuring they are and remain safe after transiting from the services into civilian life. He lists a number of services that veterans (anyone who has served at least one day in HM Forces) can be signposted to as part of their civilian care. Stephen emphasises that many veterans are vulnerable on transition and access to these programmes preferably via a veteran friendly GP practice can be critical to their safety. -
Content ArticleIncident reporting can inform hospital safety. However, under-reporting is preventing this. Authors of this study, published in the Journal of General and Family Medicine, conducted a nationwide survey among Japanese physicians-in-training by including a questionnaire in the General Medicine In-Training Examination to assess incident reporting behaviour and participation in patient safety lectures. Responses of 6,164 physicians-in-training indicated that although 78% had attended patient safety lectures, 44% had not submitted an incident report in the previous year and 40.6% did not know how to submit an incident report. The authors conclude that discrepancy between attendance at safety courses and incident reporting behaviour must be addressed to improve hospital safety.
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Catherine Picton is a health and policy consultant who has worked for over 25 years for the NHS, professional bodies, health think tanks and patient charities. A pharmacist by professional background, her policy work is often connected to medicines. In this blog, Catherine talks about the recent report she co-authored for the Royal Pharmaceutical Society; Medicines Shortages Policy: Solutions for empty shelves, and minimising the risk to patient safety. -
Content ArticleThis document tells you everything you need to know if your Emergency Department (ED) wishes to participate in the 2023/26 RCEM national quality improvement program (QIP) on Time Critical Medications (TCMs). Time Critical Medication is currently not a priority in Emergency Departments, it is a concept that is not widely understood and one which is not applied well in clinical practice.
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At Patient Safety Learning, we believe listening and learning from different perspectives, expertise and experiences is essential in understanding the complexities, challenges and potential solutions around patient safety issues. Reducing avoidable harm in health and social care cannot be done in isolation; collaboration is key. In this blog, we reflect on some of this year’s activities and celebrate people who are working together for safer care and recognising the value of different perspectives. -
Content Article*Trigger warning.* This story, published by Balance, is a very hard-hitting account from a husband who lost his wife by suicide. Pete wants to tell others about Victoria’s experience to raise awareness of how suddenly and severely mental health can deteriorate during the perimenopause. What happened to Victoria is rare and there is effective treatment for low mood related to the menopause. However, it is a tragic fact that suicide rates for women peak between the ages of 45-54 years, and much more needs to be done to recognise and treat the problem of changing hormones on a woman’s mental wellbeing.
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The three national pharmacy boards at the Royal Pharmaceutical Society (RPS) identified medicines shortages as a key policy area that is impacting patients, pharmacy teams, clinicians and wider groups throughout the NHS. As a result, in January 2024, RPS commissioned a report into medicines shortages. This report is the culmination of extensive engagement and collaboration with patients, the pharmacy profession, wider healthcare professionals and the key local, regional and national stakeholders integral to ensure the continuity of medicines supply. The report concludes by setting out 19 recommendations. -
Content ArticleKeeping the NHS Honest is a campaign group calling for an Independent NHS Complaints Service (INCS) to be established, to undertake patient complaints in a truly open, honest and independent way. Find out more about their work via the link below.
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Community PostAt Patient Safety Learning we often get asked by patients and families who have received poor healthcare what they need to do to make a complaint. Although we cannot get directly involved in individual cases, we have put together a series of simple guides on the steps you can take if you need to make a complaint. Please share the links with relevant networks that may find these useful. How do I make a complaint about my NHS care? A simple guide for patients and families in England How do I make a complaint about my NHS care Northern Ireland? A simple guide for patients and families How do I make a complaint about my NHS care in Scotland? A simple guide for patients and families How do I make a complaint about my NHS care in Wales? A simple guide for patients and families How do I make a complaint about my private care? A simple guide for patients and families How do I make a complaint? Sources of help and advice We would welcome your feedback on the guides. Please comment below with your thoughts (sign up here first for free).
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Community PostHi @Nikitha can I just clarify to avoid misunderstanding, are the acronyms you have used referring to the below: Low molecular weight heparin (LMWH) Direct oral anticoagulants (DOACs)
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Content ArticleIn this article for Forbes, the author Gil Press, writes about MedAware's AI-based medication safety monitoring platform. She draws on Ballad Health who has worked to deploy MedAware's AI-based medication safety monitoring platform, embedding it within the workflow of its Epic electronic medical record or Electronic Medical Records system.
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Amanda Wynn is an independent consultant, researcher and trainer based in Cambridgeshire, specialising in older and disabled survivors of domestic abuse and sexual violence. In this blog, Amanda talks about her recent research into sexual assaults against older people by hospital staff. She shares an overview of her findings and calls for greater awareness and support. -
Content ArticleThe death of nine-year-old Dylan Cope at University Hospital of Wales could have been avoided and neglect contributed, a coroner has concluded. Giving a narrative conclusion, senior coroner for Gwent Caroline Saunders, said Dylan’s death would have been avoided had he not been discharged from Grange University Hospital, Cwmbran, on 7 December 2022. This article, pushed by Leigh Day law firm, describes the events leading up to Dylan's death, the coroners findings, and includes an account from Dylan's mother.
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Content ArticleThis report sets out why Mencap believe there is institutional discrimination within the NHS, and why people with a learning disability get worse healthcare than non-disabled people. They present the stories of six people who they believe have died unnecessarily. They do so because they argue that healthcare professionals need to realise the serious – even fatal – consequences of their lack of understanding. They call for professionals to work to ensure that such tragedies can never happen again
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Content ArticlePatient_Safety_Learning posted an article in Human factors (improving human performance in care delivery)This webinar from THIS Institute asks; what does the evidence tell us about the role of human factors and ergonomics in healthcare, and why haven’t the approaches been more widely adopted?
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Content Article"When the secretary of state for health and social care, Wes Streeting, asked me to investigate the state of the NHS in England, I thought I knew what we would find. All of us who have worked in the NHS in recent years have known it was under pressure. But, as a surgeon, I am used to seeing just one piece of the puzzle. Hearing the experiences of millions of patients and staff across the country brought together left me shocked and angry." In this article for the Guardian, Lord Darzi reflects on the findings of his review and argues that making healthy life expectancy central to all government policy is the surest way of stemming demand on the health service.
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Content ArticleParticularities in psychiatry care can increase the risk of medication errors (MEs). The objective of this study was to analyse the MEs that occurred in a psychiatric hospital and to quantify relationships between the use of certain types of medication and the type of MEs. This study, published in Research in Social and Administrative Pharmacy, sheds an innovative approach to analyse MEs by demonstrating that certain medication situations were more likely to lead to certain types of error. This enables the most appropriate prevention barriers to be put in place to intercept ME.
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Content ArticleThis article published in Frontier Myanmar, describes how patients have to pay bribes in public hospitals on the brink of collapse for lack of staff and funding, leaving charities struggling to care for the poor while dangerous quacks and charlatans exploit the most vulnerable.
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Sandra Igwe is the Founder and CEO of The Motherhood Group and author of the bestselling book "My Black Motherhood: Mental Health, Stigma, Racism and the System". She served as Co-chair for the National Inquiry into Racial Injustice in Maternity Care and is also a Topic leader for Patient Safety Learning’s hub, with a focus on Black Maternal Mental Health. In this interview Sandra tells us about a new partnership project, bringing together The Motherhood Group, Centre for Mental Health, and the Maternal Mental Health Alliance to address critical gaps in Black maternal mental healthcare. -
Community PostWe are looking for someone based outside of the UK, with expertise in an area of patient safety 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 are interested in becoming an international topic leader for the hub, the job description and application is attached. If you'd like an informal chat about the role, you can contact the hub team at [email protected]. Topic leader application form (2).docx Topic leader JD (4).pdf
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The Patient Safety Partner (PSP) role was introduced in 2022 by NHS England as part of its Framework for involving patients in patient safety and National Patient Safety Strategy. Patient Safety Partners can be patients, carers or members of the public who want to support and contribute to an organisation’s governance and management processes for patient safety. This webpage brings together a toolkit of resources, designed to share insights and information about the Patient Safety Partner role. It will be particularly useful for: Patient Safety Partners. Managers of Patient Safety Partners. Organisations who have not yet introduced the role. People that are interested in patient engagement and patient safety.
