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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. Content Article
    The Covid-19 public inquiry has been in the news recently, with former Chancellor George Osborne and ex Prime Minister David Cameron denying that austerity policies in the UK before the pandemic weakened how prepared the NHS was for such a crisis. In this blog, published by the Nuffield Trust, Leonora Merry and Sally Gainsbury take a closer look at how true this is.
  6. Content Article
    Authors conducted a before and after, retrospective, observational study using anonymised, routinely collected, patient-level data from a single English NHS ED between April 2018 and December 2019. The primary outcomes of interest were the proportion of admitted patients, that is, the admission rate, the length of stay in the ED and ambulance handover times. They used interrupted time series models to study and estimate the impact of removing the 4-hour access standard.
  7. Content Article
    The Trinity Challenge is a coalition of partners united by the common aim of developing insights and actions to contribute to a world better protected from global health emergencies. They focus on three core activities which will improve the use of data and analytics and our understanding of human behaviour in response to health emergencies: Set a new global challenge to the world Facilitate unique collaborations amongst the coalition to improve outcomes Strengthen the data, analytics and learning ecosystem for global public health.
  8. News Article
    Medical clinics are using fake Google reviews to boost their profiles online, a BBC investigation has found. Consumer groups say fake reviews are a "significant and persistent problem" and have called on internet firms to do more to remove them and fine companies. Which? has warned it could be a serious issue if someone chooses a treatment clinic based on reading a fake review. Read full story Source: BBC 2 August 2023
  9. News Article
    Jonathan Medland's voice crackles with anger and emotion when he talks about his beloved son Jon, who tragically took his own life aged just 22. 'He was the most exuberant, engaging, funny and amazing young man you could ever wish to meet — nobody had a bad word to say about him — he was really going places,' says Jonathan, 66, a retired driving instructor from Barnstaple in Devon. 'But that drug did something terrible to his brain.' The drug he's referring to is isotretinoin — brand name Roaccutane — a pill first licensed in the UK for the treatment of severe acne in 1983 and since taken by hundreds of thousands of patients. Read full story Source: Mail Online 31 July 2023
  10. News Article
    In the U.S., the prescribing label of Ozempic's sister drug, Wegovy, already warns of possible suicidal ideation because of similar side effects linked to other weight loss drugs. Following reports of self-injury and suicidal thoughts among a small number of people who’ve taken Ozempic or Wegovy in Europe and the United Kingdom, health regulators there are investigating whether the drugs carry a risk of these side effects. The European Medicines Agency said last month that it was reviewing 150 such reports from people who took drugs in this class, called GLP-1 receptor agonists, which lower blood sugar and suppress appetite by mimicking a hormone in the gut. Then last week, the U.K.'s Medicines and Healthcare products Regulatory Agency told Reuters that it was reviewing safety data about the drugs following similar reports. Neither Ozempic nor Wegovy, which are both versions of a drug called semaglutide at different dosages, carry warnings about suicidal ideation in Europe or the U.K., since clinical trials have not shown evidence of an increased risk. But in the United States, the Food and Drug Administration requires that medications for weight management that work on the central nervous system carry a warning about suicidal thoughts. Because the agency approved Wegovy as a weight loss treatment, its prescribing label asks medical professionals to monitor for these symptoms and to discontinue the medication if people develop them. Ozempic, which is only FDA-approved to treat diabetes, does not come with that warning. But some patients think it should. Read full story Source: NBC 1 August 2023
  11. News Article
    The use of artificial intelligence in breast cancer screening is safe and can almost halve the workload of radiologists, according to the world’s most comprehensive trial of its kind. Breast cancer is the most prevalent cancer globally, according to the World Health Organization, with more than 2.3 million women developing the disease every year. Screening can improve prognosis and reduce mortality by spotting breast cancer at an earlier, more treatable stage. Preliminary results from a large study suggest AI screening is as good as two radiologists working together, does not increase false positives and almost halves the workload. The interim safety analysis results of the first randomised controlled trial of its kind involving more than 80,000 women were published in the Lancet Oncology journal. Read full story Source: Guardian 2 August 2023
  12. News Article
    A hospital trust has apologised to families after dozens of children suffered hearing loss following failures in their care. Croydon Health Services Trust had already revealed three children “may have been at risk of serious hearing loss or a delay to their speech development”, but it has now confirmed to HSJ that a further 49 “incurred mild to moderate hearing loss or impairment”. The south London trust would not disclose the results of its internal review that begun after it declared a serious incident in March 2021, saying it was “ongoing”, but said it had acted on all the “immediate recommendations”. The incident was declared after more than 1,400 children were found not to have been followed up by the trust. There was also an external review carried out by an audiologist from Guy’s and St Thomas’ Foundation Trust. It is unclear which review uncovered the incidents of harm. Read full story Source: HSJ 1 August 2023
  13. Content Article
    This book, edited by Chartered Health Psychologist Holly Blake, demonstrates the breadth of research on work, health and wellbeing, during and beyond the COVID-19 pandemic, covering workforce impacts and workforce interventions in various countries and settings. Learning from this research will help to build global preparedness for future pandemics and foster resilience for responding in times of crisis and uncertainty.
  14. News Article
    Groundbreaking treatments for Alzheimer’s disease that work by removing a toxic protein called beta amyloid from the brain may benefit whites more than Black Americans, whose disease may be driven by other factors, leading Alzheimer’s experts told Reuters. The two drugs - Leqembi, from partner biotech firms Eisai (4523.T) and Biogen (BIIB.O), and an experimental treatment developed by Eli Lilly (LLY.N), donanemab — are the first to offer real hope of slowing the fatal disease for the 6.5 million Americans living with Alzheimer’s. Although older Black Americans have twice the rate of dementia as their white peers, they were screened out of clinical trials of these drugs at a higher rate, according to interviews with 10 researchers as well as four Eisai and Lilly executives. Prospective Black volunteers with early disease symptoms did not have enough amyloid in their brain to qualify for the trials, the 10 researchers explained. Read full story Source: NBC 31 July 2023
  15. News Article
    Desperately ill people with eating disorders are being refused NHS treatment for “not being thin enough”, as new figures reveal the health service is in the grips of a growing eating disorder crisis. Shocking figures obtained by The Independent show at least 5,385 patients – the overwhelming majority, 3,896, of whom are children – were admitted to general wards for conditions such as anorexia and bulimia in 2021-22, more than double the number in 2017-18. It comes as separate analysis of NHS figures suggests the number of children being treated for eating disorders more than doubled from 5,240 in 2016-17 to 11,800 in 2022-23. Read full story Source: Independent 1 August 2023
  16. News Article
    Coroners have warned of increasing numbers of deaths caused by problems in the emergency pathway, with some citing ‘severe’ staffing shortages. HSJ has identified that at least 24 “prevention of future death” reports were sent to NHS organisations in England and Wales in the first half of 2023, which noted shortcomings within emergency services. In six of the 24 cases, coroners found ambulance, emergency room and other delays caused or contributed to patient deaths. Read full story Source: HSJ 1 August 2023
  17. Content Article
    These new updated guidelines, produced in collaboration between the Healthcare Infection Society and The European Society of Clinical Microbiology and Infectious Diseases, used NICE-accredited methodology to provide further advice on which practices in the operating theatre are unnecessary. The guidelines are intended for an international audience. Specifically, they discuss the current available evidence for different rituals that are commonplace in the operating theatre and highlight the gaps in knowledge with recommendations for future research.
  18. Content Article
    Witness statement from Professor Kevin Bampton LLB FCMI FRSA FHEA, who is also: a member of the Covid-19 Airborne Transmission Alliance (CATA) Chief Executive Officer of the British Occupational Hygiene Society (the Chartered  Society for Worker Health Protection) on the Board of the Council for Work and Health Chair of the British Standards Institute Health and Safety Management Committee Chair to the Occupational Health Multidisciplinary Forum a member of the International Standards Organisation Infectious Diseases Committee. In response to the COVID-19 Inquiry Rule 9 Request in relation to Module 1, Professor Kevin Bampton responds to the Inquiry's questions under four broad headings: i) overview of who CATA is, how it was formed and why ii) discussion of the basis in principle for claiming that the failure to recognise the airborne  route of transmission was a fundamental barrier in pandemic resilience, preparedness and emergency planning iii) expressing CATA's position, advocacy and engagement around  issues of pandemic resilience, preparedness and emergency planning iv) CATA's proposed lines of enquiry and interim recommendations for Module 1.
  19. Content Article
    This procedure describes the Trust wide process of retrospective case review that is to be implemented following an in-hospital death. The document outlines roles and responsibilities and provides guidance on the  process of identifying, reviewing, sharing and escalating mortality case reviews.
  20. Content Article
    This policy sets out a framework describing how the Trust and its staff will respond to and learn from deaths that occur under their care.It will provide guidance for all staff involved in the mortality review process ensuring clarity on roles, responsibilities and expectations. Reviewing mortality can help make improvements to the quality of care received by patients at the Trust by identifying care related issues. This enables the identification of learning themes and provides evidence of a high standard of care. Mortality is a fundamental component of clinical effectiveness, one of the three dimensions of quality described by Lord Darzi in High Quality Care for all (2008). The Trusts aims are to: Have continuous improvement of our Hospital Standardised Mortality Ratios (HSMR) and the Trusts Standardised Hospital-Level Mortality Index (SHMI) Achieve a year-on-year reduction in avoidable mortality  Improve learning from mortality reviews Ensure robust and timely governance processes regarding mortality outcomes and reviews Provide assurance of mortality processes in the Trust.
  21. Content Article
    In this article Steven Shorrock argues that understanding the complexities and nuances of human work is critical if we are to improve how work really works. In healthcare, as clinicians and other healthcare professionals navigate their roles, they encounter a diverse array of situations that create goal conflicts, dilemmas and other challenges. One way to explore these is via micro-narratives. These are short stories based on personal observations and experiences. One method to capture these is via simple written postcards. Postcards from Work (Healthcare Edition) delves into these experiences. A sample of the cards is shown within the article.
  22. Content Article
    In 2021, a multi-professional staff support group was established under the Northern Care Alliance NHS Foundation Trust’s Freedom to Speak Up process which raised new questions and concerns around the probity and clinical standards of a Consultant Spinal Surgeon (“Consultant Spinal Surgeon A”) whilst they were employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) (“the Trust”). As a result, the Trust commissioned the Spinal Patient Safety Look Back Review (“SPSLBR”) and Investigation Group to evaluate these concerns, including obtaining independent expert advice.In January 2022, the Trust commenced the SPSLBR to investigate and manage patient safety concerns raised in respect of Consultant Spinal Surgeon A who was employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) between 1991 and January 2015. This report outlines the investigation carried out by the SPSLBR Investigation Group on behalf of the Trust to investigate and manage potential Serious Incidents (“SI”) caused by the errors and omissions attributable to clinics, surgery and/or consultations undertaken by Consultant Spinal Surgeon A within the scope identified in the Terms of Reference. 
  23. Content Article
    The objective of this study, published in the BMJ, was to determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England and to determine the association with the trust’s hospital-wide standardised mortality ratio assessed using the two commonly used methods - the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI). Authors conclude that reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist.
  24. Community Post
    Thank you for sharing your experience. I am so sorry you went through such pain. It is interesting to hear that the medication you were given to relax the cervix and uterus helped to some extent, I am unsure how often this is offered. At Patient Safety Learning we continue to call for more research and training in this area, and for all pain management options to be consistently offered to, and discussed with, women undergoing IUD procedures. Most importantly we are calling for women to be listened to and their experiences routinely captured by health services so the extent of these experiences can be fully understood. Thank you again for sharing yours.
  25. Content Article
    Jane Plumb is the Co-Founder of Group B Strep Support and the Women's Voices Lead for the Royal College of Obstetricians & Gynaecologists. In this interview, she emphasises the importance of actively involving patients and families in patient safety discussions so that improvements can be informed by their insights and experiences. Jane also talks about her campaigning and advocacy work, reflecting on the challenges and achievements to date as well as looking ahead to future aims and activity. 
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