Patient_Safety_Learning
PSL Moderators
-
Joined
-
Last visited
Everything posted by Patient_Safety_Learning
-
Content ArticleOveruse of diagnostic testing is pervasive, but the extent to which it varies by race and ethnicity in the acute care setting is poorly understood. The objective of this study, published in JAMA Network Open, was to use a previously validated diagnostic intensity index to evaluate differences in diagnostic testing rates by race and ethnicity in the acute care setting, which may serve as a surrogate for diagnostic test overuse. White patients discharged from the ED with a nonspecific diagnosis of interest were significantly more likely than Black patients to receive related diagnostic testing. The extent to which this represents diagnostic test overuse in White patients vs undertesting and missed diagnoses in Black patients deserves further study. This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.
-
Content Article
In this blog, Patient Safety Learning looks ahead to World Patient Safety Day 2024 (WPSD 2024) and the theme of this year’s event, ‘Improving diagnosis for patient safety’. -
Community PostHi @Kassie Thank you for sharing your experience here. I am so sorry that you did not receive the compassionate, patient-centred care you should have and that it has, understandably, left you physically and mentally affected. As you'll see from this forum, although the pain experienced by those having IUD procedures does vary, too many women have had unacceptably high levels of pain, many without forewarning of this as a possibility. We have heard of others too who have not had their pain responses responded to with compassion and care which has sadly affected their relationship with healthcare services. If you have any concerns about your physical or mental health following the procedure please do seek medical advice. If you feel able to, I would recommend feeding back to your service provider too, so that your experience is recorded and hopefully might contribute to an improvement in this area. At Patient Safety Learning we are working with patients, clinicians, researchers and others to raise awareness of these issues. We will continue to highlight the accounts shared with us as part of this work. The CDC has recently released guidance around this issue, which may also be of interest. We recently published a blog by a clinician here in the UK, where she explains how they've adapted their service to better meet the needs of patients. Fitting coils: developing a safe and supportive service. It is clear from patient accounts that much more needs to be done to ensure no one has a traumatic experience while accessing important gynaecology services.
-
Content ArticleThe Improvement Academy has published a short guide about being a Patient Safety Partner. The guide has been written by people who have been in PSP roles across Yorkshire and Humber for 6-12 months.
-
-
Content ArticleThere is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved. The objectives of this study, published in Health and Social Care Delivery Research, were to identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement. Authors concluded: "We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study’s findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research."
-
Content ArticleWhile safety-dedicated professional roles are common in other high-risk industries, in health care they have tended to have a relatively narrow, technical focus. Authors of this study, published in the Journal of Health Services Research & Policy, present initial findings from a mixed-methods evaluation of a novel, senior role with responsibility for leadership of safety in English National Health Service organisations: the patient safety specialist. They conclude: "The vision for the patient safety specialist role is clear, and supported by a plausible account of how the work of role holders might result in the intended objectives. The degree to which specialists are supported and resourced to deliver on these ambitions, however, varies markedly across organisations."
-
Content ArticleIf you were a patient and been given the wrong drug in error, would you want to be invited to attend an After Action Review (AAR) with the staff directly involved? This is the fourth article in a series to share the findings of Judy Walker Associates Snapshot survey into how the Learning Response Tools, especially AAR, are being used. Here, Judy reviews survey respondents' answers to the questions about involving patients in AARs and explore what the future might hold.
-
Content ArticleDecontamination of non-critical objects shared by patients is key in reducing hospital-acquired infections (HAIs), but it is a complex process that needs precise guidance from UK National Health Service (NHS) acute care organizations (ACOs). This study, published in the Journal of Hospital Infection, aimed to review the indications given by NHS ACOs' policies regarding the decontamination of shared non-critical devices.
-
Content Article
Jessica Jacobson is a Professor of Criminal Justice and Director of the Institute for Crime & Justice Policy Research (ICPR) at Birkbeck, University of London. In this blog, she talks about the Voicing Loss project. Drawing on interviews with bereaved people who had experienced an inquest, she highlights how the process can cause further harm and distress. Jessica also explains that, when people are given the right support, an inquest has the potential to help rather than hinder the grieving process. The majority of the bereaved people who took part in the Voicing Loss research believed that failings by state or other bodies, most often providers of health and social care services, had caused or contributed to the death. -
Content Article
In this blog, we draw on insights shared by Patient Safety Partners and their managers in a recent workshop. The outputs from the workshop, facilitated by Patient Safety Learning and AQUA are being written up into a series of blogs. The first illustrated how a lack of role clarity can be a barrier for impact and the second looked at recruitment and induction. In our third blog, we share some suggested approaches and actions that Patient Safety Partners and trusts might take to help the role have influence and impact. -
Content ArticleThe National Health Executive podcast, speaks to award-winning and internationally acclaimed broadcaster and journalist, Pete Price, about his life and experience with aversion therapy on the NHS. Pete discusses his childhood, family and the period of time he spent in a ‘hospital’ undergoing aversion therapy. The podcasts explores how aversion therapy ties in with conversion therapy and what the Bill that has been making its way through parliament since last year means for the LGBTQ+ community and society as a whole.
-
Content ArticleImagine Citizens Network is an Alberta-based, independent, citizen-led organization whose focus is on the priorities of citizens in the healthcare system. Their mission is to enable and mobilize citizens’ ability to influence, and become valued partners in improving health care experiences and outcomes for all. Their 2023/2024 Report to the Community explores Imagine Citizens Network’s achievements throughout 2023/2024, which revolve around their core working themes of Listen, Link, Learn, and Lead.
-
Content Article
The charity Group B Strep Support have launched a new FREE eLearning module on group B Strep and it comes with one hour of Continued Professional Development (CPD) credit. This vital resource is for midwives, doctors and others working in maternity and neonatal care. It has been co-produced with families, midwives, obstetricians, neonatologists and others involved in maternity and neonatal services. The module takes around 30-40 minutes to complete and provides an overview of group B Strep. It’s based on the latest guidelines from the Royal College of Obstetricians & Gynaecologists and the National Institute for Health and Care Excellence. -
Content ArticleMedical examiners are senior doctors who provide independent scrutiny of the causes of death and are supported by medical examiner officers. They provide that independent scrutiny in three ways. They carry out a proportionate review of the medical records They offer bereaved people an opportunity to ask questions and raise concerns. They also talk to the doctor who is completing the medical certificate of cause of death. If medical examiners detect a concern, they pass it on to established clinical governance processes that are in place at the relevant provider to be looked at in more detail. Two patient safety partners (PSPs) were a key part of NHS England's implementation group. As lay representatives, patient safety partners bring a different perspective in terms of patient safety that's been very valuable and ensures that bereaved people are central to the work. They also shared close family experiences with the group and championed an approach that ensured that the key material is available in 12 languages. In this podcast, one of the PSPs describe their experience of working with NHS England and what they would recommend to others to enable real partnership in co-designing healthcare.
-
Content ArticleThe Patient safety healthcare inequalities programme has resulted in the generation of recommendations for improvement that were co-designed with clinicians, patient safety specialists, people with lived experience or expertise in inequalities, and our lay patient safety partners (PSPs). In particular, two PSPs were part of this large multi-disciplinary group which met virtually each month. In this NHS England podcast, the PSPs describe their backgrounds and reasons for helping the national patient safety team and outline how they have contributed to the plan for reducing patient safety healthcare inequalities. They describe how they were able to be a voice for people from ethnic backgrounds that are often not heard; to shape future NHS services making them more inclusive and safe; using ‘real time insight’, to help to close the gap in health inequalities and provide more equitable access to services. As part of the team they were able to challenge perceptions of barriers and bring solutions in how to overcome them. They have also contributed by helping to develop the role of PSPs by being involved in discussions about how to shape the role and how to ensure recruitment is effective in attracting people from diverse groups.
-
Content ArticleThe Health Services Safety Investigations Body (HSSIB) was formally established on 1 October 2023 as an Arm’s Length Body of the Department of Health and Social Care. Their first annual report and accounts covers the six months from launch to 31 March 2024, and sets out their priorities as a new organisation, with achievements and progress to date.
-
Content Article
In this blog, we draw on insights shared by Patient Safety Partners and their managers in a recent workshop. The outputs from the workshop are being written up into a number of blogs; the first illustrated how a lack of role clarity can be a barrier for impact. This blog will focus on recruitment and induction. The knowledge captured here provides guidance to anyone involved in embedding the Patient Safety Partner role within their own organisation. We also share advice for Patient Safety Partners to help them navigate their new role, settle in and have a positive influence on patient safety. -
Content ArticleIn this blog for National Voices, Eamonn Dunne writes about working together for health service equity for blind and partially sighted people.
-
Content ArticleThe attached handbook (version 2.0) has been written primarily to support colleagues in NHS England’s Patient Safety team in their roles as mentors to Patient Safety Partners (PSPs). This guide may also be a helpful source of information for our Patient Safety Partners, and may be adapted for use by other NHS teams to support their partnership working with their PSPs.
-
Content Article
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. The Strategy set out the ambition for safety-related clinical governance committees (or equivalents) in NHS organisations to include two Patient Safety Partners by April 2022. They 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. In this blog, we draw on discussions from the Patient Safety Partners Network and a recent workshop, to highlight the need for role clarity and guidance for Patient Safety Partners. We share insights from areas of good practice, where the role has been well supported and integrated locally. These examples show how clarity and guidance has helped remove barriers, enabling Patient Safety Partners to have a positive impact for patient safety, as intended. -
Community PostPatients are increasingly being asked to access online systems to: request prescriptions or make medication requests access healthcare records and test results make appointments communicate health concerns sign consent forms. These developments can have a positive impact but they can also carry potential challenges, as highlighted in this recent blog - Digital-only prescription requests: An elderly woman sent round the houses. We'd like to hear your experiences of using online systems in healthcare. Have they made things easier? Does it feel like your care is more joined up for it? Have any of these changes been challenging? If so why? Comment below (sign up first for free) or contact us directly at [email protected] to share your experience.
-
Content Article
This blog is part of a series written by Dr Charlie*, taking a closer look at some of the patient safety issues affecting people's lives today. In this blog Dr Charlie describes how their homeless friend Robbie* has struggled to access the care and clarification he needed around his liver abscesses. Dr Charlie explains how important it is for healthcare professionals to take into account individual circumstances if they are to provide people with the information and care they need. *not their real name -
Content ArticleThis article published by The Justice Gap highlights new research that has revealed the psychological toll of the inquest system on people whose loved ones die in contested circumstances, including struggling with a complicated legal process and suffering due to cuts to the system.
-
Community Post@blueiii I am so sorry to hear about your painful and traumatic experience. The points that you and many others have raised, are incredibly important and we refer to this forum when we connect with others in the gynae space, highlighting the need for urgent improvement. More recently we have been seeking examples of good practice to share, with the aim of helping others learn from their work to provide safer care. We have also been working with researchers who have been exploring this area. I am including a few links below to content that may be of interest. Many of the issues raised by patients undergoing IUD procedures mirror those we have heard in relation to hysteroscopies. So I have also included a piece we wrote calling for action on that. Better data collection, patient reported outcomes and making sure women can have access to all of the available pain relief options (with the relevant information) would be a start to improving things. You'll see from the example in one of the links below that the team in Oxford also have a complex pathway for patients who they identify as having the potential to experience high levels of pain or trauma. It is a flexible system, based on listening to the patient - another key area for improvement. There is so much to learn in this space, to make sure patients don't continue to suffer as you have or lose trust. Fitting coils: developing a safe and supportive service Pain experiences during intrauterine device procedures: a thematic analysis of tweets (11 June 2024) Coil procedures: Exploring negative experiences through qualitative research (an interview with Sabrina Pilav) The ripples of trauma caused by severe pain during IUD procedures (BMJ Opinion, July 2021) Hysteroscopy: 6 calls for action to prevent avoidable harm
