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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Community Post
    Hi @perbinder thank you for posting. @Claire Cox might be able to help share your request among relevant networks.
  2. Content Article
    This editorial, published in BMJ Quality & Safety, the author notes that the involvement of medical trainees in patient care means it is vital that the impact of changes to medical training programmes on patient outcomes are assessed with well-designed studies. They take a look at the impact of medical education on patient safety specifically.
  3. News Article
    The author of a Parliamentary report into ‘failing’ eating disorder services in 2017 says the number of concerning deaths still being reported five years on is ‘very distressing’. In the five years since ombudsman Rob Behrens warned of major shortcomings around adult eating disorder services, HSJ has identified at least 19 women whose deaths sparked concerns from coroners about their care (see list below). At least 15 of these were deemed avoidable, and resulted in formal warnings being issued to mental health chiefs. Source: HSJ, 14 February 2023 Read full story
  4. News Article
    Capitalizing on the pandemic explosion in telehealth and therapy apps that collect details of your mental health needs, data brokers are packaging that information for resale, a new study finds. There’s no law stopping them. In a study published Monday, a research team at Duke University’s Sanford School of Public Policy outlines how expansive the market for people’s health data has become. After contacting data brokers to ask what kinds of mental health information she could buy, researcher Joanne Kim reported that she ultimately found 11 companies willing to sell bundles of data that included information on what antidepressants people were taking, whether they struggled with insomnia or attention issues, and details on other medical ailments, including Alzheimer’s disease or bladder-control difficulties. Justin Sherman, a senior fellow at Duke who ran the research team, says that mental health data should be treated especially carefully, given that it could pertain to people in vulnerable situations — and that, if shared publicly or rendered inaccurately, could lead to devastating results. Source: Washington Post, 13 February 2023 Read full story
  5. News Article
    A third of those with a women’s health condition have been made to wait three years or longer for a diagnosis, damning new research has revealed. The same study found half of those women took a year or more to be given their diagnosis. Srdjan Saso, a consultant gynaecologist and surgeon who works with King Edward VII’s Hospital, told The Independent: “A delayed diagnosis can mean a severe impact on quality of life both professionally and personally. “It can have a significant impact on a woman’s day-to-day life and hence needs to be addressed properly and seriously. From a more sinister perspective, in certain cases, it can be cancer and we are picking it up late.” Source: Independent, 14 February 2023 Read full story
  6. Content Article
    Kay Khan, Head of Improvement Programme Delivery at East Midlands Academic Health Science Network, explores two new ‘React To’ resources they’ve developed to support care homes and their staff to improve the safety of residents."Care home staff know their residents really well, and by using deterioration management tools like RESTORE2mini they can spot and record the warning signs, and crucially, use a structured communication tool like SBARD to relay their concerns to a GP or other healthcare professional."In the East Midlands, we have worked with health and social care design specialists Crocodile House over the last few years to produce a series of resources for care homes called ‘React To’. These cover a wide range of topics such as falls, frailty and infection. We’re excited to launch our latest two modules, which include ‘React to Managing Deterioration’ – information and training about frailty, advance care planning, and how to recognise and escalate those soft signs".Read the full article and access the resources via the link below
  7. Content Article
    In this article, published by the Pharmaceutical Journal, Julia Robinson reviews the data and action taken so far to reduce avoidable harm caused by sodium valproate. Julia says that while there has been some progress in managing the risks of sodium valproate, babies are still being born after exposure to the drug, and safety concerns over antiepileptic use in men and women are multiplying.
  8. Content Article
    This report includes findings from a two-month-long study of data brokers and data on U.S. individuals’ mental health conditions. The report aims to make more transparent the data broker industry and its processes for selling and exchanging mental health data about depressed and anxious individuals. The research is critical as more depressed and anxious individuals utilise personal devices and software-based health-tracking applications (many of which are not protected by the Health Insurance Portability and Accountability Act), often unknowingly putting their sensitive mental health data at risk.
  9. News Article
    A&E waiting times have deteriorated so much this winter that at some hospitals in England more than half of patients have had to wait more than four hours. BBC analysis of data for December and January shows Hull University Hospitals, Wye Valley and Shrewsbury and Telford were worst for A&E waits. The best trust out of the 107 providing data, Northumbria Healthcare, had fewer than 10% waiting more than four hours. NHS England said plans were being put in place to support struggling trusts. Source: BBC, 13 February 2023 Read full story
  10. News Article
    Virtual wards, set up to relieve pressure on A&E departments, could create extra NHS demand as some are only staffed for 12 hours a day, the country’s top emergency doctor has warned. The service allows patients to be monitored remotely from their own homes, freeing up hospital beds and capacity in emergency departments. Patients are given devices to track their vital signs, such as blood pressure and oxygen levels, with readings sent back to doctors via smartphone apps. Dr Boyle, President of the Royal College of Emergency Medicine, said that virtual wards “must not be seen as a silver bullet for all the problems in urgent and emergency care”. “We’re very wary of virtual ward beds being used to say that there are increased beds within hospitals because that’s simply not true,” he said. “The plan for 7,000 or 5,000 extra beds need to be actual beds, with pillows, sheets and staff looking after them.” Source: Telegraph, 11 February 2023 Read full story
  11. News Article
    GPs are attempting to deal with up to 3,000 patients each, amid worsening staff shortages, according to new analysis. The research shows that the number of patients per GP has risen sharply, as rising numbers of doctors reduce their hours, or opt for early retirement. Daisy Cooper, spokeswoman for Liberal Democrat Health and Social Care, said: “This ever-worsening GP shortage is having a terrible human cost, as people face delayed or missed diagnoses and A&Es fill up with desperate patients looking for treatment." Read full story (paywalled) Source: Telegraph, 14 February
  12. News Article
    GPs have raised concern about a new colorectal cancer pathway aimed at reducing referrals into one of England’s largest acute hospital trusts. The pathway was implemented in December 2022 to tackle long waiting lists at United Lincolnshire Hospitals Trust (ULHT) by reducing the number of referrals from primary care. But the Lincolnshire LMC and Primary Care Network Association both raised concerns about the pathway and its impact on general practice in a letter to their ICB earlier this month. Read full story Source: Pulse, 13 February
  13. News Article
    A heart failure patient has become the first in the UK to be fitted with an early warning sensor the size of a pen lid which gives off an alert if their condition deteriorates. Consultant cardiologists Dr Andrew Flett and Dr Peter Cowburn have pioneered the procedure to fit the FIRE1 System during trials at University Hospital Southampton (UHS), Hampshire. Dr Flett said: “This innovative new device has the potential to improve patient safety and outcomes in the management of patients with chronic heart failure and we are delighted to be the first site in the UK to implant as part of this ground-breaking study". Read full story Source: The Independent, 12 February 2023
  14. Content Article
    The Royal College of Obstetricians and Gynaecologists (RCOG) has launched a consultation to seek views on the draft Green-top Guideline on Outpatient Hysteroscopy document. This consultation is open to both professionals and patients. You can return your comments using this online form by midnight Monday 13 March 2023. Please also see the guidance for reviewers page on the RCOG website.  
  15. Content Article
    Hysteroscopy is a common and valuable intervention to diagnose and treat gynaecological conditions arising in the uterus. Many women have an acceptable experience of outpatient hysteroscopy, with pain levels tolerable to them and rapid recovery. However, it is important to recognise that hysteroscopy can cause severe pain and be traumatic for women. This is difficult to predict. Therefore, units need to share with women clear, accurate and relevant, written and verbal information. This Good Practice Paper from the Royal College of Obstetricians and Gynaecologists has been written for healthcare professionals who are involved in providing outpatient hysteroscopy with the aim of achieving optimal outcomes for women.
  16. Content Article
    A Black woman is 3.7 times more likely to die in pregnancy than a white woman. [1] They are more likely to experience postnatal depression.[2] and less likely to seek support.[3]. Mental ill-health in pregnancy and beyond is an increasing cause of maternal death,[1] making it more important than ever to understand and address racial inequality.   In this interview, we talk to Sandra Igwe, CEO of The Motherhood Group, and Author of My Black Motherhood: Mental Health, Stigma, Racism and the System, about the Black Maternal Health Conference UK, taking place on 20 March 2023.   Sandra, who is hosting the event, explains how the day has been designed to support the rebuilding of trust between Black mothers and the healthcare system. She introduces us to the rich and interactive agenda and explains how it will provide opportunity for deeper exploration and collaboration.   Sandra welcomes everyone to sign up to the event, from mothers and healthcare professionals to researchers and journalists.   Event hashtag - #BMHCUK 
  17. Content Article
    In this blog, Mark Amphlett, clinical negligence specialist, looks at the recently launched Patient Safety Incident Response Framework (PSIRF), the aims of moving away from the Serious Incident Framework, and the challenges of implementation.
  18. Content Article
    This is a brief summary of a Westminster Hall debate in the House of Commons on the 31 January 2023 on NHS hysteroscopy treatment, tabled by Lyn Brown MP.
  19. Content Article
    One solution often proposed for the NHS’s problems is to change how it is funded, and move instead to a social insurance model. In the latest in his series of myth-busting commentaries published by Nuffield Trust, Nigel Edwards describes why such a move in the UK would be unlikely to provide most of the benefits that its advocates hope for.
  20. Content Article
    Providing an overview of the work of the Group and its key findings, the Report of the Strategic Workforce Advisory Group on Home Carers and Nursing Home Health Care Assistants presents a suite of 16 recommendations spanning the areas of areas of recruitment, pay and conditions of employment, barriers to employment, training and professional development, sectoral reform, and monitoring and implementation.
  21. Content Article
    Women and birthing people from black, Asian, or mixed ethnic backgrounds are significantly more likely to experience poor outcomes during their maternity journey. Between September 2021 and October 2022, Darzi Fellow Rosie Murphy undertook work in Croydon to explore these inequalities and what could be done to improve local services. This is the first in a series of blogs published by the Health Innovation Network, reflecting on the learnings and experiences from her Fellowship.
  22. Content Article
    In this book, Sandra Igwe shares her journey as a young Black mother, coping with sleepless nights, anxiety and loneliness after the birth of her first daughter. Burdened by cultural expectations of the 'good mother' and the 'strong Black woman' trope, her mental health struggles became an uphill battle. Black women are at higher risk of developing postnatal depression but are the least likely to be identified as depressed. Sharing the voices of other mothers, Sandra examines how culture, racism, stigma and a lack of trust in services prevent women getting the help they need. Breaking open the conversation on motherhood, race, and mental health, she demands that Black women are listened to, believed, and understood.
  23. Content Article
    In this blog, published by What's The Pont, the author provides a summary of the The Swiss Cheese Model of Accident Causation, developed by Professor James T. Reason, and looks at what it means for learning from failure. Related reading: The Swiss cheese respiratory virus pandemic defence Reverse Swiss Cheese – Driving safety culture from the blunt end (24 June 2022) Good and bad reasons: The Swiss cheese model and its critics (June 2020)
  24. Event
    until
    NHS England in their collaborative work with the Heads of Patient Experience (HOPE) network have focussed on how narrative and stories can be used to make improvements to experiences of delivering and receiving care. Part of this work has been to use digital stories and to explore the use of broader storytelling activities. Digital stories are a method of sharing personal experiences; encouraging people to share their story in the first person, working in partnership to process and edit an audio recording, then overlay it with pictures and/or art to create a 3-to-5-minute digital story. In this first session they explore the how stories are used in Trusts and at a strategic level in NHSE to start improvement work, how this is being done working in partnership with the people who share their stories and how stories are shaping future policy. They will update on progress and share their approach to measuring impact and outcomes. You will hear from people who have shared personal stories about what it has meant to them and from staff who have worked in partnership to improve services. They will also share how stories are unpeeling the layers of other more traditional sources of data and how multiple data sources can enhance our understanding and improve care. Join for a packed session of learning, insight, and networking the first of series of sessions across the month of March. Reserve your place
  25. News Article
    A hospital trust is facing a fine in a criminal prosecution over the death of a baby. The Care Quality Commission (CQC) is prosecuting Nottingham University Hospitals (NUH) NHS Trust over the death of Wynter Andrews. Wynter died 23 minutes after she was born by Caesarean section in September 2019 at the Queen's Medical Centre.  The prosecution is one of only two the CQC has brought against an NHS maternity unit. The trust is due to face sentencing at Nottingham Magistrates' Court later. Read full story Source: BBC News, 25 January 2023
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