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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    Pulmonary embolism is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Although life-threatening, when diagnosed promptly survival rates are good.  This report, authored by risk expert Tim Edwards and published by Patient Safety Learning, highlights serious and widespread patient safety concerns relating to the misdiagnosis of pulmonary embolisms.  Drawing on existing data, freedom of information requests and his mother’s case, he outlines nine calls for action to improve pulmonary embolism care. 
  2. Content Article
    This briefing paper, from the Royal College of Radiologists, was produced to help inform an adjournment debate in the house of commons focusing on pulmonary embolism misdiagnosis. The briefing highlights concerns around staffing gaps, workforce planning and equipment shortages within this area, and the threat this poses to patient safety.
  3. Content Article
    Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient (NHS England, 2017). From 1 April 2011 until 31 March 2021 the NHS paid £15.6 million in damages relating to extravasation. This leaflet, published by NHS Resolution, aims to share learning from those claims.
  4. Content Article
    Supporting staff to speak up is essential to patient safety. The PACE communication tool is designed to help anyone in a team challenge an action or behaviour they feel is inappropriate. You can read more about PACE (probe, alert, challenge, emergency) and other communication tools on the Victorian Trauma System website via the link below.
  5. Content Article
    Pressure ulcers, or bed sores as they are often called, can affect people of all ages. They can lead to serious complications and immense pain for patients, so prevention and awareness is key. Patients with mobility difficulties, conditions affecting blood flow (such as Type 2 Diabetes), and those over 70 are particularly vulnerable.  Stop Pressure Ulcer Day is organised annually by the European Pressure Ulcer Advisory Panel and aims to bring knowledge to a wider audience to reduce the harm caused by pressure ulcers.  In support of the campaign, we're shining a spotlight on 10 fantastic resources that have been shared with us via our patient safety platform - the hub. 
  6. Content Article
    As part for their #STOPthepressure 2022 awareness campaign, Guys and St Thomas' started a pledge wall where all staff can make a personal pledge. Their goal is to foster a culture that aims to eliminate avoidable pressure ulcers. Click on the image below to be taken to see all of the pledges.
  7. Content Article
    In this 56 minute presentation by The Society of Tissue Viability, Jacqui Fletcher looks at how wound care and pressure ulcer prevention can be improved for patients with darker skin tones. She highlights the importance of recognising how pressure ulcers present on different skin tones and explains why strategies like the 'react to red' prompt need to be challenged in order to address health inequalities in this area. 
  8. Content Article
    This study, published by the Journal of Clinical Nursing, explores health disparity in on-campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries. Authors conclude: "Radical critique of all teaching and learning activities needs to occur, to help explore, improve and meaningfully and authentically include diversity and inclusivity in nurse education, and in particular, how people across the skin tone spectrum are included and represented in teaching and learning activities." Read the paper in full via the link below.
  9. Content Article
    Wounds UK have developed a number of Best Practice Statements, designed to help clinical staff improve wound care.
  10. Content Article
    This long read article, published by the Guardian, looks at the data captured on long covid so far, including risk factors and impact of vaccination. It comments on the uncertainties and challenges that remain for patients, healthcare providers, researchers and resources. 
  11. Content Article
    According to the 2016 US News and World Report (USNWR) ranking, The Mayo Clinic is America’s best hospital. The CEOs are both physicians and the hospital has in fact always been physician-led. In this article, published by The American Association for Physician Leadership, the authors look at why doctors make good managers.
  12. Content Article
    In this letter, campaign group Hysteroscopy Action, have written to Women’s Minister, Maria Caulfield, to raise its concerns about the levels of pain and trauma experienced by many women undergoing outpatient hysteroscopy procedures. The letter, which has over 20 signatories, including Helen Hughes, Chief Executive of the Patient Safety Learning charity. It calls for more theatre space for women to have procedures under general anaesthetic as well as offering women the choice of intravenous sedation.  Related reading Horror as women are facing major medical procedures without anaesthetic, warn experts Guidance for outpatient hysteroscopy: Consultation Response (Patient Safety Learning) Patient experiences shared with us in our community thread Pain during ambulatory hysteroscopy: A presentation by Richard Harrison (3 minute video) 2020: Raising awareness about painful hysteroscopies (8 minute video) Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy Ministers respond to concerns about painful hysteroscopies: Northern Ireland, Scotland and Wales Read the letter to Maria Caulfield in full below.
  13. Content Article
    Mersey Care Foundation Trust's development of a respect and civility agenda has been shortlisted for several national awards. They have developed a free course called Just and Learning Culture: A New Way of Caring, which is aimed at HR colleagues but is accessible to everyone. You can read more about their work, and access the course (scroll to the bottom of the page) via the link below.
  14. Content Article
    In this 2 minute film, Jennifer Cooke from the Community Mental Health team, talks about a special Just and Learning resource, created by Mersey Care called the Civility Jigsaw. She explains how their team used it to facilitate difficult conversations about inappropriate behaviour in the workplace and how powerful it was a tool for change.
  15. Content Article
    In this 3.5 minute film, Mersey Care looks at what bullying is and how it can have a devastating impact on staff. It forms part of their work to encourage people to feel safe in speaking up about bullying and build a positive working environment.
  16. Content Article
    In this article, published by the Guardian, experts from around the world share their insights, questions and fears around long Covid and their thoughts for the future.
  17. Content Article
    This briefing, from NHS Supply Chain and the NHS Confederation, explores the lessons learnt over the pandemic and the steps being taken to ensure supply chain resilience in the future.
  18. Content Article
    In 2021-22 the House of Commons Health and Social Care Select Committee held an inquiry into Cancer services, asking for evidence of why cancer outcomes in England continue to lag behind comparable countries internationally and examine evidence relating to the underlying causes of these differences. This document was submitted by Pancreatic Cancer UK as part of the call for written evidence in this inquiry.
  19. Content Article
    In this report, US organisation RevSpring, looks at the role and importance of patient engagement in all healthcare departments . It looks at how communications can help with payments, motivate people to be partners in their medical care, and improve patient experience.
  20. Content Article
    This publication reflects on how a digital strategy can help to improve patient experience from scheduling appointments to methods of communication. Authors, Becker’s Hospital Review and RevSpring, outline the competitive advantage this can give and the importance of understanding patient preferences.
  21. Content Article
    In this analysis, published by the Human Factors and Ergonomics Society, the authors look at the impact of double checking medication to reduce errors and improve patient safety.
  22. Content Article
    This paper, summarised in the Journal of Hospital Administration, concludes: "Embedding Restorative Just Culture and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels."
  23. Content Article
    This guidance from the Department of Health and Social Care is for NHS hospitals and independent hospitals (providing NHS-funded care) in England, and police forces in England and Wales. It outlines how to comply with the requirements of the Mental Health Units (Use of Force) Act 2018.
  24. Content Article
    Restrictive practices are things that limit the rights of a person, like being able to move around freely. Restrictive Practice is used to stop a person from doing behaviours of concern. These Specialised Services Quality Dashboards (SSQD) are designed to provide assurance on the quality of care by collecting information about outcomes from healthcare providers. SSQDs are a key tool in monitoring the quality of services, enabling comparison between service providers and supporting improvements over time in the outcomes of services commissioned by NHS England.
  25. Content Article
    This short and informative guide, produced by the Quality Care Commission, is for services who may be dealing with challenging behaviour. It includes definitions of the different types of restrictive interventions and directs providers to the evidence they need to provide in order to reassure the regulator that such practice is well governed and safe.
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