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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    Dr Georgia Richards provides oral evidence to the UK Parliamentary Justice Select Committee's follow-up inquiry to the Coroner Service on 20 February 2024. Watch all of the evidence given by Georgia including: Part 1: Inconsistencies in coroner reports Part 2: Could sanctions improve the Coroner Service? Part 3: Improving the status and ability of coroner reports Part 4: Barriers to making changes Part 5: The potential future utility of the Tracker In part 1, shown in the below video, Dr Richards is asked what the evidence is for variation in writing coroner reports in England and Wales.
  2. Content Article
    Safety leader Helen Macfie describes why she appreciates that Safer Together: A National Action Plan to Advance Patient Safety includes workforce safety as one of its foundational areas.
  3. Content Article Comment
    Hi @Sue Deakin, thank you for sharing these experiences. They reinforce the need for electronic systems to be safe and for changes to services, like the ceasing of funding, to be communicated to key stakeholders. These communication failures can contribute to a loss of faith in the NHS, as Miriam says in her blog. In your experience, what do you think would make a difference to patient safety when it comes to improving communications?
  4. Content Article
    Demos is Britain's leading cross-party think tank, working on different policy areas, from improving public services to building a more collaborative democracy. In this blog, Miriam Levin, Director of Participatory Programmes at Demos, tells us about their recent report, “I love the NHS but…”: Preventing needless harms caused by poor communication in the NHS. She argues there is an urgent need to improve NHS communications for patients and staff if we are to prevent people falling through the gaps and suffering worse health outcomes. Miriam highlights key issues with NHS referrals, disjointed computer systems and gaps in patient information, and offers some potential solutions. 
  5. Content Article
    Despite its reported benefits, breastfeeding rates are low globally, and support systems such as the Baby Friendly Initiative (BFI) have been established to support healthy infant feeding practices and infant bonding. Increasingly reviews are being undertaken to assess the overall impact of BFI accreditation. A systematic synthesis of current reviews has therefore been carried out to examine the state of literature on the effects of BFI accreditation. 
  6. News Article
    A coroner has issued a warning over a hospital’s new computer system after the death of a 31-year-old woman. Emily Harkleroad collapsed on 18 December 2022 and was taken to the University Hospital of North Durham, where she died the next morning from a pulmonary embolism – a clot on the lung. The assistant coroner for County Durham and Darlington concluded, on balance, that Ms Harkleroad’s death could have been prevented, external. She also noted computer system concerns had been raised by a number of clinicians. Read full story Source: BBC News, 24 February 2024
  7. Content Article
    Although several studies have tried to quantify the cost of ‘adverse events’ in healthcare, the true costs remain unknown. To understand the ‘true cost’ of serious incidents, Jane Carthey argues we need to consider:The cost of additional treatment for the affected patient.The opportunity costs that accrue from reporting and managing incidents, claims and complaintsBusiness costs that accrue when, for example, healthcare staff are suspended.Costs resulting from implementing the duty of candour process, andPenalties and sanctions imposedIn other industries, the HSE’s Incident Cost Calculator is used to quantify the true costs of incidents. Inspired by this tool, Jane developed the Healthcare Serious Incident Cost Calculator. Available via the link below.
  8. Content Article
    This video, was produced by Long Covid Support to show why effective Long Covid research is urgently needed.
  9. Content Article
    North Central London Integrated Care System has piloted new guidelines and a local dashboard to ensure there is a safety net in place for females taking sodium valproate.This is a paywalled article published by the Pharmaceutical Journal.
  10. Event
    until
    NHS Resolution’s Safety and Learning team, are hosting a virtual forum on the recently published research conducted by Dr Rebecca Payne and Professor Greenhalgh into the safety of remote consultations. The purpose is to raise awareness of the research evidence from incidents, claims and complaints which inform the findings and recommendations on patient safety in remote consultations. This will be of interest to all involved in telephone consultations across primary and urgent care but also of relevance to telephone consultations taking place in secondary care. The format is interactive, with presentations followed by questions and panel discussion Event programme: Patient safety in remote encounters in primary care Q&A panel discussion Contributors: • Dr Rebecca Payne - NIHR in-practice fellow, General practictioner | University of Oxford and Chair | NICE Quality Standards Committee • Prof Trisha Greenhalgh - Professor of Primary Health Care | University of Oxford • Dr Anwar Khan - Senior Clinical Advisor for General Practice | NHS Resolution Book your place
  11. News Article
    Covid vaccines have been linked to small increases in heart, blood, and neurological disorders, according to the largest global study of its kind. An international coalition of vaccine experts looked for 13 medical conditions among 99 million vaccine recipients across eight countries in order to identify higher rates of those conditions after receiving the shots. They confirmed that the shots made by Pfizer, Moderna, and AstraZeneca are linked to significantly higher risk of five medical conditions - including a nerve-wasting condition that leaves people struggling to walk or think. Read full story Source: Daily Mail, 19 February 2024
  12. News Article
    An inquest into the death of a baby has been adjourned after a whistleblower claimed hospital inspectors ignored safety concerns about a NHS trust. Ian Kemp has raised concerns the University Hospitals of Morecambe Bay NHS Trust was "covering up" the death. The former health watchdog inspector said he had been asked to investigate maternity care at the trust in December 2019 after the death of Ida Lock. Read full story Source: BBC News, 19 February 2024
  13. News Article
    The Liverpool Care Pathway (LCP) was abolished in every hospital and hospice in the country just under a decade ago. This end-of-life-care protocol was scrapped by the Government as a “national disgrace”, in the words of Norman Lamb, then Care Services Minister, after a review by Baroness Neuberger found widespread failings and abuses. But troubling evidence since the scrapping suggests that the practises established under the LCP are in fact still continuing today in the UK’s National Health Service (NHS). Read full story Source: Catholic Herald, 18 February 2024
  14. News Article
    Another inquiry has been launched into the sudden death of a second teenage girl in the Accident and Emergency department of University Hospital Limerick three weeks ago. The 16-year-old girl died suddenly on January 29, hours after she was rushed to UHL suffering from breathing difficulties. The girl, a much-loved only child, died in front of her mother in what an informed source described as “deeply traumatic circumstances”. It is the latest tragedy under review at UHL following the death of Aoife Johnston (16) from Shannon, Co Clare, Read full story Source: Irish Independent, 20 February 2024
  15. Content Article
    Intravenous therapy is an essential aspect of modern healthcare. While the benefits of using intravenous therapy usually outweigh the risks, occasionally the administration of IV therapies can go wrong. Infiltration and extravasation is a complication whereby the drug or IV therapy leaks into the tissues surrounding the vascular access device. This toolkit, developed by the National Infusion and Vascular Access Society (NIVAS), is intended to enable local services and healthcare organisations to implement polices, protocols and guidelines that will increase awareness about non-chemotherapy extravasations.
  16. Content Article
    This BMJ article summarises a selection of new and updated recommendations within The National Institute for Health and Care Excellence (NICE) guidelines on intrapartum care for healthy women and babies.
  17. Community Post
    Thank you @Lisa Riste for sharing your experience and the related safety risks of patients not being able to access their full prescriptions. Patient insights like yours will help to build a picture of the range of issues faced, and the impact these can have on individuals physical health and mental health.
  18. Content Article
    In this long-read article, Abbie Mason-Woods talks about her experience of having a high-risk pregnancy, pre-term birth and two baby girls in a Neonatal Intensive Care Unit (NICU). Abbie shares her deep insights as a patient and parent, highlighting the importance of trauma-informed, person-centred care throughout the care pathway, and the risk in forgetting the mother. 
  19. Content Article
    In this multi-centre randomised clinical vignette survey study, published in JAMA, diagnostic accuracy significantly increased by 4.4% when clinicians reviewed a patient clinical vignette with standard AI model predictions and model explanations compared with baseline accuracy. However, accuracy significantly decreased by 11.3% when clinicians were shown systematically biased AI model predictions and model explanations did not mitigate the negative effects of such predictions.
  20. Content Article
    This white paper presents a framework for health care organizations to improve health equity in the communities they serve, guidance for measuring health equity, a case study, and a self-assessment tool.
  21. Content Article
    In this HSJ Expert Briefing, Ben Clover explores the impact of the Junior Doctor strikes and the related issues affecting staff.
  22. Community Post
    Hi @Kellie Wilden, thank you for sharing your experience. The issues you raise regarding availability of medication and the associated challenges of changing brand are really interesting, and very frustrating for patients who need their medication. Thank you also for highlighting that this was via a private route too as it helps us to understand the wider picture and all of it's complexities. Have you been given any reason for the medication not being available or indication of when it would be?
  23. Content Article
    With two notable exceptions, the common law does not recognise one person as having any legally compensable interest in the physical well-being of another. The law compensates the victim but not others who suffer harm as a result of the victim’s injuries or death, however severely impacted and whether the harm is psychological, physical or financial. The exceptions are found in the Fatal Accidents Act 1976 and in claims by secondary victims. It was this latter category that came to be examined in the much anticipated judgment of the Supreme Court in the conjoined appeals of Paul and another (Appellants) v Royal Wolverhampton NHS Trust (Respondent), Polmear and another (Appellants) v Royal Cornwall Hospitals NHS Trust (Respondent) and Purchase (Appellant) v Ahmed (Respondent). This article from Bevan Brittan, explores this in greater depth.
  24. Content Article
    Authors of this editorial, published in BMJ Quality and Safety, conclude by stating that while the use of classification to identify patients who have additional needs and/or are at increased risk of harm has potential benefits, care needs to be taken to avoid possible harm and unintended consequences. They highlight several actions that would help ensure the benefits of classification are maximised, but note that none of these are necessarily easy to achieve in practice, especially in the context of overwhelmed and under-resourced health services. However, ensuring that patients with additional needs and/or risks have these appropriately identified and responded to while receiving healthcare must be a priority. The need for healthcare to be equitable, that is, not vary in quality because of a patient’s personal characteristics, is recognised as an important quality dimension, and this issue has received increased attention in recent years. If used well, classification can be part of the move to ensuring more equitable care for those with additional needs.
  25. Content Article
    Prolonged stays in hospital can be bad for patients. Individuals who have longer hospital stays are at greater risk of falling and catching infections. Their physical and mental capabilities, including mobility, physical strength and awareness levels, may also be negatively impacted.  Increases in length of stay can also affect patients waiting for elective and emergency care. The NHS has limited ability to increase hospital capacity. Therefore, longer stays mean fewer patients can be admitted. This analysis from The Health Foundation, suggests that, despite accounting for just 9% of hospital admissions, COVID-19 is likely a key driver of the increase in length of stay. This suggests that whilst the impact of COVID-19 on hospital capacity was less severe in 2022 than during the peak of the pandemic throughout 2020 and 2021, it was still significant. As the government and the NHS in England look to recover waiting times, reduce the backlog and improve productivity, it is important to recognise the ongoing challenges posed by the virus.
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