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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. 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. 
  2. 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.
  3. 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.
  4. Content Article
    In this HSJ Expert Briefing, Ben Clover explores the impact of the Junior Doctor strikes and the related issues affecting staff.
  5. 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?
  6. 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.
  7. 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.
  8. 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.
  9. Content Article
    Drawing upon the findings of a PhD that captured the experiences of midwives who proactively supported alternative physiological births while working in the National Health Service, their practice was conceptualised as ‘skilled heartfelt practice’. Skilled heartfelt practice denotes the interrelationship between midwives’ attitudes and beliefs in support of women’s choices, their values of cultivating meaningful relationships, and their expert practical clinical skills. It is these qualities combined that give rise to what is called ‘full-scope midwifery’ as defined by the Lancet Midwifery Series. This book illuminates why and how these midwives facilitated safe, relational care. Using a combination of emotional intelligence skills and clinical expertise while centring women’s bodily autonomy, they ensured safe care was provided within a holistic framework. 
  10. Community Post
    Thank you @Darren for sharing your knowledge.
  11. Content Article
    Nurses are at the forefront of health and social care delivery. Often they are also leading, championing and driving change for patient safety. In this edition of our ‘Top picks’ series we celebrate some of the amazing work nurses are doing to prevent avoidable harm and improve patient and staff experience. The examples below include blogs, interviews and practical improvement projects. They have been shared with us by members of the hub, a global community of people passionate about patient safety. You can sign up to the hub here, it’s free and easy to do. 
  12. Content Article
    The role of the board is critical in ensuring that high quality patient outcomes are first and foremost in an organisation’s culture. Health care organisations should capitalise on the expertise of their board, applying their knowledge to guide improvement in organisational performance. For board members to be effective, they need the knowledge, information and guidance on board processes that support quality and safety. By providing resources and education on best practice processes, boards can successfully impact efforts to improve quality and patient safety across the world.
  13. Content Article
    Can anti-bias training help to reduce inequities in health care? A range of stakeholders share their recommendations for how implicit bias training could improve Black maternity outcomes.
  14. Community Post
    Thank you @Darren for sharing yours and your daughters experience and insights. And for highlighting the wide ranging impact on people when they do not get their medication. Your perspective is of enormous value to this conversation. In your role as a pharmacist, do you get told the reasons for supply issues? Are there some common themes? Do you have any changes you would make to help the system run more smoothly and reduce supply issues?
  15. Content Article
    Regardless of a proliferation of interest in reducing unsafe practices in healthcare, threats to patient safety (PS) remain high. Moreover, little attention has been paid towards the role of interprofessional education (IPE) in enhancing PS. This qualitative study was conducted to unfold the insights of the senior medical, dental and health sciences students at the University of Sharjah (UoS) in the United Arab Emirates (UAE) about PS in an online IPE-based workshop.
  16. Content Article
    Joint Commission Resources (JCR) has created the Board Education Resource Center: a collection of complimentary resources to give boards and executive teams the vital support and education they need to best serve their organisations and communities.
  17. Content Article
    The leadership and management functions of Patient Safety Incident Response Framework (PSIRF) oversight are wider and more multifaceted compared to previous response approaches. When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”. To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations). Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control. 
  18. Content Article Comment
    @Fiona Barnard hopefully the below link works for you: appendix-5-risk-assessment-approach.docx (live.com)
  19. Content Article Comment
    Hi @Fiona Barnard thank you for flagging the broken link to us. It looks like the URL for the NHS risk assessment approach has changed. I will take a look into this so we can edit the attached document and share the updated link with you.
  20. Community Post
    Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? Was there an impact on your health (physical and mental)? Were you told the reason for it not being available? Was the issue resolved? If so, how long did it take? If you are still impacted by medication supply issues, have you been told when you will be able to access them again? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in the comments below. You'll need to register with the hub first, its free and easy to do. We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes? Please comment below or email us at content@pslhub.org
  21. Content Article
    Patients for safer nuclear medicine (PSNM) is a coalition of patient advocacy groups and corporate partners demanding that patients get the information they need about extravasations so their diseases are accurately diagnosed and treated. Pam Kohl is a metastatic breast cancer patient whose length of life depends on the accuracy of her nuclear scans. During a recent scan, she was extravasated. “I felt something burn,” she says. “I really felt something wasn’t right.” Watch Pam's story and find out more about PSNM.
  22. Content Article
    This report is divided into two sections. The first section is contextual and reviews literature, both national and international, that provides insights into the experiences of Black and Ethnic Minority (referred to in this report as BME) and internationally recruited nurse (IRNs). The second section focuses specifically on the literature related to health and social care regulatory bodies within the UK, and the reporting of professionals in relation to fitness to practise.
  23. News Article
    Thousands of Australian women who had previously feared uncomfortable Pap smears and speculum examinations have now had cervical screening tests for the first time because of a new option to take their own swab in private. The federal government expanded eligibility for a new self-collected cervical screening test in July 2022, resulting in a 25-fold increase in people doing their own tests. In the past, some people have avoided a potentially life-saving cervical screening test with a doctor because they had suffered sexual violence or trauma, had cultural objections, or had a bad experience with a test in the past. Read full story Source: The Sydney Morning Herald
  24. Content Article
    This is a video presentation from the Royal College of Surgeons in Ireland, looking at facilitation skills for after action reviews (AAR) and the wider process.
  25. Content Article
    Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anaesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, authors performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures.  The authors conclude: "Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure."
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