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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. 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. 
  2. Community Post
    Thank you @Darren for sharing your knowledge.
  3. 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. 
  4. 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.
  5. 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.
  6. 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?
  7. 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.
  8. 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.
  9. 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. 
  10. Content Article Comment
    @Fiona Barnard hopefully the below link works for you: appendix-5-risk-assessment-approach.docx (live.com)
  11. 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.
  12. 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
  13. 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.
  14. 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.
  15. 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
  16. 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.
  17. 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."
  18. Content Article
    This is the first edition of this guidance, published by the Royal College of Obstetricians and Gynaecologists. It highlights the challenges in maternity triage departments* and defines their role as emergency portals into maternity units. It has been produced in response to a UK Government and Parliament petition in 2021, which requested a national review of triage procedures used by NHS maternity wards, and proposed to mandate the implementation of a standardised risk assessment-based system for maternity triage; assessing every woman within 15 minutes and prioritising care based on urgency. The paper is aimed at stakeholders responsible for developing and improving maternity services. It presents the recommendations for the operational structure and pathways within maternity triage to improve safety and experience for both women and staff, by recommending implementation of the Birmingham Symptom-specific Obstetric Triage System (BSOTS), while recognising opportunities for future research and evaluation
  19. Content Article
    This 'Element' from Cambridge Core, reviews the evidence for three workplace conditions that matter for improving quality and safety in healthcare: staffing; psychological safety, teamwork, and speaking up; and staff health and well-being at work. The authors propose that these are environmental prerequisites for improvement. They examine the relationship between staff numbers and skills in delivering care and the attainment of quality of care and the ability to improve it. They present evidence for the importance of psychological safety, teamwork, and speaking up, noting that these are interrelated and critical for healthcare improvement. They present evidence of associations between staff well-being at work and patient outcomes. Finally, they suggest healthcare improvement should be embedded into the day-to-day work of frontline staff; adequate time and resources must be provided, with quality as the mainstay of professionals' work. Every day at every level, the working context must support the question 'how could we do this better?' This title is also available as Open Access on Cambridge Core.
  20. Content Article
    Lessons from service and system failures describe the pivotal roles played by governance and leadership in delivering high-quality, safe care. This 'Element' publication from Cambridge Core, sets out what the terms governance and leadership mean and how thinking about them has developed over time. Using real-world examples, the authors analyse research evidence on the influence of governance and leadership on quality and safety in healthcare at different levels in the health system: macro level (what national health systems do), meso level (what organisations do), and micro level (what teams and individuals do). The authors describe behaviours that may help boards focus on improving quality and show how different leadership approaches may contribute to delivering major system change. The Element presents some critiques of governance and leadership, including some challenges that can arise and gaps in the evidence, and then draws out lessons for those seeking to strengthen governance and leadership for improvement. This title is also available as Open Access on Cambridge Core.
  21. Content Article
    The Health Services Safety Investigations Body (HSSIB) was established by the Health and Care Act 2022 as a new non-departmental arm's length body, replacing the former Healthcare Safety Investigation Branch. HSSIB exists to help reduce patient harm by understanding the complex interactions that exist within healthcare that may lead to patient safety events occurring. In other safety critical industries, a safety management system (SMS) approach is used to help enable proactive assessments of risks, specification of how risks should be managed, and set clear lines of accountability and responsibility in addressing risks. This research paper published in the Journal of Patient Safety and Risk Management, shows how HSSIB has begun to explore how an SMS may operate in healthcare to help better equip the system to identify, respond, and proactively identify emerging and recurring concerns that may impact on the safety of patients.
  22. Content Article
    In this blog, Sexual and Reproductive Health Consultant, Neda Taghinejadi tells us about the coil fitting service she is part of in Oxfordshire. Neda explains how the service has integrated a number of tools, including a triage system to identify more complex cases, to help support a safe and quality service. 
  23. News Article
    More than 1 million people in England died prematurely in the decade after 2011 owing to a combination of poverty, austerity and Covid, according to “shocking” new research by one of the UK’s leading public health experts. The figures are revealed in a study by the Institute of Health Equity at University College London led by Sir Michael Marmot. They demonstrate the extent to which stark economic and social inequalities are leading to poorer people dying early from cancer, heart problems and other diseases. Using Office for National Statistics figures, the report’s author Prof Peter Goldblatt looked at the life expectancy of people across England who do not live in the wealthiest 10% of areas. The report, titled Health Inequalities, Lives Cut Short, found that between 2011 and 2019, 1,062,334 people died earlier than they would have done if they lived in areas where the richest 10% of the population reside. A further 151,615 premature deaths were recorded in 2020, although this number was higher than expected because of the coronavirus pandemic. Read full story Source: Guardian, 8 January 2024
  24. News Article
    Portable X-ray machines "can literally be the difference between life and death", says radiographer Sam Pilkington. For most of us, if we need to be X-rayed the procedure is done in a hospital. But for acutely unwell patients, or for infection control, Ms Pilkington says that portable machines are very helpful. This is because "they remove the excess burden of transportation from the patients", says the final-year student at the University of the West of England in Bristol, who is also a member of the Institute of Physics. Instead the X-ray equipment goes to them. There are obvious advantages for remote locations, including battlefields, roadsides and disaster zones. Read full story Source: BBC News, 8 January 2024
  25. Content Article
    The Public Interest Disclosure Act 1998 came into force on 2 July 1999. The Act protects workers who disclose information about malpractice at their workplace, or former workplace, provided certain conditions are met. The conditions concern the nature of the information disclosed and the person to whom it is disclosed. If these conditions are met, the Act protects the worker from suffering detriment or dismissal due to having made the disclosure. If the conditions are not met a disclosure may constitute a breach of the worker’s duty of confidence to his employer. This legal framework has received some criticism in recent years for failing to protect some whistleblowers and there have been a number of calls for reform. This research briefing produced by the House of Commons Library, titled Whistleblowing and gagging clauses, includes: Summary Background The duty of confidentiality The legal framework Evolution of the law Proposals for reform of whistleblowing law Whistleblowing in the NHS Gagging clauses Support and advice.  
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