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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. 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
  2. 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.
  3. 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.
  4. 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.
  5. 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. 
  6. 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
  7. 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
  8. 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.  
  9. Content Article
    This report was published by the Royal Society for Public Health (RSPH). Key points • Antibiotic resistance is described bythe WHO as a ‘major threat’ • Drug-resistant infections kill 25,000people each year in the EuropeanUnion • Without a global and multi-faceted response, an increasing number of previously treatable infectious diseases will become life-threatening conditions Call to action • Investment in initiatives to promote hand hygiene • Campaigns to increase understanding of the appropriate use of antibiotics • Greater utilisation of the wider public health workforce to support patient compliance with medicines
  10. Content Article
    Lions Clubs Message in a Bottle is a simple but effective way for people to keep their basic personal and medical details where they can be found in an emergency on a standard form and in a common location – the fridge. Message in a Bottle (known within Lions as MIAB) helps emergency services personnel to save valuable time in identifying an individual very quickly and knowing if they have any allergies or take special medication. Find out more about the initiative and how to order a bottle via the link below.
  11. Content Article
    The Professional Standards Regulatory Body are holding a series of webinars in January 2024 designed for professionals working in or with maternity services where they will review the updated Digital Maternity Record Standard. Each session will focus on different aspects of maternity care.  Having access to the right information at the right time helps professionals make decisions for safer, more personalised care and supports people using services to manage their own information. Health and care professionals, organisations that support people during and after pregnancy, IT system suppliers and people who use maternity services are welcome at these sessions. Find out more about the sessions and how to sign up via the link below.
  12. Event
    until
    The Professional Records Standards Body are holding a dedicated webinar on 25 January 2024 for IT system suppliers to explore the updated Digital Maternity Record Standard in more detail. If you are a system supplier, you can find out more about the event and how to register here.
  13. Content Article
    If you’ve recently used maternity services, or if you’re pregnant at the moment, the Professional Records Standards Body (PRSB) would like to invite you to join one of their online workshops in January 2024. Each session will last no longer than 1 hour 30 minutes and you’ll receive a £25 shopping voucher to thank you for your time if you attend. The PRSB are working with the NHS to improve how information about your health is recorded and shared during your pregnancy and after your baby has been born. This could include information about treatment or advice you’ve received, tests and scans you’ve had or decisions you’ve made about your maternity care.   Find out more about the project, and how to book onto a workshop via the link below.
  14. Event
    This event is designed for people working in mental health to come together to reflect on how we can improve the safety of our patients. There will be talks from experts, sharing of good practice and time for discussion with the opportunity to build networks. After attending this course you will: 1. Be aware of some main areas in which patient safety can be improved 2. Understand the importance of safety systems and how they can be used to develop better care 3. Be able to build networks with others who champion patient safety The day will be chaired by Dr Wendy Burn, Consultant Psychiatrist at Leeds and York Partnership NHS Foundation Trust and Past President of the Royal College of Psychiatrists. Keynote speaker is Professor Nav Kapur, Centre for Suicide Prevention at University of Manchester. The event is for clinical staff and is eligible for 6 CPD points subject to peer group approval. Book here
  15. Content Article
    This website is the home for ‘conversation for kindness’, which is a monthly meeting that was set up in the summer of 2020 by a group of colleagues and friends working in healthcare across Sweden, the UK and the USA. The initial purpose of getting together was to have some time together to continue some initial conversations around kindness, and to explore its role at the ‘business end’ of healthcare.
  16. Content Article
    As representatives of the European Patient Safety Foundation, the authors share with the wider patient safety community some current perspectives from across Europe. As the title suggests, in their view, the healthcare systems are dominated by the reality of having to deal with what are seen as multiple crises at the same time, and somehow keep patient safety on the agenda and come up with strategies and initiatives to make improvements. The situation is made even more complex by the fact that these crises take an additional toll on those responsible for delivering safe care, healthcare staff themselves, who already have to cope with difficult working conditions in normal times. This article was published by the Journal of Patient Safety and Risk Management.
  17. Content Article
    This is a guide, published by Shaping Our Lives, to help you get involved with organisations and researchers and share your views to help shape services, research and policy.
  18. Content Article
    Professor Joe McDonald, Principal Associate for health system collaboration for Ethical Healthcare Consulting, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.
  19. Content Article
    Authors of this report conclude that: "...patient-reported experience measures (PREMs) offer great insights into what is happening on the ground. The chances of any intentional/ unintentional bias are minimal as it comes directly from the patients. If appropriately implemented, PREMs can be a great proactive tool to ensure good quality of service rather than depending on near misses or incidents to happen and be reported. PREMs offer a unique opportunity to directly involve the patients in their care as they are essential stakeholders in the quality of care."
  20. Content Article
    Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, authors of this study, published in BMJ Quality and Safety, sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk.
  21. Content Article
    In this blog, Lucy Wilkinson, CQC’s Interim Head of equality, health inequalities and human rights, talks about the fundamental link between human rights and delivering safe, good quality care.
  22. Content Article
    Joanna Lloyd and Hannah Taylor from law form Bevan Brittan, are joined in conversation by Graeme Irvine, Senior Coroner for East London. In this session, Graeme considered how PSIRF may work with the coronial process. Access the video via the link below. 
  23. Content Article
    As part of the Care Quality Commission's (CQC's) commitment to person-centric care, they have worked with the University of Bedfordshire to produce guidance for care home managers and members of the public on the availability and management of alcohol in care homes.   This guidance focuses on both the benefits of having alcohol available to care home residents who want it, as well as how to mitigate potential risks.   The University of Bedfordshire spoke to residents, their family members, care home managers and CQC inspectors, and captured their expectations and requirements on how alcohol is managed in care settings.  
  24. Content Article
    Record numbers of people are waiting for NHS treatments. The numbers have soared in recent years from 4.4 million before the pandemic to 7.8 million today. As winter approaches they look set to increase further still. With a pandemic and industrial action its been a very challenging time for the NHS. Monthly treatments are growing at a faster rate than pre-pandemic levels. But the waiting list is still rising as people come forward having postponed seeking treatment. On this episode of Call You and Yours, the host asks- "how are NHS waiting lists are affecting you and your family?"
  25. Content Article
    The evidence presented in this report makes the undeniable case that people living with a mental health condition and taking medicines need better access to the expertise of pharmacists across the whole spectrum of care.
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