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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    This guide from NHS England outlines the processes involved in developing safety actions. This includes sections on: agreeing areas for improvement defining safety actions prioritising safety actions defining safety measures writing safety actions monitoring and reviewing.
  2. Content Article
    This living guideline from the World Health Organization (WHO) and published by the BMJ, incorporates new evidence to dynamically update recommendations for covid-19 therapeutics.
  3. Content Article
    Improving Healthcare Safety by Enhancing Healthcare Facility Design is the third in a series of AHRQ publications that summarise the Agency for Healthcare Quality and Research's (AHRQ's) investments in patient safety research as a pathway toward safer care. This research has shown that optimising the physical, functional, and aesthetic details of healthcare facilities (e.g., units, rooms, equipment, logistics and technologies) can improve patient outcomes, reduce injuries and hospital-associated infections, and increase provider satisfaction.
  4. Content Article
    This document provides examples of how the justice system is failing mesh victims and why a Redress Agency is imperative.
  5. Content Article
    In this article, sponsored by DHL Supply Chain, the author argues that to tackle challenges and enable a safety-focused culture, a two-pronged approach is needed – introducing safe processes and promoting accountability.
  6. Content Article
    In this blog by Sling The Mesh, the author reflects on the recent case of a mother left in debilitating pain and faecally incontinent from vaginal mesh being awarded a record settlement of at least £1 million. She highlights that in reality many cases are thrown out before they get to court, some never get off the ground owing to being out of the legal time frame and many more women don’t even attempt a medical negligence claim as the process feels too stressful, triggering PTSD and anxiety.
  7. Content Article
    On 8 November 2023, NHS England wrote to health leaders and staff with a focus on addressing the significant financial challenges created by industrial action in 2023/24, and immediate actions to take. Follow the link below for full details.
  8. Content Article
    In this article, published by Med Page Today, clinical trials are the cornerstone of evidence-based medicine authors argue that: "All trial results - positive, negative, and neutral - must be made publicly available to allow for transparent decision-making by patients, physicians, and regulators. Without complete data, the evidence gets distorted: harms are downplayed, and benefits are overstated."
  9. Content Article
    Just Culture got its roots in the airline industry, but according to Dr. Danielle Scheurer, it was tailor-made for health care.
  10. Content Article
    This is the report, together with formal minutes relating to the report, by the House of Commons Public Accounts Committee looking at Access to urgent and emergency care. It includes a number of conclusions and recommendations relating to: Productivity, accountability and oversight Service performance NHS workforce.
  11. Content Article
    The 2022 LeDeR report seeks to investigate and learn from the avoidable deaths of people with a learning disability in England. The report, which is produced for NHS England, was led by researchers from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London, the University of Central Lancashire, and Kingston University London. Researchers found: gentle but continuous improvement in the median age of death for people with a learning disability in 2022. In 2018, the median age of death for adults with a learning disability was 61.8 years but has since risen to 62.9 in 2022. If children are included, the age at death increased from 60.1 years in 2018 to 62.7 in 2022. a drop in the number of avoidable deaths since 2021 – 42% of deaths were deemed “avoidable” for people with a learning disability in 2022 compared to 50% in 2021. a sharp drop in the number of deaths due to Covid-19 – from 24% of all causes of death in 2020 to 19% in 2021 and 6% in 2022 for adults with a learning disability. "While there are positives, it’s also clear that more work still needs to be done. People from ethnic minority groups died younger, and there is a need to improve access to care pathways to improve prevention and better manage some conditions in people with a learning disability, such as cancer, lung, heart and circulatory conditions. We also identified a concerning effect on excess deaths of people with a learning disability during heatwaves. This means care homes and hospitals looking after people with a learning disability need to be better prepared for weather events in the light of climate change. Improvements during 2022 should certainly be celebrated, but we shouldn’t overlook how much we still don’t know." Professor Andre Strydom, Chief Investigator and Professor in Intellectual Disabilities at King’s IoPPN. Read the full report via the link below.
  12. Content Article
    Good medical practice has been updated. It sets out the standards of patient care and professional behaviour expected of all doctors in the UK, across all specialties, career stages and sectors. These standards will also apply to physician associates and anaesthesia associates in the future, once they’re regulated by the General Medical Council (GMC). It’s important to familiarise yourself with the updated standards before they come into effect on 30 January 2024.
  13. News Article
    Open letter to government from experts and politicians says rising usage ‘is a clear example of over-medicalisation’. Medical experts and politicians have called for the amount of antidepressants being prescribed to people across the UK to be reduced in an open letter to the government. The letter coincides with the launch of the all-party parliamentary group Beyond Pills, which aims to reduce what it calls the UK healthcare system’s over-reliance on prescription medication. Read full story Source: Guardian, 5 December 2023
  14. News Article
    NHS figures obtained by Labour reveal 11,507 women sought care but did not get any last year. Almost 20,000 women a year living with mental health problems triggered by being pregnant or giving birth are being denied support by the NHS, the Guardian can reveal. Furthermore, those who do receive mental health help for their trauma are having to wait up to 19 months to start treatment in some parts of England because specialist services are so overstretched. The situation has been described as “an absolute scandal” and sparked warnings that “rationing” of such vital care could leave women who do not get it in a very vulnerable state and risk their children facing lifelong health problems and stop mothers bonding with their baby. Read full story Source: Guardian, 5 December 2023
  15. News Article
    MPs have backed a move to speed up compensation for victims of the NHS infected blood scandal, delivering the prime minister his first Commons defeat. Ministers will now have to set up a body to run the scheme within three months of a new bill becoming law. The vote was passed by 246 votes to 242 after 22 Conservatives rebelled. The Haemophilia Society said Rishi Sunak "should be ashamed" he had been forced "to do the right thing". Read full story Source: BBC News, 5 December 2023
  16. News Article
    A senior doctor who won a record £3.2m payout says her boss tried to "break" her after she raised concerns about how Covid was being handled. Rosalind Ranson, medical director on the Isle of Man during the pandemic, experienced months of humiliation, an employment tribunal found. Dr Ranson has given BBC News her first interview since the hearing. Read full story Source: BBC News, 5 December 2023
  17. Content Article
    This visual summary (link below) is for healthcare professionals to use together with people who have had a stroke to help start or inform conversations about all aspects of their care, and give them details on what care and support they should expect.
  18. Content Article
    Knowledge about adverse drug events caused by drug–drug interactions (DDI-ADEs) is limited. Authors of this study aimed to provide detailed insights about DDI-ADEs related to three frequent, high-risk potential DDIs (pDDIs) in the critical care setting: pDDIs with international normalised ratio increase (INR+) potential, pDDIs with acute kidney injury (AKI) potential, and pDDIs with QTc prolongation potential. They found that the highly preventable nature and severity of DDI-ADEs, calls for action to optimize ICU patient safety. Use of e-triggers proved to be a promising preselection strategy.
  19. Content Article
    These two Introductory Videos on Non-technical skills for surgeons (NOTSS) were produced by the University of Edinburgh in conjunction with the RCSEd for the ChM in Clinical Ophthalmology programme.  These videos introduce the principles behind the NOTSS system, and although they were made to accompany the ChM in Clinical Ophthalmology, they are suitable for all surgical specialties.
  20. Content Article
    Authors of this study, aim to describe the development of a post-simulation reflective learning conversations model in which a number of contributing factors to achieve clinical reasoning optimization were addressed.
  21. Content Article
    In this blog, Angela Osei, associate director, NICE implementation support, sets out to understand some of the challenges, benefits and considerations of setting up and running a virtual ward, from the perspective of teams on the front lines.
  22. Content Article
    In this report authors make a case for the urgent need to improve communication within the NHS. We demonstrate how fundamental good communication is to the quality of care and  treatment that people receive and the levels of trust and satisfaction they feel. They argue that communication and supporting administration should not be seen as a ‘nice to have’, but as fundamental to the functioning of the NHS. DEMOS delivered this work and this publication with our partners, the Patients Association and the PMA. Calls to action: 1. An expansion of the system of care coordinators and improving access to clinicians with oversight of all the care received by people with complex conditions. 2. An expansion of the system of care navigators in GP surgeries across the country, helping people to navigate complex systems and linking people up with the right services. 3. Improvements to the uptake and use of the NHS App through improved functionality and greater publicity Read the full report via the link below.
  23. Content Article
    The General Medical Council opened its first office in Scotland in 2003. Here Nicola Cotter, Head of GMC Scotland, looks back at the 20 years since, and just a few of her team’s achievements.
  24. Content Article
    This CPD course, run by Health Services Safety Investigation Branch (HSSIB), is aimed at those who lead investigations and other learning responses and those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course meets the minimum training requirement of this specific element of the new PSIRF. This course will begin on Friday 24 November and will close on Friday 24 May 2024. You will only have from the time you enrol to the close date to complete this course. The course includes: An introduction to complex systems, systems thinking and human factors Investigation practice such as interviewing, capturing work as done, use of a systems framework (SEIPS), data synthesis, and report writing Developing effective safety actions and recommendations Engaging and involving those affected by patient safety incidents. HSSIB courses are currently available free of charge to NHS staff in England, with a focus on those with patient safety and investigation roles.
  25. Content Article
    Orchid is the UK’s leading charity for those affected by male cancer. In this interview, we speak to Ali Orhan, Chief Executive and Director of their Overcoming the Barriers to Engaging with Prostate Cancer project.  Ali tells us how they are working alongside a network of volunteer community champions to improve awareness, support better outcomes and reduce health inequalities. 
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