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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    Just Culture got its roots in the airline industry, but according to Dr. Danielle Scheurer, it was tailor-made for health care.
  2. 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.
  3. 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.
  4. 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.
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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. 
  18. Content Article
    This guidance was developed by the Mental Health and Learning Disability Nurse Directors Forum in collaboration with experts by experience and the Care Quality Commission.Four key themes were identified:Co-design evidence-based approach ligature harm reduction planning: Incorporate local expertise through collaborations with staff and experts by experience when reviewing ligature harm risks.Therapeutic environment: Consider the balance of safety versus privacy and dignity when assessing and controlling for potential ligature harm, including the extent to which restrictions may impact on patient recovery.Individualised risk assessment: Focus on individualised approaches to risk assessment rather than tools to predict future suicide risk and treatment. Minimise use of blanket restrictions to manage known risks to aid reduction in institutional dependence.Integration into other aspects of treatment and care planning: Consider the role of other aspects of treatment and support (for example, levels of observations) and how risk assessment should be integrated into care planning and therapeutic risk assessment and co-produced safety planning, where possible.Read the full guidance via the link below.
  19. Content Article
    Two reproductive health conditions common in women, polycystic ovary syndrome and dysmenorrhea, are each associated with increasing cardiovascular disease risk, according to two preliminary studies presented at the American Heart Association’s Scientific Sessions 2023. 
  20. Content Article
    Falsified, potentially harmful Ozempic and Saxenda products have been found in the UK. This drug safety update from the Medicines and Healthcare products Regulatory Agency (MHRA) asks healthcare professionals to remind patients using these products to always obtain prescription medicines from a qualified healthcare provider and not to use products they suspect are falsified as this may lead to serious health consequences. Healthcare professionals must also remain vigilant for symptoms linked to hypoglycaemia in patients who may have obtained a falsified product containing insulin. Read the full update and advice for healthcare professionals and the public via the link below.
  21. Content Article
    This leaflet helps signpost people to support and information about prostate cancer, both nationally and regionally. It has been produced as part of the Overcoming the Barriers to Engaging with Prostate Cancer project led by Orchid, the UK’s leading charity for those affected by male cancer. The regional signposting section covers: Birmingham Bradford Bristol Dudley Leeds Liverpool Manchester Newcastle Nottingham Wolverhampton
  22. Content Article
    Paediatric drug optimization (PADO) exercises aim to identify key priority products and their preferred product characteristics for research and development. These have been successfully undertaken for HIV, hepatitis C, tuberculosis and antibiotics, demonstrating their potential and impact to accelerate access to optimal formulations in the context of fragmented, small markets for medicines for children. WHO convened and facilitated a paediatric exercise for neglected tropical diseases to ensure that more targeted research and development efforts can address the specific needs of infants and children. These are schistosomiasis, human African trypanosomiasis (HAT), scabies, onchocerciasis and visceral leishmaniasis (VL).
  23. Content Article
    Watch this short film about what to do if you experience pain in your testicle/s, by Cardiff Fertility Studies and the British Fertility Society, made in partnership with Orchid. 
  24. Content Article
    In this episode of the British Journal of General Practice podcast, the host talks to Dr Georgia Richards, a Research Fellow in the Centre for Evidence-Based Medicine at the University of Oxford, about her recent study into opioid prescribing. Opioids can also be acquired from outside of NHS services, including private prescribers, over-the-counter (e.g. CoCodamol), and through online healthcare services and pharmacies or the “dark web”. Without exploring non-NHS data, the full picture of opioid use in England cannot be understood. This is one of the first studies that sought to fill this important gap by investigating opioid prescribing in the private sector.
  25. Content Article
    Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of Deep Vein Thrombosis and Pulmonary Embolism in hospital.
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