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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    A survey, carried out by The Aortic Dissection Charitable Trust, assessed how Acute Aortic Syndrome is managed across NHS trusts in Great Britain, revealing some significant areas for improvement. The survey showed that the majority of NHS trusts have established policies for managing patients with chest pain, a common symptom of AAS. This demonstrates a good degree of preparedness in identifying and treating cardiovascular issues. However, the survey also found that only about half of the trusts have dedicated teaching on AAS for emergency department staff. Furthermore, there’s a lack of uniform policy for the recognition and treatment of AAS specifically. This absence of standardised guidelines and insufficient educational focus could lead to delays in diagnosis and treatment, potentially affecting patient outcomes. Find out more via the link below.
  2. Content Article
    The Care Quality Commission's new assessment framework will apply to providers, local authorities and integrated care systems. Their ratings and key questions will stay central to their approach. They will continue to use: 5 key questions (safe, effective, caring, responsive and well-led) 4-point ratings scale (outstanding, good, requires improvement and inadequate).
  3. Content Article
    The Care Quality Commission (CQC) have published the findings of their five local authority pilot assessments. Assessing how local authorities meet their duties under Part 1 of the Care Act (2014) is a new responsibility for CQC. During the pilots, the CQC looked at nine of their quality statements to assess how well each local authority is meeting its responsibilities. This enabled them to give an indicative rating. Birmingham City Council – indicative rating of good Lincolnshire County Council – indicative rating of good North Lincolnshire Council – indicative rating of good Nottingham City Council – indicative rating of requires improvement Suffolk County Council – indicative rating of good.
  4. Content Article
    This pragmatic and modular tool is user friendly, flexible, easy to navigate, and adaptable to the needs of countries. It can be used to calculate and visualise detailed costs for prioritised activities included in the NAPs on AMR. Taking into account the different country contexts, the tool can be filled using a modular approach which allows different sectors, ministries or event departments to fill in the tool independently and these plans can then be consolidated into one national costed plan.
  5. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. To mark Men's Health Awareness Month, we are sharing 10 resources relating to men's health, including information about male cancers, how to engage men earlier and insights around the impact of traditional ideas of masculinity on patient safety.
  6. News Article
    Three patients died after delayed transfers from a private hospital within a nine-month period, coroner’s findings reveal. Three prevention of future deaths reports reviewed by HSJ raised concerns about the deaths of patients whose transfer from Spire’s Norwich facility to the NHS hospital in the same city was delayed. The sites, which are one mile apart, are run by £1bn-turnover private company Spire Healthcare and Norfolk and Norwich University Hospitals Foundation Trust respectively. Read full story Source: HSJ, 15 November 2023 Prevention of Future Deaths reports: Geoffrey Hoad (13 September 2023) Prevention of Future Deaths report: Christina Ruse (3 October 2022) Prevention of Future Deaths report: Barbara Hollis (3 October 2022)
  7. Content Article
    Research fellow, Lavanya Thana, talks to Patient Safety Learning about her latest project, looking at experiences of healthcare-related harm in the NHS. Lavanya explains why this research is so important, how people can register to take part and her hopes for how the findings might help improve safety for patients from minority backgrounds.
  8. Content Article
    On Nov 7 2023, NHS Resolution’s Safety and Learning team, hosted a virtual forum on learning from venous thromboembolism (VTE) claims in primary care. The purpose was to raise awareness of the cost and scale of harm, discuss the challenges and recommendations around recognition and treatment of VTE in general practice. We heard from a range of experts in the field with experience in developing and spreading best practice.
  9. News Article
    Large numbers of midwives report being left feeling undervalued and afraid to speak up due to bullying and widespread staffing shortages, which some say is putting mothers’ and babies’ lives at risk, according to a new publication shared with HSJ. The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online. The report said: “Midwives have described their experiences of toxic cultures within their workplaces, with cliques, preferential treatment, unfounded allegations and poor working conditions leading to a negative impact on their health and wellbeing, including suicide attempts and midwives leaving their job or profession. Read full story Source: HSJ, 13 November 2023 Order a copy of the report
  10. Content Article
    *Trigger warning: This report contains accounts of bullying behaviours and consequences and may trigger those who have experiences of bullying. The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online. In the numerous accounts shared all areas of the system from CQC, CEO, HR, midwifery management, universities and the unions are described as being complicit, inadequate, disinterested and even corrupt. Accounts also refer to: Unsafe work environments Exit interviews not being performed, recorded or acted upon Staff not being valued Whistle-blowers being demonised until they leave Health and safety issues and truly evidence-based practice ignored with no lessons learned. To order your copy, follow the link below.
  11. Content Article
    Orchid is the UK’s leading charity for those affected by male cancer. Since 1996, Orchid has been working to save men’s lives from testicular, penile and prostate cancer through a range of support services, education and awareness campaigns and a world-class research programme. Visit the website via the link below to find out more.
  12. Event
    In commemoration of World Diabetes Day 2023, the WHO Regional Office for the Eastern Mediterranean is organizing a thought-provoking and informative 3-hour webinar under the theme "Access to diabetes medicines and care: using WHO packages as enablers". The meeting intends to serve as a platform for information exchange between Member States, WHO country offices, the WHO Regional Office for the Eastern Mediterranean, HQ, and experts. 10am-1pm GMT. Register here
  13. Content Article
    In this article, published by Psychology Today, Eva Krockow looks at research questioning the notion that we can run out of willpower. Key points:Decision fatigue describes a depletion of choice quality with repeated decision-making.Previous studies suggested people make poorer choices late in the day, possibly affecting healthcare outcomes.Recent findings question the existence of decision fatigue and suggest a self-fulfilling prophecy.Read the full article via the link below.
  14. Content Article
    Steven Shorrock begins this editorial, published by Hindsight, by explaining what he means by work-as-judged: "We all have a habit that we are hardly even aware of; we judge others’ work performance, every day, throughout the day. Whether it’s the work of people in other organisations, in other parts of our organisation, in our own immediate work environment, when driving home, or at home, we evaluate, appraise and judge others’ performance. We don’t pay much attention to how we judge, but we ask ourselves all sorts of questions: “Did they do a good job?” “Did they work with due care and attention?” “Would I have done that?” I call this ‘work-as-judged’,and it has several characteristics that we should bear in mind." Read the full article via the link below.
  15. Content Article
    The 6 Cs are a set of values required by all patient-facing health and social care staff. This includes not only registered healthcare professionals, but also clinical support staff and non-clinical staff who may come into contact with patients or members of the public. 
  16. Content Article
    This report makes several recommendations to unlock the preventative potential of Prevention of Future Deaths (PFD) Reports. These reports should be viewed as an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs. PFD reports have an integral function in ensuring compliance with the state’s duties under Article 2 of the European Convention of Human Rights (ECHR), the right to life, both locally and nationally. This, as well as their immense importance to bereaved families, must be borne firmly in mind.
  17. Content Article
    This report published by the 99% Organisation, takes a non-partisan, citizen-focussed, data-driven, and strategic view and asks: "...is there evidence that changing the fundamental business model of the NHS – e.g. introducing insurance-based funding or breaking the NHS up into smaller units which can be privatised – could be effective as ways of tackling the current issues?"
  18. Content Article
    Reducing inequalities in maternal health care in England is an important policy aim. One part of achieving that is to ensure that women from Black, Asian and minority ethnic communities, as well as women from the most deprived areas, see the same midwife or midwifery team throughout their pregnancy and postnatal period. Emma Dodsworth takes a closer look at the data to reveal what progress is being made on this.
  19. Content Article
    The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. Authors conducted a prospective intervention study of children with medical complexity discharged at a children’s hospital from April 2018 to March 2020. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalisations, and emergency department visits were all reduced following implementation of the I-PASS bundle.
  20. Content Article
    Medical Protection have brought experienced medical educators, medicolegal consultants and world leading experts together to help inform, protect and connect doctors from across the globe. This channel offers three distinct series; Real World focuses on the challenges and solutions to modern day practice, Headliners ensures you are kept up-to-date, and Case files lets us learn through real life cases.
  21. Content Article
    This report published by the National Confidential Enquiry into Patient Outcome and Death, is a review of the care provided to patients aged 16 and over with a diagnosis of, and who underwent surgery for, Crohn’s disease. In summary, the report says that surgery for patients with drug resistant Crohn’s disease surgery should be considered earlier in the treatment pathway for patients, instead of surgery being perceived as a failure of medical care. Once a decision to perform surgery has been made it should be undertaken within a month to prevent patients on elective waiting lists deteriorating and requiring emergency surgery. Furthermore, closer working between all members of the multidisciplinary team would benefit patients, to reduce delays as well as providing all the holistic care that patients with Crohn’s disease need. Read the full list of recommendations and the report via the link below.
  22. Content Article
    This report investigates just what is happening on the ground in relation to listening to patients, collecting feedback about their experience of services and putting the intelligence that is gathered from different approaches to use. Based on interviews with patient experience managers and others in NHS trusts closely associated with the work of collecting, analysing and using data from patients, it provides answers to questions about: Who is doing this work? What kind of training and preparation do they have for the tasks? Who supports them? Where do they fit in their organisation? To whom do they report? And how do they feel about their roles?
  23. Content Article
    In this issue of Psychological Safety, Tom Geraghty, shares some stories of “bad” management that newsletter readers have shared with him, so we can all learn from them. A selection of the stories, chosen because they highlight key themes. Geraghty highlights the importance of self reflection and learning from our own mistakes in order to improve. Also noting that when we share our mistakes and what we’ve learned from them, the potential for learning extends beyond ourselves to everyone around us.
  24. Content Article
    Working in partnership to improve patients' experiences of outpatients was chaired by Sarah Tilsed, Head of Patient Partnership at the Patients Association. Joining her were: Dr Fiona McKevitt, Clinical Director for Outpatient Recovery and Transformation, NHS England Dr Theresa Barnes, Clinical Lead for Outpatients, Royal College of Physicians Irene Poku, Representative Patient and Public Involvement and Engagement with experience of using outpatient services. In a wide ranging discussion, the panel talk about collaboration, equity of access and group consultations.  This webinar was part of Patient Partnership Week 2023. 
  25. Content Article
    In this interview we talk to Trainee Clinical Psychologist, Sabrina Pilav, about her latest research project exploring negative experiences of coil/ intrauterine device (IUD) procedures. Sabrina explains how their in-depth qualitative methodology could contribute to improvements in the future and shares details of how people can participate.
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