PatientSafetyLearning Team

In this blog, retired Occupational Health Doctor, Clare Rayner draws on personal experience to illustrate the impact delayed surgery can have on a patient.

"The young girl is now unable to walk and there is a very real possibility that lengthy delays to her surgery will continue to lead to progressive disability."

A child left waiting for ‘urgent’ surgery, a blog by Clare Rayner

Friday 17 September 2021 will mark the third annual World Patient Safety Day.

The theme of this year’s event is ‘Safe maternal and newborn care’. Its objectives are to raise awareness of maternity safety issues, engage stakeholders to take action to improve maternal and newborn safety and advocate for the adoption of good practice to prevent avoidable risks and harm

Do you have an experience to share around maternity safety, as a pregnant woman or birthing person? Or perhaps you are a healthcare professional looking to share your frontline insights to help improve patient safety?

Please share your stories and experiences with us by commenting in the conversation below.*

*You’ll need to be a hub member to comment, it’s quick and easy to do. You can sign up here.

Earlier this month we published a blog looking at some of the key patient safety issues faced by the healthcare system in tackling the care and treatment backlog created by the Covid-19 pandemic. We provided some examples of how this is impacting on the treatment of people with various health conditions, such as cancer, cardiovascular disease, and chronic health conditions.

We’re now asking for patients, carers, family members and friends to share their stories and experiences of this with us by commenting in the conversation below.* We’re looking for people to share with us:

• Experiences of care and treatment being impacted by the backlog and the consequences of this.
• Advice/guidance that has been given to manage any health concerns relating to delays in treatment.
• Advice/guidance that has been given on how to escalate concerns and how to keep healthcare professionals informed of changing health conditions.
• What more you think could be done to improve the experience for patients affected by the backlog.

Your insight will help inform our work in this area.

*You’ll need to be a hub member to comment, it’s quick and easy to do. You can sign up here.

Student midwife Deepa Santosh recently wrote to the Royal College of Midwives highlighting concerns that many midwives were not able to access water regularly while on shifts. 

She has kindly shared her letter (attached), and the below poster, which can be used by others to highlight the importance of staying hydrated and the potential harm that dehydration can cause to both staff and patient care. 

Have you struggled with similar issues where you work? Or do you have processes and policies in place that ensure you never have to go without water? Share your experiences, by commenting below. 

To comment you'll need to sign up to the hub, it's free and easy to do. 

RCM letter.pdf

Did you know that one in 20 patients who undergo a surgical procedure in the NHS contract an surgical site infection and 60% of these are preventable? 

If you've had an infection during or after surgery, how did it affect you? 

Understanding patient experience is key to improving safety in this area, so please share your thoughts in the comments below or get in touch with us directly at hello@patientsafetylearning.org 

You'll need to sign up to the hub to comment, it's free and easy to do. 

*Trigger warning. This post includes personal gynaecological experiences of a traumatic nature.

Have you had a contraceptive device fitted (also known as an IUD or coil)?

What was your experience like?

Perhaps you are a healthcare professional who can share your clinical insight?

Today (21 June), we've published an interview with Lucy Cohen who experienced high levels of pain and is now calling for better consent processes and pain management for women. 

Please share your thoughts on the interview below. You'll need to sign up to the hub to comment, it's free and easy to do. 

More than a million people in the UK are now living with prolonged symptoms of Covid-19, also referred to as Long Covid. In this blog (see link below), Patient Safety Learning have identified 4 key areas where better information around Long Covid could help to improve care and outcomes. 

Long Covid: Information gaps and the safety implications

Are you living with Long Covid? Or perhaps you’re a healthcare professional supporting those who are struggling to recover?

We want to know:

• What did you think of the points raised in the blog?
• What is your experience of accessing or delivering Long Covid services?
• What’s working well?
• What are the main challenges and barriers?
• What more needs to happen to support healthcare professionals and patients?

Your perspectives are integral to developing this conversation, so please do share your insights by commenting below. You’ll need to sign up to the hub (its free and easy to do). 

Hi @Val Noble, we'd love to hear more about this work, to share your learning through a blog perhaps for the hub? Are you able to share a template here of the survey you designed? Or to share any challenges or successes you found during the process?

This month, NICE released new guidance on the assessment and management of chronic pain . 

We'd like to hear your thoughts on the new guidance and how you feel it may impact you, your loved ones or your patients.

How do you think it will work in practice? What support will patients and doctors need when applying the guidance? Is there anything that might need more clarity? 

Please share your thoughts below. You'll need to be a hub member to comment, it's quick, free and easy to do. You can sign up here.

@Michelle Chunger we'd love to hear how you get on and to share any learning or outcomes. Bets of luck, and keep us posted! 

Hi @nickbouere, there are many people who, like you, were unable to access a test at the time when they would have tested positive. Helen's reply above references the NICE guidelines and also a leaflet we joint produced to help patients evidence how GPs should be supporting. 

The Royal College of GPs also states:

"You do not need a positive SARS-CoV-2 test, or have been admitted to hospital to be diagnosed with post COVID-19 syndrome. Anyone with an acute infection of COVID-19, however mild, can go on to develop post COVID-19 syndrome"

Taken from this document: Management of the long term effects of COVID-19. The RCGP response and top tips for caring for our patients 

Are you an NHS Manager who oversees intentional rounding or double-checking medications administration?

Daisy Halligan, a researcher at the University of Leeds, is looking to interview matrons, heads of nursing, risk leads, clinical governance leads and and other managers who oversee intentional rounding or double-checking medications administration.

For more information, see the poster below or contact Daisy via email at psdh@leeds.ac.uk

Hi @Val

Thank you for sharing your difficult experience. Unfortunately your testimonial bears similarities to that of others who also felt they were not given enough information before the procedure or adequate pain relief options. 

At Patient Safety Learning, we have been working with clinicians, researchers, campaigners and of course patients to understand the barriers to safer hysteroscopy treatment so that we can call for action that will be effective in improving care. 

A few links below that may be of interest:

Improving hysteroscopy safety

Presenting my work on pain during hysteroscopy to RCOG

Through the hysteroscope: Reflections of a gynaecologist

Ministers respond to patients’ concerns about painful hysteroscopies: Northern Ireland, Scotland and Wales (February 2021)

Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken? (January 2021)

A recent study (not yet peer reviewed) indicates that 30% of COVID patients were readmitted after discharge from hospital.

What implications does this have for service planning?

Is enough being done to recognise and respond to the longer term symptoms and damage caused by COVID-19? 

Staff at the Royal London, Barts Health and beyond are working harder than ever to provide intensive care in vastly increased numbers to patients struggling with COVID in addition to caring for 'regular' patients. Staff are working extremely long hours without much time for a break.

Together with Cantine, they are fundraising to get 100 meals daily to feed their doctors, nurses, logistical staff and all other frontline workers at the Royal London. Any donation will help boost morale and ensure that frontline staff have their basic needs met while caring for patients.

https://www.gofundme.com/f/feed-the-nhs-frontline?utm_source=facebook&fbclid=IwAR3FhLFAxkMFSLqjgM3umG-0V0VYrQLH2qFENGUpy4RkimqjTsm1uATxb-8

Hi @SusieL

I really am very sorry to hear of your traumatic experience. The principles of informed consent are that you should be made aware of the Benefits, Risks, Alternatives and what happens if you choose to do Nothing (also known as BRAN). It doesn't sound like you were made aware of the risk of severe pain or given any alternative pain relief options. Have you submitted any feedback to the NHS on your experience? 

You may be interested in our recent blog and video explaining what we have been doing over this past year to work with others and raise our concerns around painful hysteroscopies, and particularly the absence of informed consent. We will continue to call for safer hysteroscopies.

Link below to the recent blog and video:

2020: Raising awareness about painful hysteroscopies

@SusieL @LiSaRa @RHarrison what are your thoughts?

It was announced today that more than 60 clinics are operating in England to provide support to Long COVID patients. 

Have you had a medical appointment at a Long COVID clinic? What was your experience? 

Or perhaps you're a patient who would like share your thoughts on the newly published NICE guidelines for managing the long-term effects of COVID-19?

You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.

Do women experience poorer medical attention when it comes to pain?

What are your experiences? What are the solutions? What are the barriers? 

This week, Hysterical Women and THE FEMEDIC ran a joint webinar, asking the question "How close are we to closing the gender pain gap"?

Panellists included clinicians and researchers, with discussions around research gaps, empowerment and informed consent (to name just a few). It was a lively, energised event and an important topic. 

We'd love to hear from clinicians, researchers, patients and anyone else who is interested in women's health and health equality. Please comment below and join the conversation. 

Hi Guest S L,

Thank you for adding your comment. A recent NHS press release said: 

"Ten sites have been earmarked for the Midlands, seven in the North East, six in the East of England, South West and South East respectively, five in London and three in the North West."

It is important that people with Long COVID can access the relevant services, regardless of where they live. At Patient Safety Learning, we have called on the NHS to provide more clarity on the clinics including specific locations. We have also recommended they set out plans to address regional disparities, should there be any, to avoid a post-code lottery of access (you can read our blog below).

Clear NHS plan needed to reassure Long COVID patients 

If you would like to discuss your concerns further, please do get in touch via content@pslhub.org 

You can read Patient Safety Learning's blog about improving hysteroscopy safety here. 

When patient harm occurs, caregivers involved are often devastated along with the patient and family, yet many have had to navigate this storm alone. A 'systems approach' in our healthcare workplace, along with the just culture, cultivates the sharing of knowledge and helps prevent patient harm from occurring altogether.

This short video of 'Annie's Story', shows how healthcare organisations seeking high reliability embrace a just culture in all they do.

How did the video make you feel? Have you experienced a systems approach? How can we work towards a more just culture?

*You'll need to be a hub member to comment, it's quick and easy to do. You can sign up here.

In a blog, published on the hub today, Midwife Samantha Phillis talks about her experience of the Midwifery Continuity of Carer (CoC) model. Samantha reflects on the benefits of getting to know your patients throughout their pregnancy journey and how this can lead to better outcomes. 

What are your thoughts on Continuity of Carer?

Do you have experience of working this way? Have you seen an impact on patient safety? Perhaps you want to ask others how they set it up in their area? 

Or maybe you're a patient and had the same midwife care for you throughout your pregnancy. Can you tell us more about your experience and how it made you feel?

Please share your thoughts in the comments below.

You'll need to be a hub member to comment, it's free and easy to do. You can sign up here. 

We are currently seeking a couple of patients who would be happy to help us with a hysteroscopy communication piece. It will involve a short video recording via zoom, talking about your experience and also to share any benefits you have found in coming together via this forum and the hub. If you have any questions or would like to take part, please email me at stephanie@patientsafetylearning.org.