Jump to content
  • Posts

    1,216
  • Joined

  • Last visited

PatientSafetyLearning Team

PSL Moderators

Everything posted by PatientSafetyLearning Team

  1. Content Article
    Knowing your rights and the law in pregnancy and childbirth is important. The charity Birthrights has produced a series of factsheets to provide you with the latest information on your rights, where they come from in law, and how they are backed up in guidance.
  2. Content Article
    Developed by David Havard, this poster shows a number of ways in which reasonable adjustments can easily be made for patients with a learning disability.
  3. Content Article
    This Patient Safety Notice has been developed by Sandwell and West Birmingham NHS Trust following a serious incident inquest of a case involving sampling from a central line. A patient, under renal physicians, required blood cultures from their central venous line (normally used for haemodialysis). Due to unfamiliarity with the correct procedure the line was not clamped prior to use. Air therefore entered the port causing an air embolus and subsequently cardiac arrest.
  4. Content Article
    This survey, published by the Parliamentary and Health Service Ombudsman, found that one in five people did not feel safe while in the care of the NHS mental health service that treated them.
  5. Content Article
    This report, No Patient Left Behind, has been published by The APPG on Stem Cell Transplantation and Advanced Cellular Therapies, following an inquiry into barriers which patients face when accessing treatment and care.  
  6. Content Article
    The Royal College of Obstetricians and Gynaecologists reviewed maternity care at two hospitals:  The Royal Glamorgan hospital Prince Charles hospital The report makes recommendation on improvements to ensure the safety of mothers and babies. "During interviews and in group sessions the assessors were repeatedly and consistently told by staff of a reluctance to report patient safety issues because of a fear of blame, suspension or disciplinary action." "The assessors found little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety, or an understanding of their roles and responsibilities towards patient safety beyond the care they provided for a specific woman or group of women. This perception extended to senior members of midwifery and medical staff."
  7. Content Article
    Preventable harm during labour can be catastrophic for parents, babies and families, as well as for the staff involved. Reducing avoidable brain injury in childbirth means building on everyone’s experiences and expertise, working together to improve care in labour for all. THIS Institute, in partnership with The Royal College of Midwives and The Royal College of Obstetricians & Gynaecologists, is inviting maternity staff, parents and birth partners from across the UK to contribute their views to their Avoiding Brain Injury in Childbirth (ABC) campaign. The focus is on monitoring and responding to babies’ wellbeing during labour and on managing the emergency complication at caesarean section known as impacted fetal head. The ABC campaign aims to give maternity staff tools and support to be able to provide the highest quality of care when there are concerns about the baby’s wellbeing during labour. It also aims to improve communication with everyone using maternity services and make sure they are listened to and involved in decisions about their care.
  8. Content Article
    In this article, published by the Harm & Evidence Research Collaborative, Sharon Hartles examines the UK Government’s response in relation to the implementation of the recommendations set out in the Independent Medicines and Medical Devices Safety Review, First Do No Harm report. She explores how the Government’s response has impacted on those harmed by the side effects of Primodos, Mesh and Sodium Valproate.
  9. 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.  This month, our Content and Engagement Manager, Steph, has hand-picked seven resources, particularly relevant for patient safety managers working in hospital settings. Shared with us by hub members and patient safety advocates, they are jam-packed with practical tools and rich insights. 
  10. Content Article
    When a patient can’t breathe by themselves, healthcare staff may decide to intubate them to make it easier to get air into and out of the lungs. A tube goes down the throat and into the windpipe, and a machine called a ventilator pumps in air with extra oxygen. It can be life-saving, but life-threatening complications can also occur during a significant number of these procedures.  Sam Goodhand is a registrar in the Sussex region, specialising in anaesthetics and intensive care medicine. In this interview for Patient Safety Learning he tells us how and why he developed an accessible checklist for staff involved in intubation processes. 
  11. Content Article
    Co-producing a research project is an approach in which researchers, practitioners and the public work together, sharing power and responsibility from the start to the end of the project, including the generation of knowledge. This guidance, from the National Institute for Health Research, is a first step in explaining what is meant by co-producing a research project. It sets out the key principles and features of co-producing a research project and suggests ways to realise them. It also outlines some of the key challenges that will need addressing, in further work, to aid those intending to take the co-producing research route. Read the guidance in full. Related reading: Patient engagement resources Listening to the patient saved many lives
  12. Content Article
    Healthier Together and The Royal College of Paediatrics and Child Health have developed a set of resources to help you know what to do if a child is experiencing breathing difficulties or wheezing. These resources include information on: When to worry What to do How long symptoms should last Where to go for help.
  13. Content Article
    The Government has recently published it's response to the recommendations set out in the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, chaired by Julia Cumberlege. One of the recommendations was for manufacturers to publish details of payments they make to teaching hospitals, research institutions, and individual clinicians, similar to the American Physician Sunshine Payment Act. The Government has said it is “exploring options to expand and reinforce current industry schemes, including making reporting mandatory through legislation.” In this editorial, Sonia McLeod looks at the gaps that exist in the UK's current system for disclosure and highlights some important considerations when setting up a new system or process if it is to be effective. Read the full article Related reading: A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021) Independent Report of the Patient Reference Group – response to the report of the Independent Medicines and Medical Devices Safety Review (21 July 2021) No such thing as a free lunch – why recording conflicts of interests must be mandatory
  14. Content Article
    The Patient Safety and Quality Improvement Act of 2005 (PSQIA) establishes a voluntary reporting system designed to enhance the data available to assess and resolve patient safety and health care quality issues in the United States.
  15. Content Article
    This report, from the The Mental Health Policy Group, considers the steps that must be taken if the ambition of ‘parity of esteem’ for mental health is to be achieved in England. Its starting point is the belief that improving the nation’s mental health cannot be achieved through a focus on health services alone, vital though these are. A much more ambitious, cross-government approach to mental health is also required.
  16. Content Article
    This project, led by Hertfordshire Partnership NHS Foundation Trust, focused on acute mental health care and dementia care pathways across the Eastern region’s five mental health trusts. It aimed to improve patient safety in mental health care by addressing teamwork and communication issues that can affect the safety and effectiveness of care, and patient experience. Clinical teams were trained in system safety assessment (SSA) and human factors (HF).
  17. Content Article
    These webpages, published by Nuffield Trust, look at the latest NHS England data on key activity and performance measures. They highlight some of the statistics and how they compare to previous trends. These might include for example, data on waiting times and urgent care. Each summary links to 'indicators' detailing the statistics in greater depth, for example around A&E or diagnostic test waiting times or emergency readmissions.
  18. Content Article
    Evidence regarding the value of virtual care tends to narrowly focus on short-term measures of financial value. There remains little literature regarding the long-term effects of virtual care, such as improvements in access to care, clinical outcomes, the impact on the patient and clinician experience, the potential for operational efficiencies, or the impact on health equity. This report, which was jointly developed by the American Medical Association and Manatt Health Strategies (Manatt Health), expands on existing research by articulating a more robust framework for measuring the value of digitally enabled care that accounts for the various ways in which virtual care programmes may increase the overall “return on health” by generating positive impact for patients, clinicians, payers and society going forward.  To read the full report, follow the link below.
  19. Content Article
    This report, Long COVID and speech and language therapy, looks at the mid to long-term speech and language therapy needs of people with Long COVID, the impact these difficulties have on people’s lives and the essential role that speech and language therapy plays in supporting them. Published by the Royal College of Speech and Language Therapists (RCSLT), authors conclude: "The RCSLT firmly believes that any person with a communication or swallowing difficulty has a right to access high quality speech and language therapy when and where they need it. Any person with such needs after COVID-19 must receive timely, individual, person-centred rehabilitation, which will support and maximise their mental health and wellbeing, participation in society, and ability to return to work." To achieve this, the report sets out a number of recommendations at national, system and workforce levels. They also set out recommendations for raising awareness to the wider public.
  20. Content Article
    Healthcare is becoming both increasingly data driven and automated. Authors of this blog, published by the London School of Economics, found that opportunities for patients to influence and inform these future technologies are often lacking, which in turn may heighten disillusionment and lack of trust in them. As such, they propose four priorities for new data driven technologies to ensure they are ethical, effective and equitable for diverse patient groups: Public voice Individual’s diversity Participatory co-design Open knowledge development and exchange. Read the blog in full via the link below.
  21. Content Article
    This discussion paper, published in The Journal of Patient Safety and Risk Management, explores some of the opportunities which healthcare organisations could embrace to positively influence the effects of power and hierarchy on staff safety. The author concludes: "This exploration into how power and hierarchy influence both staff and patient safety has identified and briefly explored some of the tensions created by misplaced brand loyalty inherent within healthcare institutions, and the legacy of harms resulting."
  22. Content Article
    In this indicator update, Nuffield Trust look at trends in the quality of urgent and emergency care both before and during the pandemic. This includes measures of other parts of the health system which affect urgent care services.
  23. Content Article
    The unintentional connection of a patient requiring oxygen to an air flowmeter is listed by the NHS as a 'Never Event'. The patient safety notice poster below (and attached for better viewing) has been developed by Sandwell and West Birmingham NHS Trust, to help raise awareness among staff and prevent future errors. Do you use posters or infographics to improve patient safety locally? Why not get in touch by emailing content@patientsafetylearning.org, to share your examples more widely on the hub. 
  24. Content Article
    The Health Foundation’s COVID-19 impact inquiry has drawn on a broad range of available evidence to consider two main questions: How were people’s experiences of the pandemic influenced by their pre-existing health and health inequalities? What is the likely impact of actions taken in response to the pandemic on the nation’s health and health inequalities – now and in the future?
  25. Content Article
    Interactive Drug Analysis Profiles (IDAPs) contain complete listings of all suspected adverse drug reactions or side effects that have been reported to the MHRA via the Yellow Card Scheme for a particular drug substance. This includes all reports received from healthcare professionals, members of the public, and pharmaceutical companies.This Interactive Drug Analysis Profile (iDAP) displays an overview of all UK spontaneous suspected Adverse Drug Reactions (ADRs) reported through the Yellow Card Scheme. It is important to note that reported adverse reactions have not been proven to be related to the drug, and should not be interpreted as a list of known side effects. 
×
×
  • Create New...