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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This Postnatal Risk Assessment Matrix (PRAM) resource was developed by Dr Cindy Shawley, Quality Improvement Lead for Maternity at Hampshire Hospitals NHS Foundation Trust. The pack includes a number of monitoring and assessment tools to help keep mums and babies safe. The following two sections have been selected for the finals of the Nursing Times Awards, under the Patient Safety category: The First Hour of Care: Keeping mums and babies together (a proforma and pathway to promote normal adaptation to life) Holding your baby safely poster (as referenced in the recent National Learning Report, Neonatal collapse alongside skin-to-skin contact) Please open the attached documents to view the full PRAM resource pack as well as the two award-nominated sections that can be downloaded independently.  Many thanks to Dr Shawley for giving permission to share these important patient safety resources on the hub.
  2. Content Article
    With evidence of the impact of COVID-19 on BAME communities, on 15 April 2020 NHS England CEO Simon Stevens convened a meeting of leaders in healthcare and representative bodies such as the British Medical Association and Royal College of Nursing to agree a plan of action to support staff. The NHS response has since been underpinned by three principles of protecting, supporting, and engaging staff.
  3. Content Article
    In this Editors choice piece from the BMJ, the author discusses the persisting and debilitating symptoms that many sufferers of COVID-19 are experiencing and how some are also facing further challenges of dismissive attitudes from doctors.
  4. Content Article
    In this commentary, published by Infectious Diseases, authors argue that more support for research is needed on the trajectory of people recovering from COVID-19. 
  5. Content Article
    This health seminar focuses on one of the most taboo issues in women’s health, incontinence. An estimated 7 million women suffer urinary incontinence which can affect all areas of life, yet it is rarely spoken about and regarded as an issue that only affects older women.  Wellbeing of Women talk to Luce Brett, author of PMSL: Or How I Literally Pissed Myself Laughing and Survived the Last Taboo to Tell the Tale and Elaine Miller a women’s health physiotherapist, for what is a hilariously open but also vital conversation about living with incontinence, why we shouldn’t have to accept it and what we can do.
  6. Content Article
    We all have to deal with pressure. Sometimes it's minor like "do I go left or right at the roundabout?". Sometimes it's the difference between life and death. But how can we manage and work with that pressure, rather than against it? Dr Stephen Hearns is a critical care doctor and search and rescue specialist in Scotland, who has spent his career understanding what pressure is and how he can try to handle it in stressful times. His new book 'Peak performance under pressure' goes into detail about the tools and techniques we can all use to manage stress when the going gets tough. In this podcast, produced by eeast (East of England Ambulance Service) General Broadcast, Stephen talks about why pressure is sometimes good for us, how to recognise stress in other and what to do when you're maxed out.
  7. Content Article
    Authors of this BMJ Opinion piece, recently had the opportunity to present the existing evidence and highlight patients’ experiences of having Long Covid at a meeting attended by Maria Van Kerkhove, (WHO Covid Technical Lead) and Janet Diaz (WHO Head of Clinical Care) from the central WHO team. At the meeting, Clare Rayner and Amali Lokugamage, both doctors who are experiencing long term impacts of COVID-19, discussed their perspective of having long covid. In this article, the authors summarise the points they raised at the meeting. They also highlight the supportive comments made by Dr. Tedros Adhanom Ghebreyesus, which indicated genuine recognition of long covid sufferers and hope for the future. 
  8. Content Article
    Authors of this editorial, published in BMJ Quality & Safety, discuss the significance of the results of two new studies on hospital medicine and implications for emerging research and practice improvement efforts. The first study was a systematic review to determine the prevalence of harmful diagnostic errors in hospitalised patients. The second studied readmitted patients using established methods for diagnostic error detection and analysis to gain insights into contributing factors. Both studies advance the science of measurement and understanding of how to reduce diagnostic error in hospitals.
  9. Content Article
    The US-based Institute for Healthcare Improvement (IHI) reviewed available evidence for interventions that can help protect staff mental health in the face of extreme working conditions such as natural disasters, terrorist attacks, and previous pandemics. They synthesised this research into evidence-based “psychological PPE” recommendations for use by staff providing care during the COVID-19 pandemic.
  10. Content Article
    The ability to speak up to express concerns is a key safety behaviour all health and care staff should have. Teaching and using the 'probe, alert, challenge and escalate' (PACE) tool can allow any health or care professional of any type or seniority to use graded assertiveness to challenge any action or behaviour they may feel is inappropriate or unsafe.
  11. Content Article
    By understanding how physicians make clinical decisions, and examining how errors due to cognitive biases occur, cognitive bias awareness training and debiasing strategies may be developed to decrease diagnostic errors and patient harm. Studies of the impact of teaching critical thinking skills have mixed results but are limited by methodological problems. The authors of this paper, published in Academic Medicine, argue that explicit instruction in metacognition in medical education, including awareness of cognitive biases, has the potential to reduce diagnostic errors and thus improve patient safety.
  12. Content Article
    In the area of patient safety, recent attention has focused on diagnostic error. The reduction of diagnostic error is an important goal because of its associated morbidity and potential preventability. A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics, and biases; collectively, these have been referred to as cognitive dispositions to respond (CDRs). The author of this paper, published by Academic Medicine, provides an extensive list of CDRs and a list of strategies to reduce diagnostic errors.
  13. Content Article
    Authors of this journal piece, published by The American Journal of Medicine, present a comprehensive review of the available literature and current thinking related to diagnostic error. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.
  14. Content Article
    Within the research community, there is no consensus on the definition of diagnostic error, in part due to the complexity of diagnosis. This paper, published by Diagnosis, looks at the challenges in defining and measuring diagnostic error.
  15. Content Article
    Patients often carry medication lists to mitigate information loss across healthcare settings. The authors of this paper, published in BMJ Quality & Safety, aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use.
  16. Content Article
    As a healthcare worker, you could be asked to write a statement for an investigation at work, in response to a complaint, or about an unexpected incident. These are the main points to consider, developed by the Royal College of Nursing (RCN).
  17. Content Article
    As a leader how can you foster a work environment where people feel safe to speak up, share new ideas and work in innovative ways? In this video from the Kings Fund, Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, talks about the importance of psychological safety in health and care and what leaders can do to create it. 
  18. Content Article
    This Heathcare Huddle video focuses on key themes that came out of the First Do No Harm report. You can watch it in two parts or as one full video. PART ONE (with Darren Thorne, Managing Director of Facere Melius) - Theme 1: ‘No-one is listening’ – The patient voice dismissed - Theme 2: ‘I’ll never forgive myself’ – Parents living with guilt - Theme 3: ‘I was never told’ – the failure of informed consent PART 2 - Theme 4: Redress – ‘We want justice’ - Theme 5: ‘We do not know who to complain to’ – Complaints - Theme 6: Duty of Candour – ‘preventing future errors’ - Theme 7: Conflicts of interest – ‘we deserve to know’.
  19. Content Article
    Despite the increasing policy focus on integrated dementia care in the UK, this paper published in Health and Social Care in the Community, argues that little is known about the opportunities and challenges encountered by practitioners charged with implementing these policies on the ground.
  20. Content Article
    With a lot of medical care on hold during the coronavirus pandemic, Paul Landau, founder and CEO of digital cancer care company Careology, looks at the UK’s ‘next big crisis’.
  21. Content Article
    This alert, from the National Institute for Health Research, provides a synopsis of a new study which suggests that many early warning scores are based on flawed research. It looks at the issue and the next steps in terms of patient safety.
  22. Content Article
    This web page, from the Society for Endocrinology, contains useful information and guidance for patients and clinicians on the management of adrenal crisis. The information includes links to where organisations can order NHS Steroid Emergency cards. There is also a downloadable version for patients to download and print off immediately. Some patients are also uploading the pdf version as the lock screen on their mobile phones, to show health care professionals in a medical emergency. Follow the link below to find out more.
  23. Content Article
    In this BMJ Opinion article, Helen McKeown talks asks why the menopause is still a taboo topic when it comes to the well being of healthcare colleagues and argues more could be done to help staff.
  24. Content Article
    Hazardous Hospitals aims to elicit a wide range of viewpoints and experiences about the historical development of safety in NHS hospitals. They are interested to hear from anyone with direct experience of encountering health and safety risks in hospitals, promoting safety, or exposing shortcomings in healthcare quality. Follow the link below to find out more and how to participate.
  25. Content Article
    This project, led by a team of researchers, aims to give a voice back to the critical care nurse so that there is a much greater understanding of the mental challenges of the profession and so that appropriate supportive measures can be developed that improve working conditions.  In order to carry out the research, the team need volunteers to participate and share their own views and experiences of mental health and well-being in the profession. We are looking for any active critical care nurse who is open to discussing mental health and well-being to shed light on what is a too often ignored and overlooked subject.  Find out more about the project and how to sign up via the link below.
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