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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    Pregnant people receive many public health messages that are intended to guide their decision making; intended to improve outcomes for babies and mothers. However, there is growing concern that messages do not always fully reflect or explain the evidence base underpinning them, and that negotiating the risk landscape can sometimes feel confusing, overwhelming, and disempowering. This may negatively affect women’s experiences of pregnancy and motherhood, and be exacerbated by a wider culture of parenting that tends to blame mothers for all less-than-ideal outcomes in their children. The WRISK Project draws on women’s experiences to understand and improve the development and communication of risk messages in pregnancy.
  2. Content Article
    This chapter in the National Health Executive magazine, looks at infection prevention.
  3. Content Article
    The findings of this study, published in the Patient Experience Journal, indicate that the policy to allow for visitors, or subjective advocates, individuals with a vested interest in the well-being of the patient, is beneficial not only for the patient, but also in sustaining high quality of care. Recommendations are given for how hospitals might achieve improved quality and safety outcomes even in instances when organisations believe visitation needs to be disallowed or restricted. The results of this study suggest those decisions should be made with great care and in only the most extreme circumstances.
  4. Content Article
    This article, published in JAMA, tells the story of a 6 year-old boy who was initially misdiagnosed, which led to months of agony. Here, his mother, Thalia Margalit Krakower MD, asks that the medical community shift focus from promoting a false sense of perfection to one that embraces humility enough to apologise as essential to the healing process. "A deep cultural shift is needed in medicine to openly acknowledge and understand that imperfection is part of being human – no one knows everything, makes every diagnosis without delay, answers every patient message, or even delivers an apology just right. It is our humanity that makes us vulnerable to make mistakes and also empowers us to connect and heal." Read the article in full Related content Safety of candour: how protected are apologies in open disclosure? When the Duty of Candour becomes personal by Sarah Seddon Mothers Instinct: Reframing Duty of Candour in our hearts and minds – a blog by Joanne Hughes (15 October 2020) AvMA: Regulating the duty of candour. Requires improvement (October 2018) Barts Health NHS Trust: Duty of Candour training film (April 2016) Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour (June 2015)
  5. Content Article
    Anyone with the signs and symptoms of sarcoma needs to be seen as early as possible and referred to services that can quickly and accurately confirm the diagnosis. Doing this can save lives. Sarcoma UK are calling on policy makers to make faster and more accurate diagnosis a reality for the sarcoma community. They recommend that: A sarcoma education programme for healthcare professionals should be rolled out, placing importance on the individual impact of sarcoma and how it is important to rule it out, not rule it in. Awareness of sarcoma and its symptoms needs to improve. Sarcoma can occur anywhere in the body and it is vital that the public are aware of this. Ensure that there are clear and efficient referral pathways that allow primary healthcare professionals to access the optimum route for all their patients. Access their reports and policy documents by following the link below. 
  6. Content Article
    Sarcomas are uncommon cancers that can affect any part of the body including bone, muscle, ligaments, fatty tissue and blood vessels. It is a condition which 75% of people in the UK are not aware of. Early detection is key to improving survival rates. In this blog, published on the NHS website, Dr Suma Kuna, MacMillan GP and Clinical Lead for Cancer and Palliative Care, talks about what sarcoma cancer is, and the signs to look out for.
  7. Content Article
    Do masks work? Why do some people claim they don’t work? Do they cause harm? What kinds of masks should we wear? How does masking need to change now we know that Covid is airborne? When can we stop wearing them? In this long-read Twitter thread Trisha Greenhalgh, Professor of Primary Care Health Sciences at the University of Oxford, outlines the data.
  8. Content Article
    This week the Department of Health and Social Care released the UK Government’s response to the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. In this blog Patient Safety Learning sets out its reflections on this.  
  9. Content Article
    More and more women are coming forward to share their stories of a painful IUD procedure. In this blog for the BMJ Opinion, Stephanie O’Donohue (Content and Engagement Manager for Patient Safety Learning) argues that healthcare services need to get better at recording these experiences. The ripples of trauma caused by severe pain during IUD procedures If you have had an IUD fitted and would like to share your experience, please visit our community forum and share your views.  Related reading  The pain of my IUD fitting was horrific…and I’m not alone The normalisation of women’s pain Through the hysteroscope: Reflections of a gynaecologist Improving hysteroscopy safety (Patient Safety Learning, November 2020)
  10. Content Article
    These patient leaflets, shared on the BMJ Bets Practice website, aim to provide concise easy to read summaries to reassure patients and carers and help them make informed, shared decisions with healthcare professionals. Search their library of leaflets by condition or treatment by clicking on the link below.
  11. Content Article
    In this blog, Neil O'Halloran, Clinical Support Specialist for Medline, describes how and why he set up a group to bring together falls prevention leads. His vision was to create a network where people could share best practices and become a resource and support for each other. You can find out more about the network by following the link below.
  12. Content Article
    Stopping antidepressants commonly causes withdrawal symptoms, which can be severe and long-lasting. This paper, published in Therapeutic Advances in Psychopharmacology, outlines the themes emerging from 158 respondents to an open invitation to describe the experience of prescribed psychotropic medication withdrawal for petitions sent to British parliaments.
  13. Content Article
    In this written evidence, submitted to the Health and Social Care Select Committee, the Independent Maternity Review Team provides commentary on the following commitment: "The majority of women will benefit from the ‘continuity of carer’ model by 2021, starting with 20% of women by 2019." They outline a number of concerns around the safe implementation of Continuity of Carer, particularly where there are significant staff shortages and/or inadequate funding.
  14. Content Article
    The European Biosafety Network (EBN) commissioned a survey to understand whether, why and how there has been a change in the number, type and location of sharps injuries as a result of the COVID pandemic. The survey, conducted by Ipsos MORI in March/April 2021, included 80 of the largest hospitals in Europe, in Spain, France, Germany, Poland and Italy, covering more than 300,000 healthcare workers. Findings showed that the number of sharps injuries has risen significantly as a result of the COVID-19 pandemic, with an average reported increase of 23% over the last year (an estimated increase of 276,000 sharps injuries). This presentation highlights several contributing factors including: Increased pressure/stress Lack of safety devices PPE Covid vaccination rollout. You can access the full presentation summarising the research by downloading the attached document.
  15. Content Article
    This independent study report is designed to be accessible, informative and a tool for learning and change. In its preparation, the project team has aimed to: develop a greater understanding of why staff across the system implemented new practices and innovations during the COVID-19 pandemic; demonstrate an inherent ‘permission’ to apply innovation and transformative change; evidence practical, real world examples of innovation that support the application of good practices to other areas; showcase NHS Wales as a leader in implementing innovation and new ways of working throughout the COVID-19 pandemic. A broad range of qualitative and quantitative evidence has been gathered from practitioners at all levels of the healthcare system, who have worked tirelessly to adapt to an unprecedented set of circumstances while still caring for and protecting Welsh citizens.
  16. Content Article
    This blog, published in The Journal of Medical Ethics, is authored by individuals from New Zealand, Australia and the UK. They draw on their co-produced Cultural Safety framework to address structural iatrogenesis where patients are harmed by unconscious or conscious racist power imbalances in the bureaucratic and cultural systems within healthcare systems, including those systems originally intended to help them. Included is an infographic to illustrate the Cultural Safety Tree Model and how to translate Cultural Safety to the UK. Person-centred care, staff reflexivity, structural reflexivity and listening to the voices of the recipients of healthcare are the crucial roots to this model.
  17. Community Post
    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
  18. Content Article
    This online tool, from the Patient Experience Library, allows you to search by condition and treatment to access information on waiting times at NHS Trusts in England. This data is sourced from NHS England, and is published two months in arrears.
  19. Content Article
    Jacqui Shaw, 54, underwent surgery for pelvic organ prolapse during which surgical mesh was inserted. She assumed the operation would improve her quality of life. Instead, her days are now blighted by agonising pain and despair.  In this video, published on the Mail+, Jacqui bravely shares her story, and her uncertainty for the future. She describes how she found the support group Sling the Mesh, and subsequently many others who were also experiencing devastating consequences of surgical mesh.
  20. Content Article
    The MASIC Foundation is the only multi-disciplinary UK charity to support women who have suffered severe maternal perineal trauma during childbirth known as OASI (Obstetric Anal Sphincter Injury). They carried out an online survey in January 2021, exploring the impact of severe maternal perineal trauma on the physical and mental health of the women who sustained the injuries and on their relationship with their child. This report outlines the results and calls for several actions to improve care. 
  21. Content Article
    The charity Group B Strep Support (GBSS) has produced an information leaflet, written in partnership with the Royal College of Obstetricians and Gynaecologists (RCOG), aimed particularly at pregnant people and new parents and includes information on: What group B Strep is What group B Strep could mean for a baby How to reduce the risk of group B Strep infection to a baby The key signs of group B Strep infection in a newborn baby The leaflet, Group B Streptococcus in Pregnancy & Newborn Babies, has been translated from English into 14 other languages and is available in Arabic, Bengali, Chinese, English, French, Hebrew, Latvian, Lithuanian, Polish, Portuguese, Punjabi, Romanian, Somali, Urdu and Welsh. Follow the link below to the GBSS website to access and download all versions for free.
  22. Content Article
    Baroness Julia Cumberlege, produced the First Do No Harm report that looked into two drugs and a medical device which caused women or their babies harm. In this episode of Women's Hour, she joins host Emma Barnett to talk about her anger and frustration at the lack of progress made since the report was published a year ago. The report made a list of nine recommendations to support victims and prevent future, avoidable damage. Eight of these have seen no action. Listen from 31:20
  23. Content Article
    The gap between doctor supply and patient need is widening each year. This report, from the British Medical Association: illustrates how severe medical workforce shortages in England have become demonstrates how the situation will worsen based on anticipated population growth and demographic changes without significant and swift intervention from Government analyses trends in the medical workforce up to 2021 highlights the value of the doctor to the health of patients.
  24. Content Article
    Monitoring surgical wounds for infection: information for patients explains surgical wound infection, and the national programme for monitoring infections acquired in hospitals. This patient guide had been produced by Public Health England and is available in English and 8 other languages.
  25. Content Article
    The Perfect Patient Information Journey (PPIJ) is a 7-step process to embed high-quality patient information along care pathways, helping people get the right information at the right time.  This video from the Patient Information Forum (PIF), explains why this is so important and how it can improve patient outcomes and safety.
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