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Content ArticleWe’ve come to the final instalment of our 2020 blog series, where we’ve reflected on key patient safety issues we’ve seen this year and our work in those areas. First, our Chief Executive, Helen Hughes, introduced the series, giving an overview of the year. We then looked at: The impact of the COVID19 pandemic on patient safety Advice and support for people living with Long COVID Painful hysteroscopies Staff safety. Lastly, we turn our attention to one of the most significant reports we’ve responded to this year, First Do No Harm – also known as the Cumberlege Review – by the Independent Medicines and Medical Devices Safety Review.
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In this short video, Associate Professor, Paediatric Podiatrist and Research Lead, Cylie Williams shares practical tips to help people wear their masks safely. Cylie talks about how to shape the mask effectively to different face shapes and how to prevent glasses from steaming up which can cause people to fall. -
Community PostIt 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.
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This guideline covers identifying, assessing and managing the long-term effects of COVID-19, often described as ‘Long COVID’. It makes recommendations about care in all healthcare settings for adults, children and young people who have new or ongoing symptoms 4 weeks or more after the start of acute COVID-19. It also includes advice on organising services for Long COVID. -
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So far in our 2020 overview series, we’ve heard an introduction to how the year has gone from our Chief Executive Helen Hughes, and looked at the impact of the COVID-19 pandemic on patient safety, as well as the work we’ve done in the areas of Long COVID and painful hysteroscopies. In our penultimate blog of the series, we turn our attention to the work we’ve done in staff safety.- Posted
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NICE guidance on shared decision making
PatientSafetyLearning Team posted an article in Consent and privacy
Shared decision making is when health professionals and patients work together. This puts people at the centre of decisions about their own treatment and care. When making decisions together, it's important that: care or treatment options are fully explored, along with their risks and benefits different choices available to the patient are discussed a decision is reached together with a health and social care professional. The link below includes guidance and tools to support patients and healthcare staff with shared decision making. -
Content ArticleThe Canadian Patient Safety Institute's (CPSI's) strategic plan for 2018-2023 promises to lead health system-level strategies to ensure safe healthcare by demonstrating what works and by strengthening commitment. Patient safety incidents in total (acute care and home care combined) are the third leading cause of death, behind cancer and heart disease with just under 28,000 deaths across Canada (2013). This is equivalent to such harm events occurring in Canada every one minute and 18 seconds, resulting in a death every 13 minutes and 14 seconds. Strengthening Commitment for Improvement Together: A Policy Framework for Patient Safety, focuses on key policy levers available to influence system changes.
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Content ArticleIn this powerful article, GP Katie Musgrave, says that the profession is overwhelmed and under resourced. She argues that they are unable to provide the service that patients deserve and that action is needed to prevent patents from suffering harm. Her suggestions include:A COVID-pressures support fund, where part time GPs can be offered extra protected sessions in their own surgeriesThe extension of the ARRS to cover nurse practitioners or GPsA suspension of all but the most crucial bureaucracy: we certainly don’t need to be thinking about QOF this winter.
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Content ArticleIn this opinion piece, authors highlight the growing cohort of patients who are suffering symptoms many months after their initial COVID-19 infection and the increasing demand on GP services. They also highlight a need for studies that can illuminate the underlying mechanism and for insights into the nature of this condition, how long it’s likely to go on for, what can be done about it, and through which clinical specialties. "Many estimates of long covid suggest that greater than 10% of acute cases have features that do not resolve over the subsequent months. Extrapolated to the current global burden of covid-19, this suggests potentially over five million current "long haulers"."
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Content ArticleThis month, we’ve been looking back over 2020 and highlighting some of the key areas of health and care that Patient Safety Learning has worked in this year. First, Chief Executive, Helen Hughes, gave an overview, detailing some of the main ways we’ve been achieving our aims as an organisation. Following that, we looked at the impact of the COVID-19 pandemic on patient safety, and, earlier this week, we focused on advice and support for people living with Long COVID. In this blog, Patient Safety Learning reflect on the work we’ve been doing to highlight serious patient safety concerns relating to hysteroscopy procedures in the NHS and how we’ve been making the case for change.
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Community PostDo 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.
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Caitlin Wilson is a Consultant Midwife, currently leading the development and implementation of the Midwifery Continuity of Carer (CoC) model in Worcestershire. In this interview, Caitlin tells us more about the benefits to both staff and families, and offers advice for anyone thinking about adopting this model of care. -
Content ArticleAs winter pressures combined with COVID-19 create more stress for the NHS, hospitals could look at reducing exacerbating factors such as acute kidney injury, says Dr Mark Ratnarajah, managing director, UK, of digital health company C2-Ai. A study by researchers at University Hospital Southampton NHS Foundation Trust, found that Acute Kidney Infection (AKI) was a significant factor for COVID-19 admissions to Intensive Care Units (ICU) and deaths. AKI was present in 31 per cent of Covid-19 hospital patients, and the condition was associated with 27 per cent of admissions to ICU. The findings also showed that more than twice the number of COVID-19 patients with AKI died, compared to those without it. As AKI can commonly be acquired in hospital, it would be beneficial to both patients and hospitals if clinicians are able to consider the likelihood of anyone contracting the condition. For this, an individualised risk-assessment of a patient is needed, rather than a generalised catch-all approach. Click on the link below to read the full article, published in the Journal of mHealth.
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Content ArticleLast week, Patient Safety Learning’s Chief Executive, Helen Hughes, gave an overview of some of the patient safety issues we’ve focused on this year. We then published the first of five mini blogs, looking at one of these key areas, namely the impact of the COVID-19 pandemic on patient safety. This week, we turn our focus to Long COVID. Long COVID is a condition where people experience debilitating and sometimes severe symptoms for more than 12 weeks following confirmed or suspected COVID-19, and where their condition cannot be explained by an alternative diagnosis.
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In this interview, Lesley Andrews reflects on her role as Head of Governance for the Cromwell Hospital in South West London. Lesley tells us how patient safety is central to her work and why culture, data and leadership are key to improving outcomes. -
Content ArticleOrganisations expect to see consistency in the decisions of their employees, but humans are unreliable. Judgments can vary a great deal from one individual to the next, even when people are in the same role and supposedly following the same guidelines. And irrelevant factors, such as mood and the weather, can change one person’s decisions from occasion to occasion. This chance variability of decisions is called noise, and it is surprisingly costly to companies, which are usually completely unaware of it.
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Content ArticleEarlier this week, Patient Safety Learning’s Chief Executive, Helen Hughes, looked back over 2020, highlighting some of the big themes in patient safety we’ve seen this year and our own work in these areas. This is the first of five mini blogs, where we give an overview of each of these themes in turn. In this blog, we look at the impact COVID-19 has had on patient safety. As an additional option to the text below, you might like to watch the following short video from our Business and Policy Manager, Mark Hughes.
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Content ArticleThis project includes the design of templates for controlled drugs, Hypnotics/Z-drugs, DMARDs (each orally administered drug has individualized template), NOACs, Warfarin, Lithium and Amiodarone. These templates prompt the user to add compulsory details before the drug can be issued for the first time or for a repeat issue. This has led to better and safer prescribing and potential to identify group of patients who either have not been reviewed or have missed essential monitoring. To avoid visual fatigue templates are short and to the point and a clinician can navigate away by one click if the required fields have been captured recently. Audits of prescribing such drugs has shown better prescribing and more patient involvement in decision making. Read more about this case study on the NICE shared learning database, via the link below.
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Content ArticleThis case study is featured on the National Institute for Health and Care Excellence (NICE) shared learning database. The associated project aims to optimise the safe use of medicines and reduce avoidable harm to patients. Objectives: To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018) To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter). To ensure practices responded to patient safety alerts from the MHRA in a timely manner.
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Content ArticleThis paper, published in HEC Forum, focuses on undergraduate student involvement in short term medical volunteer work in resource poor countries, a practice that has become popular among pre-health professions students. Authors argue that the participation of undergraduate students in global health experiences raises many of the ethical concerns associated with voluntourism and global health experiences for medical students. They propose a framework for guidelines and curricula, argue that universities should be the primary point of delivery even when they are not organising the trips, and recommend that curricula should be developed in light of additional data.
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Content ArticleThis toolkit from the British Medical Association looks at some of the key challenges students may come across when undertaking a medical elective in a developing country. Topics covered include: Staying within your competence Emergency situations Maintaining ethical standards Minimising burdens on the host country.
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Content ArticleThis guidance, from the British Medical Association (BMA), provides doctors and medical students with the key legal and ethical considerations they need to take into account when working in conflicts and emergencies, and signposts to other sources of support and information. This guide is structured around areas known to be challenging, including: Threats to delivering care to appropriate standards, often linked to a shortage of resources. Pressures to transfer the injured, sick or wounded to substandard health facilities. Identifying an acceptable lower limit of quality: at what point do you draw the line?
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Content ArticleNurses often express a desire to serve others as a volunteer. They volunteer within their communities and across borders in global settings. While nurses considering participation or serving as a volunteer express altruistic intention, their actions may result in unintended adverse consequences to the host community. The purpose of this position statement is to promote ethically responsible volunteer efforts classified as short-term (six months or less) practice experiences in local and global healthcare and public health.
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Content ArticleThis paper, published in Tropical Diseases, Travel Medicine and Vaccines, aims to present contemporary criticism of medical volunteering. A range of ethical concerns are identified and possible ways of alleviation suggested.
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Content ArticleThe views of practitioners at the sharp end of health care provision are now recognised as a valuable source of intelligence that can inform efforts to improve patient safety in high-income countries. Yet despite growing policy emphasis on patient safety in low-income countries, little research examines the views of practitioners in these settings. We aimed to give voice to how healthcare workers in two East African hospitals identify and explain the major obstacles to ensuring the safety of patients in their care. This study, published in Globalization and Health, involved in-depth, face to face interviews with healthcare workers in two East African hospitals. Authors conclude that though the impact of resource constraints and weak governance structures are particularly marked in low-income countries, the congruence between accounts of health workers in diverse settings suggest that the origins and solutions to patient safety problems are likely to be similar everywhere and are rooted in human factors, resources, culture and behaviour.
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