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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    Very little is known about the actual harm that occurs to patients in developing or transitional countries, although the available evidence suggests that they may have an even higher risk of suffering patient harm. Understanding the magnitude of the problem and the underlying factors represents the first step towards improvement. The World Health Organization (WHO) is making a concerted effort, in different parts of the world, to identify the main issues affecting safe care in developing and transitional countries and to use these data to begin to developing and implementing effective solutions.
  2. Content Article
    Errors associated with healthcare and their effects are prevented and mitigated through patient safety interventions. There is wider evidence that substantial public health harm is caused due to poor patient safety in both developed and developing nations. In the past, research in patient safety has largely been associated with developed nations. However, there has been a shift of focus to developing countries in recent years due to the global awareness of the need to enhance patient safety standards for all patients. This article, published in the Journal of The Royal Society of Medicine, aims to discuss the contextual factors associated with patient safety through focusing on developing a systems approach to enhance the quality and safety of care in developing countries. 
  3. Content Article
    This retrospective medical record review of hospital admissions during 2005 in eight countries aimed to assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies. Authors conclude that unsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied, and hence should be a high priority public health problem. 
  4. Content Article
    In this 30 minute video presentation, we hear from Dr Victoria Brazil, Professor of Emergency Medicine and Director of Simulation, Gold Coast Health Service. Dr Brazil talks through the benefits and complexities of simulation training using real life footage to illustrate key points. She suggests there are three ways healthcare can be improved using simulation: Simulation to explore Simulation to test Simulation to embed.
  5. Content Article
    In this letter to the British Medical Journal, a group of clinicians call for thorough assessment and investigation for patients with Long COVID, highlighting that many were initially advised to 'stay at home' and were unable to access usual care. The authors note: "Pathological consequences such as myocarditis or a thromboembolic episode may explain symptoms, and these have been noted to occur months after onset in long covid support groups. The medical profession needs to evolve rapid transformative pathways to deal with the long term sequelae of covid-19 that include full investigation of patients." To read the letter in full, follow the link below.
  6. Content Article
    The objective of this study was to to report the frequency of adverse events (AEs) that occurred during the months when SARS-CoV-2 spreading rate was at its highest in the Italian nursing homes, and to identify which conditions and attributes were most associated with the occurrence of AEs. Authors note that future recommendations for the management and care of residents in nursing homes during the COVID-19 pandemic should include specific statements for the most vulnerable populations, such as people with dementia. This research paper can be viewed in full via the link below to the Frontiers in Psychiatry website.
  7. Content Article
    Research has shown differential attainment by ethnicity in the medical workforce across all measures of training and career progression. In this editorial, published in the BMJ, Victor Adebowale and Mala Rao argue that a race equality observatory is needed to provide leadership and data.
  8. Content Article
    In this analysis, published by the BMJ, professor of public health, Sarah Salway and colleagues, argue that the UK health system must take urgent action to better understand and meet the health needs of migrants and ethnic minority people.
  9. Content Article
    Women from ethnic minorities are voicing their concerns that they face endemic structural racism when seeking and accessing healthcare, and they feel that their symptoms and signs are more often dismissed. It is vital that patients are listened to when they say that they feel this is also due to structural racism in healthcare.
  10. Content Article
    Ryan's Rule is a three step process to support patients of any age, their families and carers, to raise concerns if a patient’s health condition is getting worse or not improving as well as expected. Ryan’s Rule applies to all patients admitted to any Queensland Health public hospital including the emergency department, and in some Hospital in the Home (HITH) services.Ryan’s Rule has been developed in response to the tragic death of Ryan Saunders, who died in 2007 from an undiagnosed Streptococcal infection, which led to Toxic Shock Syndrome. When Ryan’s parents were worried he was getting worse they did not feel their concerns were acted on in time. In light of his death, the Department of Health made a commitment to introduce a patient, family, carer escalation process (Ryan’s Rule), to minimise the possibility of a similar event occurring.Follow the link below to the Queensland Government website to find out more about Ryan's Rule and how it works in practice.
  11. Content Article
    As research into the long-term impact of COVID-19 continues, this guide from the Royal College of Nursing explores the symptoms and how clinicians can support their patients’ recovery. Topics covered: Post-viral fatigue Fluctuating multi-system symptoms Lasting organ damage Post-intensive care syndrome Mental health Learning and training
  12. Community Post
    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
  13. Content Article
    This infographic is from Katie Martin's book, Learner-Centered Innovation: Spark Curiosity, Ignite Passion and Unleash. It highlights four key elements as key to creating a culture of learning and innovation. Give permission Offer protection Reduce and remove policies Eliminate perfectionism. This graphic can be used to spark conversation around safety culture within health and care teams, organisations and the wider healthcare service.
  14. Content Article
    This accredited programme, approved by the Nursing and Midwifery Board of Ireland, is the first of its kind to be offered in Ireland. It aims to support learners in the development of an appropriate level of knowledge, skill and understanding to enable them to appropriately recognise and respond to domestic abuse. This course will be of particular interest to those individuals whose work may bring them into contact with victims of domestic abuse. Follow the link below to find out more.
  15. Content Article
    Staff safety is fundamental to running an effective health service and delivering quality care. This year has highlighted how important risk assessments are in protecting the NHS workforce, as it continues to respond to the COVID-19 pandemic. We know that frontline healthcare staff are more at risk of becoming infected with COVID-19. We also know the virus has a disproportionate impact on staff from minority ethnic communities, and that many NHS workers are considered “clinically vulnerable” to COVID-19. There are also risk factors that relate to gender, age, weight and many more. This can understandably leave staff feeling confused about what they should and shouldn’t be doing to look after themselves and their colleagues.  On 24 June, it became mandatory for all trusts to complete occupational risk assessments of vulnerable NHS workers. In this interview, Patient Safety Learning speaks to James Duez, CEO of Rainbird. James tells us how his company developed an automated decision-making tool, able to produce individualised risk assessments so that appropriate measures can be put in place quickly. 
  16. Content Article
    Around 1 in 12 people are exposed to domestic violence and abuse (DVA) during pregnancy. Health appointments during this time are a good opportunity for maternity staff and other health professionals to ask people about DVA and offer support. Maternity staff routinely screen for DVA, yet disclosure and referral rates remain low. This course is designed for midwives and maternity staff caring for people giving birth and their families. It may also offer useful guidance for any professional providing care for pregnant people and in the postpartum period. Participants will discover the research, guidelines and techniques for screening for DVA more effectively. They will have the opportunity to enhance their ability to support victims and contribute to creating change in DVA rates during pregnancy. Follow the link below to register for free.
  17. Content Article
    This webinar from the British Intrapartum Care Society, asks whether the medicalisation of childbirth gone too far. UK maternity services have become medicalised in an attempt to reduce pregnancy risks. But what are the risks that we use to justify these interventions and how well do we communicate these to women? How do we provide care for those who request alternative or non-recommended pathways of care? Speakers include Andrew Weeks, Jim Thornton, Maria Booker and Kemi Johnson and the webinar is Chaired by Natalie Carter from the British Intrapartum Care Society.
  18. Community Post
    You can read Patient Safety Learning's blog about improving hysteroscopy safety here.
  19. Content Article
    In this article, published by the Harvard Business Review, authors discuss how to safely tackle the backlog of elective surgeries, created by the initial wave of the pandemic. They highlight the significant role of human factors such as stress or fatigue, and suggest strategies to mitigate them.
  20. Content Article
    The Scottish Ambulance Service has recently launched a positive reporting scheme called GREATix. GREATix is a peer-to-peer tool for recognising and learning from positive feedback in the workplace. Feedback will be used to pass on words of gratitude and identify improvement strategies.
  21. Content Article
    The COVID-19 pandemic provides new challenges for the safety of people receiving and providing maternity care. This project, conducted in collaboration with the PROMPT Maternity Foundation and THIS.institute, involved a rapid-response consultation exercise to understand what good looks like for managing obstetric emergencies in women with suspected or confirmed COVID-19.
  22. Content Article
    More and more women in Worcestershire are benefiting from having an individual named midwife throughout their maternity journey. In this short video, new Continuity of Carer (CoC) midwives from Worcestershire Acute Hospitals NHS Trust, and some local mums explain what it's like to be part of a CoC model.
  23. Content Article
    With delays to promised support and trusts accused of penalising staff during their recovery, HSJ dig into why the NHS must provide support sooner rather than later for those experiencing Long-COVID. Patient Safety Learning has recently published a blog calling for better information and engagement with patients who have Long COVID: Clear NHS plan needed to reassure Long COVID patients. We have also co-produced a patient information leaflet with the Royal College of General Practitioners, to help patients understand what they can expect from their GP. To listen to the HSJ podcast, click on the link below. 
  24. Community Post
    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.
  25. Content Article
    Annie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
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