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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    Many people are experiencing health difficulties for several months after they have been infected with COVID-19. There is work underway to make sure healthcare staff have more information about the longer-term effects of COVID-19 and how to look after these patients safely. This is due to be published by the National Institute for Health and Care Excellence (NICE) at the end of this year.
  2. Content Article
    This is a guest post for the Hysterical Women website, by Kath Sansom, founder of the Sling the Mesh campaign. Content warning: mention of self-harm.
  3. Community Post
    In a blog, published on the hub today, Midwife Samantha Phillis talks about her experience of the Midwifery Continuity of Carer (CoC) model. Samantha reflects on the benefits of getting to know your patients throughout their pregnancy journey and how this can lead to better outcomes. What are your thoughts on Continuity of Carer? Do you have experience of working this way? Have you seen an impact on patient safety? Perhaps you want to ask others how they set it up in their area? Or maybe you're a patient and had the same midwife care for you throughout your pregnancy. Can you tell us more about your experience and how it made you feel? Please share your thoughts in the comments below. You'll need to be a hub member to comment, it's free and easy to do. You can sign up here.
  4. Content Article
    In this short video produced by Endometriosis Explained, retired gynaecologist, MJ Quinn, talks about the neuropathic causes of painful hysteroscopy. This includes seven recommendations for how to avoid severe pain outpatient hysteroscopy. 
  5. Content Article
    Pain is spoken about often within health and social care. Patients might be asked to locate our pain during examinations, to rate our level of pain or to describe the type of pain we are feeling. They may be forewarned of the possibilities of pain occurring during or after procedures or operations. Medical consent forms often include reference to the risk of pain and require a signature to confirm they have been appropriately ‘informed’. Pain can be acute (lasting less than 12 weeks) or chronic (lasting more than 12 weeks), and the way we experience it, our thresholds, can also vary. It can be our body’s way of warning us of potential damage, yet it can also occur when no actual harm is happening to the body.[1] It can cause trauma, physiological reactions, mental health difficulties and chronic fatigue, and can have a huge impact on someone’s quality of life and ability to perform daily tasks.[2] Pain is undoubtedly complex, but is it a patient safety issue?[3]
  6. Content Article
    As with all aspects of the NHS, a number of changes have been enacted in the operation of maternity services as a result of the COVID-19 pandemic. While many of these changes are important and justifiable in order to protect the safety of pregnant people, maternity staff and newborns, it is vital that any (incidental) adverse implications to these policies be addressed. This blog, published by the BMJ, examines one such change; the policy which has been implemented by many NHS Trusts which provides that pregnant persons will only be admitted to the labour ward once labour has been “confirmed as established”.
  7. Content Article
    In this blog by the British Society of Criminology, Sharon Hartles critically examines the journey so far towards the implementation of the remaining eight recommendations set out in the landmark publication of the Medicines and Medical Devices Safety Review First Do No Harm report in July 2020.
  8. Community Post
    We are currently seeking a couple of patients who would be happy to help us with a hysteroscopy communication piece. It will involve a short video recording via zoom, talking about your experience and also to share any benefits you have found in coming together via this forum and the hub. If you have any questions or would like to take part, please email me at stephanie@patientsafetylearning.org.
  9. Content Article
    In this short video, Respiratory Consultant, Dr Catherine Monaghan from North Tees and Hartlepool NHS Foundation Trust, talks about the complexity of coronavirus. She emphasises that this is a very real and dangerous virus that presents in a huge variety of ways. She urges people to take all precautions possible and not to 'play Russian roulette' with their health, as the virus can have devastating consequences with young, fit people also very much at risk.
  10. Content Article
    In this blog, published by the Institute for Healthcare Improvement, Kedar Mate discusses the need to explicitly address race and racism in order to work towards health equity. "We never legislated long waiting times. We never imposed rules, regulations, customs, and norms for ineffective care. We did, however, legislate inequity."
  11. Content Article
    It's important to think about how we are safe on the front line, doing the work day in and day out. How do our policies, processes and practices across an entire organisation impact the safety of our work? Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. He currently specialises as a human factors and safety specialist in air traffic control in Europe, but has worked across most safety critical sectors. In this podcast, from the East of England Ambulance Service (EEAST) General Broadcast, Steven talks about how policies can interfere with each other, how hierarchy impacts performance and reflects on incidents.
  12. Content Article
    Hysteroscopy is a diagnostic gynaecological procedure traditionally requiring administration of general anaesthesia, but more frequently completed using local anaesthesia within a day-case (ambulatory) setting. Advantages associated with this transition include decreased completion times, fewer risks, and lower clinical costs. Numerous services advertise the procedure as being either pain free or low pain; however, it is estimated that 25% of patients report experiencing intense or intolerable pain. For severe pain, local anaesthetic can be administered, but this does not guarantee effective pain management. This research, published in the British Journal of Anaesthesia, found that very few patients feel no pain and a significant number felt pain of greater than 7/10. It also found a disconnect between the patient's experience of pain and the clinician's perception of it. This research paper is paywalled, but can be purchased via the link below.
  13. Content Article
    This comprehensive guide from the Social Care Institute of Excellence, discusses the lessons learned from hospital discharge and avoidance during the COVID-19 pandemic. It highlights challenges faced and good practice to prevent unnecessary admissions going forward.
  14. Content Article
    SKYbrary is an electronic repository of safety knowledge related to flight operations, air traffic management (ATM) and aviation safety in general. It is also a portal, a common entry point, that enables users to access the safety data made available on the websites of various aviation organisations – regulators, service providers, industry.
  15. Content Article
    Among the range of avoidable harms associated with health care, health care-associated infections (HAI) are a significant burden. Surgical site infections (SSIs) are the most frequent HAI in low and middle income countries and the second most frequent HAI in higher income settings. In the most challenged settings, they can affect up to one-third of surgical patients. SSI prevention is a high priority worldwide, but it is particularly complex as the risks include multiple factors determined by the patient’s condition, the system and the environment, as well as behaviours and actions associated with the organization and delivery of health care.
  16. Content Article
    Obstetric quality of care measures have largely focused on severe maternal morbidity (SMM), with little consensus about measures of less severe but more prevalent delivery and neonatal complications. This study, published in The Joint Commission Journal of Quality and Safety, analyses risk-adjusted maternal and neonatal outcomes using both ICD-10 coding and electronic health record (EHR) data.
  17. Content Article
    The objective of this US-based study, published in The Joint Commission Journal of Quality and Safety, was to present safety briefings as a method for discovering and addressing safety events in a paediatric emergency room, describe how professionals perceive them, and characterize the classification and evolution of the incidents identified.
  18. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation focused on: the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke.
  19. Content Article
    This is an online platform and information portal for post covid syndrome (also known as Long Haul Covid, Long Tail Covid and Long Covid). It has been designed to be a central point for patients, practitioners and researchers globally.
  20. Content Article
    In this blog, Stephanie O'Donohue, Content and Engagement Manger for Patient Safety Learning, discusses some of the patient safety issues that specifically impact on women. Drawing on recent inquiries, patient testimonials and research, Stephanie focuses on three main issues; consent, patient engagement and bias. She highlights the need for people to work in partnership to understand the barriers to safe care for women and to prevent future harm. 
  21. Content Article
    Hysteroscopy is a procedure used as a diagnostic tool, to identify the cause of common problems such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. In recent years, there has been an increased focus on these procedures being performed within outpatient services. The availability of pain relief is much reduced in these settings. There are financial incentives in place to support this move to day surgery.[1] Reflecting on activity to date, Patient Safety Learning discusses the important role that consent, patient engagement and collaborative action is playing in highlighting a serious patient safety concern and in driving the change needed for safe hysteroscopy.
  22. Content Article
    NHS Commissioning guidance to assist local healthcare systems to establish post-COVID assessment clinics for patients experiencing long-term health effects following COVID-19 infection.
  23. Content Article
    This NHS document outlines new guidance on accessing and referring into the digital COVID-19 rehabilitation programme, Your COVID Recovery.
  24. Content Article
    As set out in Implementing Better Births: Continuity of Carer, continuity of carer means each woman: • Has consistency in the midwife or clinical team that provides hands on care for a woman and her baby throughout the three phases of her maternity journey: pregnancy, labour, and the postnatal period. • Has a named midwife who takes on responsibility for coordinating her care, and for ensuring all her needs and those of her baby are met, at the right time and in the right place, throughout the antenatal, intrapartum and postnatal periods. • Has “a midwife she knows at the birth”. • Is enabled to develop an ongoing relationship of trust with her midwife who cares for her over time.
  25. Content Article
    The Campaign Against Painful Hysteroscopy is a campaign group raising awareness of the safety flaws that exist within the processes surrounding hysteroscopy procedures for women.  On 20 October 2020, they wrote to Matt Hancock MP, Secretary of State for Health and Social Care and Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health. In their letter they used both empirical data and the personal stories of women to illustrate the prevalence and seriousness of the issue. 
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