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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    Dr Richard Harrison is a pain researcher employed at the University of Reading and affiliated with the School of Psychology and Clinical Language Sciences (SPCLS) and Centre for Integrative Neuroscience and Neurodynamics (CINN). His research focuses predominately on pain, examining psychological processes underlying how pain is processed, as well as individual differences in the ability to modulate (or control) the experience of pain. In this blog, Richard reflects on his recent research on pain experience and assessment during hysteroscopy procedures, published recently in the British Journal of Anaesthesia. "The dangers of advertising hysteroscopy as a mildly painful procedure are many. Firstly, this stands to put women off engaging with a very useful diagnostic test for the identification of serious medical conditions, such as ovarian cancer or endometriosis. But secondly, it is highly plausible that the resulting prediction error stands to make the experience even more painful than if patients were appropriately warned."
  2. Content Article
    Having consistent healthcare support during pregnancy, labour and after your baby’s born can make the world of difference. In this webpage, the National Childcare Trust (NCT) focuses on the following questions: What does Continuity of Care in maternity mean? What are the benefits? How can I make continuity of care more likely?
  3. Content Article
    This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care. Further research is needed to explore findings of fewer preterm births and fewer foetal deaths less than 24 weeks, and all foetal loss/neonatal death associated with midwife-led continuity models of care.
  4. Content Article
    The purpose of this study, published in Acta Bio-Medica, was to explore the skills of the continuity care of patient operated by the midwife and to research the evidences that support such model. In particular, the aim was to verify whether there are efficacy trials that support the caseload midwifery care model. The questions that have guided this work are the following: Is the midwifery-led care model a safe caring model based on the evidences? Is the continuity of care provided by the midwife during pregnancy and childbirth as safe as the one provided by physicians or multi-professional teams? Is it therefore possible to propose its implementation in the obstetric units in Italy? The second aim was to explore evidence of customer satisfaction with the midwifery-led care model, and to verify also the satisfaction from the midwives who are part of a midwifery-led care model, in terms of job satisfaction and of a good balance between private and professional life.
  5. Content Article
    This resource from the Royal College of Midwives, contains practical information and contains interactive exercises for midwives to use on their own or as part of a group, to support implementation conversations relating to continuity of carer.
  6. Content Article
    This report, from the Royal College of Midwives, found that continuity of midwifery care contributes to improving quality and safety of maternity care. High quality evidence indicates that women who receive care in these models are more likely to have effective care, a better experience and improved clinical outcomes. There is some evidence of improved access to care by women who find services hard to reach and better co-ordination of care with specialist and obstetric services. Continuity of midwifery care can provide services for all women across all settings, whether women are classified as high or low risk and current evidence shows improved outcomes with no adverse effects in populations of mixed risk. In addition improved birth outcomes also result when women receiving continuity of midwifery care give birth in obstetric units.
  7. Content Article
    Heralded as an easy fix for health services under pressure, data technology is marching ahead unchecked. In this article for the BMJ, Poppy Noor asks whether there a risk it could compound inequalities.
  8. Content Article
    Authors of this commentary published in the Canadian Medical Association journal argue that many patients suffer from a specific adverse event on a daily basis: pain. It is never reported as an adverse event and corrective action is often not taken.
  9. Content Article
    This blog, published in the BMJ, sets the context for an Evidence Based Nursing (EBN) Twitter Chat that took place on 18 March 2015. The chat focused on whether mismanaged (undertreated) pain should be considered an adverse event. The Twitter Chat was hosted by Dr Alison Twycross who is editor of EBN and has also done lots of work in the area of paediatric pain management. This blog provides some context for the chat. The examples given relate to paediatric pain but the principles apply to pain in patients of all ages.
  10. Content Article
    Involving patients in decisions about their care is of fundamental importance to effectively managing long-term conditions and improving patient safety. In 2020, AbbVie brought together patient groups, health and social care services, national organisations, policymakers, and parliamentarians to a Showcase at Westminster celebrating exemplar projects that promote shared decision making practices from across the country. The link below contains the posters from the projects showcased on the day, showcasing the creative work taking place across the UK in the shared decision-making space.
  11. Content Article
    Many working age adults in the UK lack skills to understand and use information on health and wellbeing. Health literacy skills are lacking in 43% of the population and numeracy skills in 61%. This gap between skills and the complexity of health information leaves millions excluded from making informed decisions about their health, compounding existing health inequalities. COVID-19 accelerated the digital ambition of the NHS Long Term Plan. In the four weeks to 12 April 2020, 71% of routine GP consultations were delivered remotely, according to the Office for National Statistics (ONS). Secretary of State for Health Matt Hancock has said he wants this trend to continue and it is likely remote consultations will be part of the new normal. However, nine million people lack digital skills, 8% are not connected and 66% with online access do not use the internet or digital tools to support their health. In 2019 there was already concern that people with low health literacy and those without access, skills or motivation to use digital tools would be left behind in a digital first NHS. Late in 2019 the Patient Information Forum (PIF) ran a survey of its membership about their action on health and digital literacy. Its findings and recommendations have been made more urgent by the inequalities exposed by the pandemic.
  12. Content Article
    Information to help people make the right decisions about their general health and treatment against perceived risk of COVID-19 infection has been a key concern of Patient Information Forum (PIF) members throughout the pandemic. The Covid Choices survey was developed with a collaborative group of expert patients and other partners. More than 800 people responded to the survey and made more than 1000 detailed free text comments expressing their concerns. The vast majority of people had a health condition or cared for someone who did. Around 60% said their long-term condition put them at risk of infection and just under half were shielding. Responses represented people with a wide range of health conditions.
  13. Content Article
    The National Institute for Health and Care Excellence (NICE), is developing the COVID-19 guideline: management of the long-term effects of COVID-19. The final scoping document and associated project papers are now available.
  14. Content Article
    This report is an update on the Care Quality Commission's (CQC's) work looking at the quality of, and access to, mental health services for children and young people.
  15. Content Article
    The Care Quality Commission (CQC) has revised its “Registering the right support” guidance to make it clearer for providers who support autistic people and/or people with a learning disability.  Following feedback from people who use services CQC has updated its guidance so it has a stronger focus on outcomes for people including the quality of life people are able to experience and the care they receive.
  16. Content Article
    This report is the product of a review by Baroness Doreen Lawrence, commissioned by the Labour Party, into the disproportionate impact of Covid-19 on Black, Asian and minority ethnic communities. In her introduction to the report, Baroness Lawrence says: "Black, Asian and minority ethnic people have been overexposed, under protected, stigmatised and overlooked during this pandemic – and this has been generations in the making. The impact of Covid is not random, but foreseeable and inevitable – the consequence of decades of structural injustice, inequality and discrimination that blights our society. We are in the middle of an avoidable crisis. And this report is a rallying cry to break that clear and tragic pattern."
  17. Content Article
    This blog, from the US-based Patient Safety Movement, tells the story of Gabriella Galbo who died of preventable causes. The systems that were supposed to keep her safe and bring her back to health were established on an unreliable, fragmented foundation with no checks and balances and certainly no person-centered culture of safety. Gabby’s full story can be read via the link below, as told by her father, Tony. Included are tips from Tony for using your voice to prompt tangible action and to ensure policies are in place to prevent medical errors, like those experienced by Gabby.
  18. Content Article
    In this podcast from The Health Foundation, Chief Executive Dr Jennifer Dixon talks to Jeremy Hunt about his tenure as the longest-serving health secretary. Jeremy speaks about his passion for patient safety, a topic which became his professional focus following the Mid-Staffs investigations. He highlights the importance of the patient safety agenda and the need to learn from past experiences. With the challenges of the COVID-19 pandemic holding the world’s attention, what would Hunt have done differently? And what are the key lessons for government as we enter a new phase of the pandemic?
  19. Content Article
    This report seeks to inform the six-month review of the Coronavirus legislation required by the Coronavirus Act 2020 along with any future response to a “second wave” of the virus later this year. The report begins by setting out the legislative framework in play, then focuses on the following themes and rights: Human rights impact of the lockdown (Articles 8, 9, 10 and 11 ECHR) The right to life, including both the substantive and procedural duties on government (Articles 2 and 3 ECHR) and the right to health which has been (partially) incorporated within the positive obligation to secure the right to life. Issues in relation to detention settings (Articles 5, 8, 3 and 2 ECHR) Contact tracing and privacy rights (Articles 8 and 14 ECHR) Access to justice (Articles 6 and 2 ECHR) Children’s rights —the right to education (Article 2 of Protocol 1 ECHR) and the right to family life (Article 8 ECHR) The report also reflects on the challenge of ensuring the emergency legislation required in response to the outbreak was subject to appropriate parliamentary scrutiny and review. Follow the link below to read the full report including conclusions and recommendations.
  20. Content Article
    Across the world, people are suffering from life-altering and serious chronic pain conditions caused by surgical mesh complications.Mesh Down Under are a New Zealand based campaign group whose mission is to:raise awareness amongst New Zealanders about the complications that are not rare with the use of surgical mesh. provide information to enable anyone considering having surgical mesh surgery, particularly women having pelvic floor or bladder sling repairs, to be fully informed before consenting to this surgery.shout out to our health professionals and government bodies so that patient stories are no longer 'news to them' but an acknowledged public health issue that needs to be addressed.highlight the importance of reporting adverse events associated with medical devices.Follow the link below to find out more.
  21. Content Article
    Speaking up protects patient safety and improves the lives of workers. When things go wrong, we need to make sure that lessons are learnt and things are improved. If we think something might go wrong, it’s important that we all feel able to speak up so that potential harm is prevented. Even when things are good, but could be even better, we should feel able to say something and should expect that our suggestion is listened to and used as an opportunity for improvement. Freedom to Speak Up is about encouraging a positive culture where people feel they can speak up and their voices will be heard, and their suggestions acted upon. Follow the below link to access training modules that explain in a clear and consistent way what speaking up is and its importance in creating an environment in which people are supported to deliver their best. It will help you understand the vital role you can play and the support available to encourage a healthy speaking up culture for the benefit of patients and workers. The training has been developed by the National Guardian and Health Education England for anyone who works in healthcare.
  22. Content Article
    Learning about healthcare safety often focuses on understanding what has gone wrong, but it is just as important to examine what good looks for safety in maternity units. In this blog, Elisa Liberati describes how she worked with a team and several collaborators to develop a framework describing 7 key features of safety in maternity units. To ensure the study was as rigorous as possible, they combined several different methods and worked in a highly collaborative way across the system. Follow the link below to read the full blog, published by THIS.Institute.
  23. Content Article
    There is evidence that COVID-19 may cause long term health changes past acute symptoms, termed ‘long COVID’. This paper includes detailed cognitive assessment and questionnaire data from tens thousands of datasets, collected in collaboration with BBC2 Horizon, which align with the view that there are chronic cognitive consequences of having COVID-19. This article, published by medRxiv, is a preprint and has not been peer-reviewed. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.
  24. Content Article
    This Independent Report was commissioned by NHS Improvement to review the deaths set out above, after Southern Health NHS Foundation Trust had requested their assistance. This Report considers in the order of their deaths: 1. Robert Small, who died on September 17, 2012 2. David West, who died on October 21, 2013 3. Edward Hartley, who died on May 28, 2014 4. Marion Munns, who died on November 12, 2015
  25. Content Article
    The National Institute for Health and Care Excellence (NICE) has released updated guidance which says that healthcare professionals should now prescribe those people with severe allergies two Adrenaline auto-injectors (AAIs) when discharging patients from hospital, and patients should always carry two devices with them.
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