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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    In this article Yvonne Coghill, Director of the Workforce Race Equality Standard (WRES) Implementation Team in London, talks about how she is working with others to develop a race equality strategy for the capital.
  2. Content Article Comment
    Hi @Shamim Odera RN thank you for posting this, really very interesting and useful. Do you know if there is a version online or if you would have permission to reuse? Or perhaps you are the author? If you do have permission, you could add it to the hub via the 'Share' option. Any problems sharing resources and just get int ouch - one of our team will chat you through the process. Also, I have now added the GCP to the hub - thank you for the recommendation.
  3. Content Article
    Critical Care Recovery and Life Lines have teamed up to develop this web resource, designed to help patients and families recover from COVID-19. Informed by published expert guidance, they have also worked very closely with front line health care professionals, patients and families. This website will be updated regularly, as more information becomes available. 
  4. Content Article
    Hazardous Hospitals is a Wellcome Trust Research Fellowship, exploring the history of safety in the British National Health Service.
  5. Content Article
    On 28 June 2017, 13 year-old Karanbir Cheemer was at school when another pupil threw a small piece of cheese at him. He was known to be allergic to cheese and he went into anaphylactic shock. Karanbir later died.  In this report, senior coroner ME Hassell, highlights a number of patient safety concerns relating to his death and calls for action to prevent future deaths.
  6. Content Article
    Shanté Turay-Thomas, a young woman who had a nut allergy, died of an acute anaphylaxis after eating hazelnuts on 18 Spetember 2018. In this report, senior coroner ME Hassell, highlights 20 'matters of concern' surrounding her death and calls for action to be taken for future deaths to be prevented.
  7. Content Article
    This webinar recording from ICU Steps is a session with trustees about recovery from critical illness and what can be done to help.
  8. Content Article
    In this Guardian Long Read, Neil Singh highlights that during his medical training, it was almost always assumed that his patients would be white. He argues this prejudice is harmful in its own right – and when it comes to dangerous skin conditions, it can be deadly.
  9. Content Article
    When you are ill or recovering from an illness, you are likely to have less energy and feel tired. A simple task, such as putting on your shoes, can feel like hard work. This guide from the Royal College of Occupational Therapists (RCOT) uses the 3 Ps principle (Pace, Plan and Prioritise) to help you find ways to conserve your energy as you go about your daily tasks. By making these small changes you’ll have more energy throughout the day.
  10. Content Article
    National Learning Reports offer insight and learning about recurrent patient safety risks in NHS healthcare that have been identified through HSIB investigations. They present a digest of relevant, previously investigated events, highlight recurring themes and, where appropriate, make safety recommendations. National learning reports can be used by healthcare leaders, policymakers and the public to aid their knowledge of systemic patient safety risks and the underlying contributory factors, and to inform decision making to improve patient safety. The Healthcare Safety Investigation Branch (HSIB) Summary of themes arising from HSIB maternity investigation programme report (March 2020) describes eight themes arising from the maternity investigations. Sudden unexpected postnatal collapse (SUPC) was identified as a theme for further exploration in order to highlight areas of system-wide learning. SUPC is a rare but potentially fatal event in otherwise healthy appearing term (born after 37 completed weeks) newborn babies at birth. Between April 2018 and August 2019 HSIB completed 335 maternity investigations. Of the 12 identified SUPC cases, there were 6 cases where positioning of the baby to achieve skin-to-skin contact may have contributed to SUPC. While the number of incidents found was small compared to the number of term babies who had skin-to-skin contact at birth these incidents may in future be avoided and so learning is essential.
  11. Content Article
    This month, the Institute of Public Policy Research (IPPR) published their new Injury Prevention Policy, Better Than Cure.[1] In this report they call on the Government to make injury prevention a public health priority and to take further action to prevent the transmission of Covid-19 in the workplace. Patient Safety Learning welcomes the publication of this report and its recognition of the importance of improving patient safety. We concur with its identification of unsafe care as being driven by a range of underlying systems issues, such as the culture of fear, barriers to resource sharing and insufficient focus on patient safety training and skills. These closely relate to the six foundations of safer care we have set out in A Blueprint for Action.[2] We also agree about the importance of two core areas which they highlight for action in this respect: 1) The Government should commit to long-term safe staffing This is particularly an important issue as we return to more normal levels of care following the peak of the Covid-19 pandemic, with the need to ensure that organisations and staff transition to this safely.[3] We consider that system wide (health and social care) workforce modelling is needed to inform resourcing and ensuring safe staffing. 2) The NHS should use patient safety networks to share best practice We strongly agree about the importance of sharing learning for patient safety. We need people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. This is why we have created the hub, a patient safety learning platform. Designed with input from patient safety professionals, clinicians and patients, the hub provides a community for people to share learning about patient safety problems, experiences, and solutions. References 1. IPPR. Better Than Cure: Injury Prevention Policy, August 2020.  2. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 3. Patient Safety Learning. Patient Safety Learning’s response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, June 2020.
  12. Content Article
    In this webinar, Dr Matt Inada-Kim, Consultant Acute Physician, presents his idea for a COVID-19 virtual ward. Matt talks about using tools and information to empower people to monitor themselves at home so that they know when to ask for help. Early recognition would improve the chances of survival, particularly where symptoms are less obvious but very serious with the potential for rapid deterioration, for example low oxygen levels. Matt uses a Remote Community Oximetry Care (RECOxCARE) model to frame his thinking.
  13. Content Article
    In this article, published by The Justice Gap, Theo Huckle QC discusses the issue of people not receiving treatment because of diversion of pre-existing NHS resources to the fight against the COVID-19 pandemic. There are legal issues which arise about the rights of citizens to receive – and continue to receive – treatment from their health service. What are those rights and what right do Governments in the UK or the health Trusts have to reduce services and not treat existing patients because of the current global health crisis?
  14. Content Article
    Good Clinical Practice (GCP) is the international ethical, scientific and practical standard to which all clinical research is conducted. It is important that everyone involved in research is trained or appropriately experienced to perform the specific tasks they are being asked to undertake. GCP training is a requirement set out in the UK Policy Framework for Health and Social Care Research developed by the Health Research Authority for researchers conducting clinical trials of investigational medicinal products (CTIMPs).  Different types of research may require different training, and some researchers are already well trained and competent in their area of expertise. Some researchers doing other types of clinical trials may also benefit from undertaking GCP training but other training may be more relevant. The National Institute of Health Research (NIHR) offers range of Good Clinical Practice (GCP) courses and training aids for the clinical research delivery workforce.
  15. Content Article
    This article, by Nisreen Alwan, argues that defining and measuring recovery from COVID-19 should be more sophisticated than checking for hospital discharge, or testing negative for active infection or positive for antibodies. She highlights the number of previously healthy people with persistent symptoms such as chest heaviness, breathlessness, muscle pains, palpitations and fatigue, which prevent them from resuming work or physical or caring activities.
  16. Content Article
    This article, published in the British Medical Journal, is intended for primary care clinicians and relates to the patient who has a delayed recovery from an episode of COVID-19 that was managed in the community or in a standard hospital ward. Broadly, such patients can be divided into those who may have serious sequelae (such as thromboembolic complications) and those with a non-specific clinical picture, often dominated by fatigue and breathlessness.
  17. Community Post
    Dumfries and Galloway Royal Infirmary have installed a new poster explaining the practical workings of the Critical Care Unit in clear language for visitors and relatives. The funding was received from generous donations. Have you used visual communications to improve patient safety and to engage more effectively with staff, visitors or patients? What has worked well? You'll need to be a hub member to comment, it's quick and easy to do. You can sign up here.
  18. Content Article
    In this editorial for the British Medical Journal, Helen Haskell summarises the findings and recommendations of the Cumberlege Review, First Do No Harm. Helen argues that while the report has the potential to be a powerful tool for change in and beyond the UK, patients and families now need to see evidence of action.
  19. Content Article
    Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.  This is a coroner's report into the death of 35 year-old Mr Mitica Marin. It was found that the defibrillator was set to manual mode, which  meant that staff were not automatically alerted to the fact that Mitica's heart had a shockable rhythm. This caused a delay to Mr Marin receiving CPR treatment.
  20. Content Article
    Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.  This coroners report relates to the death of 15 year-old Najeeb Katende and the delay in defibrillation due to the equipment being set to manual mode and not detecting his shockable rhythm. The coroner found that the delay in defibrillating Najeeb significantly reduced his chances of survival.
  21. Content Article
    What can we take from the steady flow of Prevention of Future Deaths Reports (PFDs) issued by coroners in relation to patient care? How do these fit into the wider learning from deaths landscape? To help answer these questions, international law business DAC Beachcroft have taken a closer look at hospital-related PFDs to see if any common themes emerge and, if so, what is in the pipeline for tackling them.
  22. Content Article
    This investigation, published in Anesthesiology, was specifically designed to determine whether errors at low saturation correlate with skin colour.
  23. Content Article
    This paper, published in the Journal of patient safety, provides evidence from the patient perspective that consent forms are too complex and fail to achieve comprehension. Future studies should be conducted using patients’ suggestions for form redesign and inclusion of supplemental educational tools in order to optimise communication and safety to achieve more informed healthcare decision making.
  24. Content Article
    This article, published in the US-based Journal of healthcare information management, looks at the relationship between consent and patient safety. The author, James E. Gottesman, highlights the benefits of clear communication between clinician and patient.
  25. Content Article
    This is a report and survey analysis from Runnymede, the UK’s leading independent thinktank on race equality and race relations. Results show that black and minority ethnic (BME) people face greater barriers in shielding from coronavirus as a result of: the types of employment they hold (BME men and women are overrepresented among key worker roles)having to use public transport moreliving in overcrowded and multigenerational households morenot being given appropriate PPE (personal protective equipment) at work. In all of these areas, most BME groups are more likely to be over-exposed and under-protected compared with their white British counterparts.
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