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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This update from the Office of National Statistics (ONS) provides the latest data and analysis related to the coronavirus (COVID-19) pandemic and its impact on deaths and health data.
  2. Content Article
    In this briefing The Health Foundation provides an overview of the impact of the COVID-19 pandemic on social care in England. In part 1 they describe how the pandemic unfolded in the social care sector from March until June 2020, and in part 2 they examine the factors that contributed to the scale and severity of outbreaks in care homes. In part 3 they attempt to quantify the disruption to health and social care access from February until the end of April 2020.
  3. Content Article
    This document was drafted on the basis of the Transparency Committee opinion, French National Authority for Health, dated 27 February 2019. It found insufficient clinical benefit of ESMYA* for the treatment of uterine fibroids to justify reimbursement. They conclude: The actual clinical benefit of ESMYA is insufficient to justify its reimbursement by public funding in its two indications. Not approved for non-hospital pharmacy reimbursement or for hospital treatment. *ESMYA - (ulipristal acetate), progesterone receptor modulator.
  4. Content Article
    In this guest blog, Sarah Graham, award winning journalist, founder of Hysterical Women and author of Rebel Bodies, talks about gender bias within healthcare. Sarah draws on research, anecdotal evidence and the recent Cumberlege report to highlight how widespread mistreatment of women can have a negative impact on their safety as a patient.
  5. Content Article
    Healthcare Quarterly is a Canadian publication and this issue, supported by the Canadian Patient Safety Institute (CPSI), focuses on patient safety.
  6. Content Article
    Authors of this article, published by Health Europa, argue that proactive patient safety and risk prevention are key to helping healthcare organisations surveil and mitigate global and local risks.
  7. Content Article
    More women than men die annually from ischaemic heart disease (IHD) in the developed world. This represents a reversal of fortune from previous decades and places women firmly as the new majority now impacted. Notably, the adverse IHD gender gap is the widest in relatively young women, where myocardial infarction (MI) mortality is 2-fold higher in women under 50 years compared with age-matched men. While it is now clear that there are many gender differences in IHD outcomes, including more frequent angina diagnosis, more office visits, more avoidable hospitalisations, higher MI mortality, and higher rates of heart failure in women compared with men, the aetiologies contributing to these differences are less clear.
  8. Content Article
    How is COVID-19 repeating patterns of existing health inequalities? What factors are driving the disproportionate impact of the pandemic on the health of ethnic minority populations? And what needs to happen next? Helen McKenna talks to Natalie Creary, Programme Delivery Director at Black Thrive, and James Nazroo, Professor of Sociology at the University of Manchester.
  9. Content Article
    This report, from the Healthcare Safety Investigation Branch (HSIB), provides insight into a current safety risk that was identified on a referral. The referral was about difficulties in identifying clinical deterioration in patients with COVID-19 on general wards. The Royal College of Physicians (RCP) highlighted the issue of rapid deterioration in oxygenation in patients with COVID-19 and how this might relate to the use of early warning scores.
  10. Content Article
    Since the release of the report Hearing and Responding to the Stories of Survivors of Surgical Mesh in December 2019, the New Zealand Ministry of Health, in collaboration with other health sector agencies, has been working to progress the agreed actions and support those who have been affected and minimise future harm. An update on each of the actions is detailed in the report is provided below.
  11. Content Article
    In this article for Stylist, Sarah Graham, founder of the Hysterical Women blog, looks at the statistics around gender and heart attacks and gender. She highlights the worrying disparities and argues that sexism plays a dangerous role. The term Yentl Syndrome is used to describe the different ways men and women are treated after heart attacks.
  12. Content Article
    Chaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – patient complaints.
  13. Content Article
    Restorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the Liverpool region, implemented restorative justice (or what it termed a 'Just and Learning Culture') to fundamentally change its responses to incidents, patient harm, and complaints against staff. This study highlights the qualitative benefits from this implementation and also identifies the economic effects of restorative justice.
  14. Content Article
    For 10 years, 29-year-old historian Robyn battled extreme endometriosis pain, but was continuously dismissed by doctors when she went to them for help. She was finally diagnosed with the condition – but five surgeries later, it was clear the damage had already been done. In this article published by Stylist, she asks why women’s health issues aren’t being taken seriously enough.
  15. Content Article
    In this article, published by BBC Future, Jennifer Billock highlights the gender disparities that exist within healthcare.
  16. Content Article
    In this article, published by Refinery 29, author Sarah Graham talks about gender bias in healthcare and the risk to patient safety.
  17. Content Article
    Authors of this article, previous argued that inadequately managed pain in children should be considered an adverse event, a harmful patient outcome. They argued that inadequately managed pain meets the definition of an adverse event and further hypothesised that treating pain as an adverse event may improve care by raising health care administrators and quality improvement experts’ awareness of this issue.  In this article, published in the Journal of Child Care Health five years on, they reflect on the progress made in both moving this proposition forward and testing out the concept. They then move on to look at what still needs to be done to ensure that children’s pain is managed effectively.
  18. Content Article
    In our final 2-minute Tuesday session of July 2020, Patient Safety Learning's Chief Executive, Helen discusses Baroness Cumberlege’s report ‘First Do No Harm’. She focuses on how the report amplifies the voices of women, identifying the scale and severity of harm going back decades to thousands of women. She adds: "This has been a problem hidden in plain sight that is now being exposed." Helen asks listeners whether they agree that transformational change is needed in the health and social care system to address these issues. Read more on our thoughts and the actions in response to the Cumberlege Review.
  19. Content Article
    In this edition of the Nursing and Midwifery Council's (NMC) public newsletter, we hear from Sarah Seddon, who was a witness in a fitness to practise investigation following the tragic loss of her baby. She shares how this process felt and how she is using her personal experience to help the NMC work in a more person-centred way.
  20. Content Article
    When recovering from COVID-19 people may still be coming to terms with the impact the virus has had on both their body and mind. Your COVID Recovery is a digital resource that has been developed by the NHS to help people understand what has happened and what they might expect as part of their recovery. Content includes: Managing the effects Wellbeing Exercises When to seek help Information for family, friends and carers.
  21. Content Article
    In this briefing the British Heart Foundation highlights the stark inequalities in awareness, diagnosis and treatment of heart attacks that are leading to women needlessly dying every day in the UK.
  22. Content Article
    It is hypothesized that 90% of antibiotic allergies documented in patients’ health records are not actual, potentially life threatening, type I allergies. This distinction is important because such documentation increases antibiotic resistance, as more second-choice and broad-spectrum antibiotics are then used. Evidence is lacking regarding causes of this inappropriate documentation. To develop interventions aimed at improving documentation, the authors of this study, published in the Annals of Family Medicine, explored experiences of family physicians and pharmacists in this area. They found that the professionals involved perceived that antibiotic allergy documentation is seldom accurate, which may contribute to development of antibiotic resistance, increased costs, and decreased patient safety.
  23. Content Article
    This US study, published in Pediatrics, found that even among apparently healthy children, being African American is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity.
  24. Content Article
    This report from the Parliamentary and Health Service Ombudsman, follows an invitation from the House of Commons Select Committee on Public Administration and Constitutional Affairs to explore the state of local complaints handling across the NHS and UK Government departments. It draws upon significant evidence taken from interviews carried out with a wide range of individuals and organisations who have first-hand experience of how the NHS and UK Government departments approach complaints. It also incorporates a review of a wide range of other research reports and over 300 of our own investigation reports documenting complainant experience. The report highlights three areas that need to change: There is no consistent way in which staff are expected to handle and resolve complaints. Staff do not get consistent access to training to support them in their complex role - complaint handling should be recognised as a professional skill. Public bodies too often see complaints negatively, not as a learning opportunity that can be used to improve their service.
  25. Content Article
    Patient experience measures are widely used as a means of assessing the quality of care from the perspective of users. Despite the recent proliferation of these measures, they are all too often poorly understood and fail to lead to service improvements. This session, from the European patient experience and innovation congress (EPIC), will look at the role that measuring and understanding experiences can play in ensuring that care services are person-centred, including the barriers to effective use of experience information and how these can be overcome.  
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