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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This video looks at design and implementation of emergency checklists for rapid sequence induction (RSI) in the emergency department and intensive care unit: Where we've gone wrong, why the evidence shows no benefit, and how we can improve. It is presented by Michael Lauria who was a Pararescueman (PJ) in the US Air Force and Critical Care/Flight Paramedic for the Dartmouth-Hitchcock Advanced Response Team (DHART) . Currently he is an Emergency Medicine resident at the University of New Mexico Health Sciences Center.
  2. Content Article
    Chaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review report, 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 – informed consent. 
  3. Content Article
    This guidance is to support Clinical Commissioning Groups (CCGs) and NHS England in meeting their legal duties in respect of equality and health inequalities. CCGs and NHS England play key roles in addressing equality and health inequalities; as commissioners, as employers and as local and national system leaders, in creating high quality care for all.
  4. Content Article
    Antibiotics are key to modern medicine and treatment. Many procedures and treatments developed over recent years, such as chemotherapy, organ transplants and other major surgery, rely on antibiotics to prevent infections. They are also crucial in treating some forms of pneumonia and other illnesses. However, an increasing number of common infections are becoming resistant to the drugs designed to treat them. This is called antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) is part of the fight against AMR. The purpose of AMS is to ensure ‘the right antibiotic for the right patient, at the right time, with the right dose, and the right route, causing the least harm to the patient and future patients’. AMS programmes might include improving prescribing of antibiotics, promoting data collection and raising public awareness of AMR.
  5. Content Article
    In this commentary piece, published in BMJ Leader, Suzanne Shale draws attention to a broader notion of moral injury found in moral philosophy. In this version, a moral wound can be experienced by anyone. It arises from sources that include injustice, cruelty, status degradation and profound breaches of moral expectations. The moral-philosophical version of moral injury associates it with moral and psychological anguish, and feelings such as bewilderment, humiliation and resentment. According to this formulation of moral injury, it could affect patients, service users, families and loved ones as well as care staff. Suzanne highlights that experiences of moral injury among the wider public, as well as staff, will call for attention from care leaders long after the pandemic surge.
  6. Content Article
    Evidence to date indicates that patients from ethnic minority backgrounds may experience disparity in the quality and safety of health care they receive due to a range of socio-cultural factors. Although heightened risk of patient safety events is of key concern, there is a dearth of evidence regarding the nature and rate of patient safety events occurring amongst ethnic minority consumers, which is critical for the development of relevant intervention approaches to enhance the safety of their care.The findings of this systematic review, published in the International Journal for Equity in Health, provide substantial evidence to suggest that people from ethnic minorities are vulnerable to a higher rate of patient safety events in the hospital and community setting compared to the mainstream population.
  7. Content Article
    This series of podcasts, supported by the Maternity Experience (#MatExp), is produced by Florence Wilcock. She explores different topics within maternity, aiming to ignite positive change and action.
  8. Content Article
    This article, published by The Conversation, highlights the mounting evidence that some people who have had COVID-19 but were not hospitalised, are experiencing prolonged illness. Reported after-effects of the virus include; overwhelming fatigue, palpitations, muscle aches and pins and needles. The author of this article looks at the research to date and talks about using twin studies to gain further insight into 'post-COVID syndrome'.
  9. Content Article
    Patient Safety Learning have been hearing from patients suffering persistent symptoms of COVID-19, that they are feeling abandoned and unsupported. But in this 2-minute Tuesday session, Stephanie O'Donohue, Hub Content and Engagement Manager, asks Long COVID patients about any positive experiences they’ve had with the healthcare system, and ways in which they’ve been made to feel safe.
  10. Content Article
    Group B Strep can be a complex topic, with some confusion about what exactly is the latest guidelines on testing, risk factors, recommended antibiotics, and the impact (if any) of GBS on homebirths, waterbirths, breastfeeding, and much more.This is why Group B Strep Support and the Royal College of Midwives (RCM) have produced an evidence-based group B Strep i-learn module.The group B Strep i-learn module focuses on the current UK guidelines for preventing group B Strep infection in newborn babies and on signs of these infections in babies. It will refresh clinician knowledge of the national guidelines, and help you tackle the FAQs you get from expectant and new parents.Follow the link below to find out how to sign up.
  11. Content Article
    Group B streptococcus (GBS) is a naturally occurring bacterium, often found in the mother’s vagina, which can be dangerous for babies during labour and immediately after birth. The mothers carry this bacterium in the birth canal without any problem to themselves. Giving antibiotics to the mother during labour reduces the incidence of GBS infection passing on to the baby (National Institute for Health and Care Excellence, 2012).
  12. Content Article
    More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review, published by The Lancet, and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital.
  13. Content Article
    COVID-19 has created unprecedented pressures for the NHS as a whole including maternity services. How can maternity leaders run a safe and rights respecting maternity service during a pandemic? This guide, produced by Brithrights, sets out a process to support maternity service leaders to reach decisions that help them to achieve this. All those affected by decisions need to be involved in making them. NHS England guidance states that Maternity Voices Partnership Chairs should be involved in decisions about temporary changes to maternity services, in addition to staff and partner organisations.
  14. Content Article
    After babies are born they have to breathe, suck, feed, wee, poo and stay warm. This NHS leaflet (April 2020) will tell you how to keep your baby safe and healthy. Do not delay seeking help if you have any concerns. Content includes: What is jaundice? Breathing, colour and movement. Feeding.
  15. Content Article
    PPROM is the acronym for Preterm Pre-labour Rupture Of Membranes. This is otherwise known as when the waters break prior to 37 weeks during pregnancy. These waters, known as the amniotic fluid, protect the baby from injury. It also helps in preventing infection being passed from mother to baby. As soon as the waters break the risks of infection to both mother and baby are high. Therefore good management of care at this stage is key to treating this condition successfully. Little Heartbeats raise awareness of PPROM, help patients share their experiences and promote the use of the Royal College of Obstetricians and Gynaecology leaflet which contains the guidelines set out for UK hospitals to follow in the event of PPROM.
  16. Content Article
    This table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment.
  17. Content Article
    Patient Safety Learning's Chief Digital Officer, Clive Flashman, discusses the patient safety concerns around the thousands of health and care apps in app stores today, and how we can ensure patients are kept safe.
  18. Content Article
    Healthcare staff have had to adapt their way of working as a result of the pandemic, which has made pre-COVID guidance obsolete. Different Trusts are doing different things. Associate Director of Patient Safety Learning and Critical Care Outreach Nurse, Claire Cox, outlines the challenges and asks, what is the solution?
  19. Content Article
    Early clinical experiences have demonstrated the wide spectrum of COVID-19 presentations, including various reports of atypical presentations of COVID-19 and possible mimic conditions. This article, published in the BMJ, summarises the current evidence surrounding atypical presentations of COVID-19 including neurological, cardiovascular, gastrointestinal, otorhinolaryngology and geriatric features. 
  20. Content Article
    This short film was created by patients who are experiencing long-lasting and debilitating symptoms of COVID-19, to raise awareness of their ongoing issues, also known as 'Long COVID'.
  21. Content Article
    The results of this study, published in the Journal of Translational Medicine, confirm previous work that demonstrated an abnormal response to exercise in fatigued ME/CFS patients.
  22. Content Article
    ‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a ‘Safety-II systems approach’ to promote understanding of how safety may be achieved in complex work systems. Authors of this paper, published by BMJ Open Quality, aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting.
  23. Content Article
    The MBRRACE-UK Saving Lives, Improving Mothers' Care report found that black women in the UK are five times as likely as white women to die during pregnancy or childbirth.
  24. Content Article
    In this blog, intensive care doctor Jake Suett draws on his personal journey and that of others to highlight the prolonged and frightening symptoms many patients with confirmed or suspected COVID-19 are experiencing. Jake outlines his concerns and sets out recommendations for future action to address the needs of these 'Long COVID' patients. Included is an example letter that can be adapted by others to call on MPs to raise awareness of those suffering persisting symptoms of COVID-19. 
  25. Content Article
    This is a series of three articles written by Kirsten Small, a specialist obstetrician and gynaecologist in Australia, exploring the risks that flow from the use of intrapartum monitoring. Part 1 Examines evidence of short and long-term physical harms to birthing women relating to higher rates of surgical birth when intrapartum Cardiotocography (CTG) monitoring is used. Part 2 Focuses on possible psychological harms which have been reported relating to CTG use. Part 3 Looks at the possibility that CTG use might cause harm to the baby, while the two previous posts have examined the risk to birthing women.
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