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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    In this interview, Dr Jake Suett talks about his experience of persisting and debilitating symptoms after he was suspected to have contracted COVID-19. Additional reading: Patient safety concerns for Long COVID patients (6 July 2020) Press release: Patient Safety Learning calls for urgent action to ensure Long COVID patients are heard and supported (6 July 2020) My experience of suspected 'Long COVID' (6 July 2020) Dismissed, unsupported and misdiagnosed: Interview with a COVID-19 ‘long-hauler’
  2. Content Article
    An increasing number of people with confirmed or suspected COVID-19 are continuing to struggle with prolonged, debilitating and sometimes severe symptoms months later.[1] Many were never admitted to hospital and have instead been trying to manage their symptoms and recovery at home. These patients are sometimes referred to as the ‘long-haulers’ or described as having ‘post-acute’, ‘chronic’ or ‘long-term’ COVID-19. Here, we will use the term ‘Long COVID’. With social distancing restrictions still in place, patients in the UK and across the world have been turning to social media support networks[2] to connect with others who are experiencing similar challenges. These patients have raised very credible concerns about the care they are receiving[3] and the uncertainties they face. Their concerns are revealing many implications for patient safety. We have recently shared on the hub the story of Dr Jake Suett[4], one of the many people experiencing symptoms of Long COVID. When we conclude this article, we will return to his story and highlight the changes that he is calling for. However, first, we will focus on the patient safety aspects of Long COVID, highlighting key areas of concern and action needed (a full list of actions can be found summarised here).
  3. Community Post
    Additional reading: Patient safety concerns for Long COVID patients (6 July 2020) Press release: Patient Safety Learning calls for urgent action to ensure Long COVID patients are heard and supported (6 July 2020) My experience of suspected 'Long COVID'
  4. Content Article
    Weeks and months after having a confirmed or suspected Covid-19 infection, many people are finding they still haven’t fully recovered. Emerging reports describe lingering symptoms ranging from fatigue and brain-fog to breathlessness and tingling toes. So why does Covid-19 cause lasting health problems? In this podcast, Ian Sample discusses some of the possible explanations with Prof Danny Altmann, and finds out how patients might be helped in the future.
  5. Content Article
    Complex systems consist of many dynamic interactions between people, tasks, technology, environments (physical and social), organisational structures and arrangement and external factors, such as the influence of national policy or regulation. The nature of these interactions often results in unpredictable changes in system conditions (such as patient demand, staff capacity, available resources and organisational constraints) and goal conflicts (such as the frequent pressure to be efficient and thorough). To achieve success, people frequently adapt to these system conditions and goal conflicts. But rather than being planned in advance, these adaptations are often approximate responses to the situations faced at the time.  Therefore, to understand patient safety or staff wellbeing (and other emergent outcomes) we need to look beyond the individual components of care systems to consider how outcomes (wanted and unwanted) emerge from interactions in, and adaptations to, everyday working conditions. Follow the link below to the NHS Education Scotland (NES) website to find out more about systems thinking and access systems approach resources.
  6. Content Article
    Safety culture can be described as our: 1. Values (what is important) 2. Behaviours (the way we do things around here) 3. Beliefs (how things work). Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. NHS Education for Scotland (NES) has adapted these safety culture discussion cards (designed by EUROCONTROL) to help us to do this. Follow the link below to download the cards.
  7. Content Article
    Human Factors (Ergonomics) is the study of human activity (inside and outside of work). Its purpose as a scientific discipline is to enhance wellbeing and performance of individuals and organisations. A number of different definitions of Human Factors exist. The key principles are the interactions between you and your environment both inside and outside of work and the tools and technologies you use. This webpage from NHS Education Scotland (NES) provides links to a number of useful Human Factors resources used in healthcare. Topics include: Training Culture Leadership Systems Thinking Communication.
  8. Community Post
    @Claire Cox @Kirsty Wood @Alex Entwisle @Phil Gurnett is anyone able to help Shabnum?
  9. Content Article
    Enhanced Significant Event Analysis (enhancedSEA) is a NHS Education for Scotland (NES) innovation which aims to guide healthcare teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved.Follow the link below for:guidance on how to perform enhancedSEA the updated report format, new Guide Tools, a short e-learning module basic educational resources on human factors science and practice.Although enhancedSEA was developed and tested with primary care teams the approach is also highly suitable for any health and social care setting.
  10. Content Article
    Black women in the UK are five times more likely to die during pregnancy and after childbirth compared to white women (MBRRACE, 2019). A petition recently called for more research into why this is happening and recommendations to improve healthcare for Black Women as urgent action is needed to address this disparity. The petition exceeded the threshold of 100,000 signatures required in order to be considered for debate in Parliament. The Government issued this written response on 25 June 2020.
  11. Content Article
    More than 1 in 10 women will experience postnatal depression within the first year after giving birth. With a recent study showing that postnatal depression is 13% higher among black and ethnic minority women than it is among white women, it raises significant questions around whether these women are receiving the right treatment and support.
  12. Content Article
    Claire Cox, Patient Safety Learning's Associate Director of Patient Safety, chats to Harriet Baker, a matron on secondment at Ashford and St Peter's Hospitals NHS Foundation Trust, about the Schwartz Rounds model and the positive impact it can have on staff well-being. Harriet explains how to get the ball rolling if you would like to implement Schwartz Rounds locally.
  13. Content Article
    The COVID-19 Recovery Collective is a small team of collaborators that wanted to do something constructive to help those that are in recovery from the COVID-19 virus. The impact of the virus across the globe has been rapid and far reaching. Many are struggling to keep pace with developments, from the recovery process of the infection itself, to the economic consequences of the virus and also the sociological impact of lockdown.The collaboration started as a token action towards helping those that are in recovery from COVID-19, in the hope that by encouraging people to share their own experiences of recovery they can instil some reassurance in others of potential expectations. Through this sharing of experiences, we might see some similar patterns of recovery and also provide an opportunity to share any knowledge or actions that might have helped others to deal with the personal impact of the infection on their health.
  14. Content Article
    Every year, avoidable unsafe care harms and kills thousands of people in the UK, with the NHS estimating that there are 11,000 deaths annually due to patient safety incidents. This causes not only untold physical and emotional damage but it also creates a huge financial burden, with the annual cost to the NHS of unsafe care and litigation standing at close to £5 billion. It is important that when organisations are considering the workplace as a whole system, safety should be at the core of its design. This blog discusses the impact of COVID-19 and workforce pressures on patient safety and outlines key considerations for Boards as we return to 'normal'.
  15. Content Article
    Richard Smith is a trained paramedic who now works as Head of Quality and Safety at Addenbrooks Hospital. In this interview with East England Ambulance Service General Broadcast, Richard talks about his recent paper on incident reporting in the ambulance service. He asks if we have a blame and fear-free culture when concerns are raised, the value of feedback and highlights the importance of reporting the positive incidents too.
  16. Content Article
    As COVID-19 spread throughout the world, clinicians and researchers rapidly published guidance and data and shared their experiences in the hope of understanding the virus better. Their shared purpose was to keep more patients safe from becoming acutely unwell or dying. While the initial focus was on treating the hospitalised, one Trust was also thinking ahead to the challenging recovery many would face.
  17. Content Article
    There is an increasing amount of evidence that co-producing change and improvement in health care leads to new approaches that are more likely to succeed and be sustained.  This blog, by the US-based Institute for Healthcare Improvement, asks: 'As health care systems grapple with planning for an uncertain future during the COVID-19 pandemic, how do we ensure that people with lived experience are real partners in what comes next?'
  18. Content Article
    COVID-19 rehabilitation will improve exercise tolerance, muscle strength, and help patients manage breathlessness, and potentially allow someone to be discharged earlier. The treatments in this guide, produced by Liverpool Heart and Chest Hospital, focus on breathing, functional and physical exercises. Only complete exercises at home and in hospital that have been discussed with a clinician.
  19. Content Article
    This document, developed by McMaster University's School of Rehabilitation Science in Canada, provides a guide for rehabilitation practice during the COVID-19 crisis. Informed by the best available evidence, including consultation with the clinical community, this living document consolidates findings from resources for front line rehabilitation professionals.
  20. Community Post
    A significant number of people (who may or may not have been acutely unwell with COVID-19) are experiencing a prolonged and debilitating recovery at home. In this interview, a patient called Barbara, speaks of her personal experience of safe and unsafe care and highlights the dangers of ‘catch-all’ diagnoses. The interview highlights the important question..."are the COVID-19 'long-haulers' receiving the right support and care?" Please join the conversation by sharing your thoughts and experiences below. If you are not already a member, you'll need to sign up first here. It's quick and easy to do.
  21. Content Article
    A significant number of people, who may or may not have been acutely unwell with COVID-19, are experiencing a prolonged and debilitating recovery at home. Symptoms and experiences of care seem to vary greatly among this group, sometimes known as the COVID-19 ‘long-haulers’. Many are finding comfort and reassurance through online communities, set up by and designed for patients who are struggling to get back on their feet.
  22. Content Article
    The National Maternity and Perinatal Audit (NMPA) is a large scale audit of the NHS maternity services across England, Scotland and Wales undertaken by the Royal College of Obstetricians and Gynaecologists (RCOG). Using timely high-quality data, the audit aims to evaluate a range of care processes and outcomes, in order to identify good practice and areas for improvement in the care of women and babies looked after by NHS maternity services.
  23. Content Article
    In the past 10 years, rates of Obstetric Anal Sphincter Injury (OASI) have increased in England. Experiences in some maternity units have shown that some of the underlying problems related to this rise in OASI include:Inconsistencies in approaches to preventing OASIsInconsistencies in training and skillsLack of awareness of risk factors and long-term impact of OASIsVariation in practice between health professionalsIn light of this, the OASI care bundle team have developed and piloted an intervention package, including a care bundle and guide, a multidisciplinary skills development module for health care professionals, and campaign materials (such as leaflets and newsletters designed to raise awareness).This scaling up programme is a collaboration between the Royal College of Obstetricians and Gynaecologists (RCOG), Croydon Health Services NHS Trust, the Royal College of Midwives (RCM) and the London School of Hygiene and Tropical Medicine (LSHTM), with funding provided by The Health Foundation.
  24. Content Article
    This patient information pack has been produced by staff at Homerton University Hospital. It is designed to help people recover and manage their symptoms following COVID-19.
  25. Content Article
    In this report, the Care Quality Commission (CQC) explain the information they have gathered on the pressures that services and local systems have faced during COVID-19 and the efforts that have been made to tackle them. These insight reports are designed to help everyone involved in health and social care to work together to learn from the first stages of the COVID-19 pandemic by: sharing and reflecting on what has gone well understanding and learning from the experience of what hasn't helping health and care systems prepare better in the future. This issue is divided into three main chapters: Working together across systems Focus on primary care How the care for people from different groups is being managed.
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