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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    An effective complaints system is a vital part of high-quality health and social care, helping services and individuals learn how to do better when things don't go according to plan. For people to speak up about their concerns, they need to be confident that the system will act in response. In order to build the trust the NHS needs to consistently demonstrate that they are taking people's complaints seriously. This report investigates how well NHS trusts across England communicate about their work on complaints and whether current effort are sufficient to build that public trust.
  2. Content Article
    This paper, published in BMC Public Health, reports the results of a qualitative study that explored UK healthcare worker's (HCW) views about working during an influenza pandemic, in order to identify factors that might influence their willingness and ability to work and to identify potential sources of any perceived duty on HCWs to work.
  3. Content Article
    Dr Hein Le Roux is Primary Care Patient Safety GP Lead at the West of England Academic Health Science Network. Here Hein interviews Dr Emma Redfern on their programme to encourage the use of the National Early Warning Score (NEWS), followed by a conversation with Dr Sheena Yerburgh on a standardised admission sheet they have helped to develop, which is being used by GPs in the Gloucestershire area when referring patients to emergency departments.
  4. Content Article
    The West of England Academic Health Science Network has produced this webpage on caring for the deteriorating patient. One of the priorities identified by their Patient Safety Collaborative was the emergency management of the deteriorating patient, in particular identifying patients at risk and avoiding patient deterioration. This webpage includes examples and resources to help others implement similar changes and initiatives.
  5. Content Article
    In this powerful blog, the author draws upon personal experience and insight to explain why she campaigns for carers and patients to have access to their own health records, and the difference this would make to patient safety. "Despite continued promises of access to all our health information by successive politicians and the talk of new gateways to our health information linking primary, secondary and social care, to people like us it seems as far away as ever. We hear about the Empowering the Person initiative, projects to improve data flows, data standards and all those new Apps but citizens like us are still as helpless as ever standing next to that stretcher in A/E without the very basic information to save our loved one’s life in a crisis."
  6. Content Article
    This US-focused article looks at the evolution of the ambulance service and the methods used to try to ensure that supply meets demand.
  7. Content Article
    Medicines errors in care homes are unacceptably high. A key study found that residents taking 7 or more medicines had a 79% chance of being a victim of a medicines error (Alldred et all 2009). In his article, published by Care Right Now, Steve Turner discusses the benefits and challenges of electronic MAR charts and best practice in medicine record keeping.
  8. Content Article
    In this article, published by Birmingham City University, Criminologists Professor Elizabeth Yardley, Professor David Wilson and Emma Kelly discuss the report found that 450 patients died after being given powerful painkillers inappropriately at Gosport War Memorial Hospital. "To kill multiple people requires not just the presence of a determined killer but the absence of protectors and guardians. When no one is looking out for the interests of the vulnerable, the vulnerable become the victims. Within organisations, failed protectors and guardians find strength in each other, denying responsibility, eschewing accountability and playing ping-pong until (they hope) people will just go away and stop demanding answers."
  9. Content Article
    Medication errors may cause harm, including death, and increase use of health care services. This project aims to summarise the evidence on the burden of medication error, namely the number of errors occurring in the NHS in England, the costs of those errors to the NHS and the health losses due to medication error. This involves two systematic reviews, one on the incidence and prevalence of medication errors, and the other on the costs of health burden associated with errors. Additionally, economic modelling estimates the number of errors occurring in the NHS in England each year, their costs and health consequences.
  10. Content Article
    In her blog, drawing on the Paterson Inquiry, Judy Walker discusses After Action Review (AAR) and the fear that exists around speaking up.
  11. Content Article
     The Jeddah Declaration on Patient Safety is founded on the principles that guided the 4th Global Ministerial Patient Safety Summit 2019, Jeddah, Kingdom of Saudi Arabia. It is a call for action on many fronts, and for many actors, at all levels of healthcare provision and delivery – from frontline, to organisational and policy arenas. The Declaration is founded on the underlying spirit that it is imperative to reflect on the effectiveness of current practices in light of the now mature patient safety evidence base of 20 years and to collectively move forward with a vision to sustainable and scalable implementation of patient safety solutions known to improve care delivery systems, patient outcomes and safety culture. The Declaration signals a strong collective and global commitment to shape truly safer systems for generations to come.
  12. Content Article
    In his blog, Danny Tucker, Associate Professor in Obstetrics & Gynaecology and Director of Clinical Training, describes how clinicians experience two types of learning: firstly, incremental learning – they study new facts, medical knowledge and technical skills. Through incremental learning, individuals align habits with established norms, conform to ideals laid out by experts and reinforce existing power structures. Incremental learning involves the process of deliberate practice. Mezirow introduced the concept of transformative learning. This is a deeper, developmental shift, where situations and dilemmas challenge underlying assumptions and beliefs about the world. Clinicians grow through reflective engagement with their experiences, the people they meet - particularly patients - and by testing new mental models of how the world works. Transformative learning changes perspectives and relationships, laying the foundation for personal growth and innovation. It requires curiosity, attention, and courage. Danny offers practical steps that can be taken to encourage and inspire transformative learning for doctors in training.
  13. Content Article
    White paper on nurse staffing levels for patient safety and workforce safety was produced in 2019 by the Saudi Patient Safety Center and the International Council of Nurses. The paper brings together evidence from a wide range of sources, covering different countries and contexts, showing that having the right numbers of nurses, in the right place and at the right time, delivers quality and safety for the populations they serve, and will help to retain nurses.
  14. Content Article
    In his blog, Steve Turner, Head of Medicines and Prescribing at Medicine Gov, talks about how to manage medicines in care homes and implement quality standards. This blog is designed to provide information for care homes and for those choosing a care home.
  15. Content Article
    The novel coronavirus began circulating in China in December 2019. The number of confirmed cases and deaths from this pneumonia-like condition are rising. This page is where all BMJ coverage of the coronavirus outbreak can be found. All articles and resources are freely available.
  16. Content Article
    The Independent Healthcare Providers Network (IHPN) has produced a short film explaining what can be expected from independent healthcare. The Patient Association were involved in this project to help clarify patients’ expectations of private healthcare, supporting them in their decision making.
  17. Content Article
    Listening and acting on patient feedback and good complaint handling can have a positive impact on your reputation. It shows you listen and care about what service users say and act on it.   Here, the Parliamentary & Health Service Ombudsman, lists four things you can do as a leader to help create a team culture that values and learns from complaints.
  18. Content Article
    This article, from the Australian-based Patient Safe Network, argues that healthcare environments have become increasingly complex, existing error reporting systems based on traditional command structures are ineffective and we need to work as a ‘Team of Teams’.
  19. Content Article
    This article, published by the Royal College of Obstetrics and Gynaecology (RCOG), talks about the 2015 Supreme Court decision on Montgomery vs NHS Lanarkshire. The Ruling has significant implications for doctor–patient communications, information sharing and informed consent. Since the ruling, the College leadership has been meeting with medico-legal experts to fully understand the impact on the profession and to determine the RCOG’s role in supporting our members to work within a shared decision-making model.
  20. Content Article
    This study, published by the International Institute of Gynaecology and Obstetrics, evaluates the safety and efficacy of flushing the cervical canal and the uterine cavity with local anaesthetic in order to reduce the pain felt by patients during office hysteroscopy.
  21. Content Article
    In his presentation to the City Club of Cleveland, renowned patient safety expert, Dr Peter Pronovost talks about why we must transform healthcare to reduce harm, to operate as an effective system for patient benefit and eliminate inefficiencies. Peter describes the power of stories for learning and how we can create moments of microtrust that will inspire and give us confidence to change. 
  22. Content Article
    Emergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study, published in BMJ Open, examined this relationship at the national level.
  23. Content Article
    Shifting the mindset (2020), a report from Healthwatch, investigates how hospitals report on complaints and whether current efforts are sufficient to build public trust. In this bog, Sir Robert Francis QC explains how hospitals can cultivate public trust in complaints.
  24. Content Article
    This report,from Healthwatch, argues that hospitals, indeed the NHS more broadly, need to shift the mindset on complaints. Reporting needs to look beyond the numbers and response times and focus more on how to effectively demonstrate to patients and the public what has been learnt. This is the only way to give the public confidence that their concerns are being listened to and acted on. 
  25. Content Article
    Readmissions to hospital are increasingly being used as an indicator of quality of care. However, this approach is valid only when we know what proportion of readmissions are avoidable. The authors conducted a systematic review of studies that measured the proportion of readmissions deemed avoidable. This study, published in Canadian Medical Association Journal, examined how such readmissions were measured and estimated their prevalence.
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