Jump to content
 View Profile  See their activity

  • Posts

    1,216

  • Joined

  • Last visited

PatientSafetyLearning Team

PSL Moderators

 Content Type 

Everything posted by PatientSafetyLearning Team

  1. Content Article
    In December 2020, Ockenden Report: Emerging findings and recommendations from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, was published. The report set out seven immediate and essential actions for Trusts under the following themes: Enhanced safety Listening to women and families Staff training and working together Managing complex pregnancy Risk assessment throughout pregnancy Monitoring fetal wellbeing Informed consent The below infographic, produced by the University of Southampton NHS Foundation Trust, sets out their plans against each of the seven actions.
  2. Content Article
    In February 2021, the list of never events was updated to exclude wrong tooth extraction, as the systemic barriers to prevent these incidents were not considered ‘strong enough.’ In this article, published in the British Journal of Oral and Maxillofacial Surgery, authors discuss the matter, and provide some recommendations to minimise the risk of wrong tooth extraction.
  3. Content Article
    At the start of 2020, NHS England and NHS Improvement commissioned The King’s Fund to provide independent support to consider how the NHS can better tackle poverty in England as part of the commitments it made to reducing health inequalities in the NHS Long Term Plan (NHS England 2019). This discussion paper sets out findings from a process of engagement with stakeholders and wider literature and evidence, in particular: how more needs to be done to raise awareness of the NHS’s role in tackling poverty what further actions the NHS can take how the NHS can be a stronger advocate for poverty reduction underpinning these three specific roles, the NHS has a partnership and leadership role that will help support them.
  4. Content Article
    This evidence report aims to identify changes across health and social care in response to COVID-19 that could offer potentially sustainable benefits..Frontier Economics, Kaleidoscope Health and Care, and RAND Europe were commissioned to lead this independent rapid review, with three core aims: Understand the impact of the response to the COVID-19 pandemic in relation to innovation, research and collaboration across the health and care system Identify any methods/practices which would support the development and adoption of high impact changes identified in the existing Beneficial Changes Network (BCN) evidence, whilst considering the impact on health inequalities Propose recommendations to support current activities and inform future priorities of the Accelerated Access Collaborative and BCN, and the wider health and social care system.
  5. Content Article
    In this blog, Consultant Neurologist Jane Alty, talks about a patient with Parkinson's who was cared for in their trust for a period of time, during which there were frequent occasions on which his Parkinson's medications were delayed or not given. This sadly contributed to a deterioration in his swallowing and overall condition, and lengthened his time in hospital.  Inspired by a letter from his wife, Jane and colleagues started the 'Improving care of patients with Parkinson’s quality improvement project' at Leeds Teaching Hospitals NHS Trust. Here she talks about the journey, the successes and challenges, and the value of involving staff from across the organisation and carers to make services better.
  6. Community Post
    Did you know that one in 20 patients who undergo a surgical procedure in the NHS contract an surgical site infection and 60% of these are preventable? If you've had an infection during or after surgery, how did it affect you? Understanding patient experience is key to improving safety in this area, so please share your thoughts in the comments below or get in touch with us directly at hello@patientsafetylearning.org You'll need to sign up to the hub to comment, it's free and easy to do.
  7. Content Article
    Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV).  In this blog, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of her son dying to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the lack of awareness of the dangers and calls for a widespread review of policy in order to prevent future deaths. 
  8. Content Article
    The objective of this study, published in JAMA Surgery, was to determine whether exposure to 30-day postoperative infection is associated with increased incidence of infection and mortality during postoperative days 31 to 365. Authors conclude that patients with 30-day postoperative infection had a 3.2-fold higher risk of 1-year infection and a 1.9-fold higher risk of mortality compared with those who had no 30-day infection. 
  9. Content Article
    Post-operative sepsis is the term used to describe a rare complication of surgery; when sepsis has occurred shortly after an operation which affects one or more organs of the body. In severe cases it can cause life-threatening multi-organ failure, which requires admission to an Intensive Care Unit. This patient/relative guide, from the UK Sepsis Trust, looks at causes, symptoms and treatments for post-operative sepsis.
  10. Content Article
    Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%–15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. SSI is associated with a maternal mortality rate of up to 3%.  This paper, published in the International Journal of Women's Health, focuses on: Risk factors Prevention strategies Intraoperative practices Post operative assessment.
  11. Content Article
    These guidelines include 13 recommendations for the period before surgery, and 16 for preventing infections during and after surgery. They range from simple precautions such as ensuring that patients bathe or shower before surgery and the best way for surgical teams to clean their hands, to guidance on when to use antibiotics to prevent infections, what disinfectants to use before incision, and which sutures to use.
  12. Content Article
    This toolkit is part of a series of explainers on vaccine development and distribution from the World Health Organization. It offers advice on how to have informed and supportive conversations with friends, family members or colleagues who may understandably have questions or express concerns about vaccination.
  13. Content Article
    This report provides an update on overall progress in meeting the National Maternity Safety Ambition and implementing the range of initiatives designed to improve outcomes for mothers and babies since 2015.  Content includes: Progress on National Ambition outcomes What has been achieved? Changing culture Specific safety initiatives System enablers Next steps.
  14. Content Article
    This article, published by freethink, tells the story of an Iowa teenager Dasia Taylor who has developed a concept of colour-changing sutures to warn of infection. Skin pH levels typically hover around 5, but an infection can cause pH to spike. When it does, Taylor's colour-changing sutures, dyed with beet juice, go from red to purple.  inspired by the concept of 'smart sutures' Taylor wanted to look at doing something that would be more accessible to developing countries. The hope is that hopes the sutures will help spot infections early, when antibiotics can treat them, instead of more invasive measures.
  15. Content Article
    The national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units Unlike other review or investigation processes, the PMRT makes it possible to review every baby death, after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,693 reviews which were completed between March 2019 and February 2020.
  16. Content Article
    This study, published in the Journal of family planning and reproductive health care, aimed to determine the prevalence of and reasons for and against the use of local anaesthesia (LA) for IUD insertion. The results suggest that more UK health professionals need to routinely discuss pain relief and offer this to their patients prior to IUD insertion as part of the care pathway for patients who choose to use intrauterine contraception.
  17. Content Article
    There have been many testimonials from patients who have experienced high levels of pain during intrauterine device (IUD) insertion. This has gained media attention and led to calls for better pain management options and informed consent processes. This study, published in Contraception, investigated if providers accurately assess pain during IUD insertion. Authors concluded that providers underestimate pain during IUD insertion.
  18. Community Post
    *Trigger warning. This post includes personal gynaecological experiences of a traumatic nature. Have you had a contraceptive device fitted (also known as an IUD or coil)? What was your experience like? Perhaps you are a healthcare professional who can share your clinical insight? Today (21 June), we've published an interview with Lucy Cohen who experienced high levels of pain and is now calling for better consent processes and pain management for women. Please share your thoughts on the interview below. You'll need to sign up to the hub to comment, it's free and easy to do.
  19. Content Article
    Lucy Cohen recently had a contraceptive device (IUD) fitted, during which she suffered extremely high levels of pain. Following her experience, she decided to launch a survey to understand how others had found the procedure. In this interview, Lucy shares her findings and calls for better pain management and improved consent processes, in order to reduce avoidable harm.  
  20. Content Article
    In this blog, published on the Learning from Excellence website, author AP introduces the philosophical theory of determinism and the implications for patient safety investigations.
  21. Content Article
    This guideline covers how to make shared decision making part of everyday care in all healthcare settings. It promotes ways for healthcare professionals and people using services to work together to make decisions about treatment and care. It includes recommendations on training, communicating risks, benefits and consequences, using decision aids, and how to embed shared decision making in organisational culture and practices.
  22. Content Article
    In the UK over 1000 people with epilepsy die every year and it's estimated that more than half of these deaths could be avoided. This is a free evidence-based tool, supporting clinicians in discussing risk with people with epilepsy. It includes risk factors linked to epilepsy mortality, including (but not restricted to) Sudden Unexpected Death in Epilepsy (SUDEP). To watch the introductory video and register for access to checklist, follow the link below to the SUDEP Action website.
  23. Content Article
    Sinead Heneghan is a GP based in the North West of England with a passion for reducing health inequalities. In this interview for Patient Safety Learning, Sinead tells us how she made sure COVID-19 vaccinations were prioritised for people with learning disabilities, when national guidance advised otherwise. She also explains how they took the opportunity locally to combine these face-to-face immunisation appointments with annual health checks, identifying unmet health needs that needed addressing.
  24. Content Article
    In this short film, National Specialty Advisor for Diabetes, Partha Kar shares 4 steps for improving the safety of diabetic inpatients.  Highlighting practical resources along the way, Partha focuses on the following key areas to help colleagues understand how they can improve outcomes locally: Identifying support needs quickly Self-management policy Peri-operative safety policy Free insulin safety training. Links to all of the resources mentioned in the film can be found at the bottom of this page. 
  25. Content Article
    Sodium Valproate is a treatment for epilepsy and bipolar disorder. It can cause an increased risk of developmental, physical and neurological harms to the human embryo or fetus. This NHS letter is a reminder of information that every woman and girl of childbearing age should receive from their doctors when the drug is first prescribed. It contains important reminders of safety considerations, including around contraception, pregnancy and regular prescribing reviews. Further recommended reading: Sodium Valproate: The Fetal Valproate Syndrome Tragedy Analysing the Cumberlege Review: Who should join the dots for patient safety? (Patient Safety Learning) Findings of the Cumberlege Review: informed consent (Patient Safety Learning) First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review Regulatory flaws: Women were catastrophically failed in the mesh, Primodos and Sodium Valproate tragedies (Kath Sansom)  
×
×
  • Create New...