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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This video, from the Healthcare Safety Investigation Branch (HSIB), will help clinical staff to understand what to expect when asked to take part in an HSIB maternity investigation interview. You will meet some of the HSIB maternity investigation team, who'll talk you through the interview. You will also hear from NHS staff, who will talk you through their experience of being involved in a maternity investigation.
  2. Content Article
    This article, published in Nursing in Practice, has been written by Thomas Buckley, Patient Safety Lead (PSL) at Sussex Community NHS Foundation Trust. Thomas talks about the role of the PSL in helping to build safer cultures for both staff and patients.
  3. Content Article
    In this 30 minute film, Adrian Plunkett introduces the concept and history of learning from from excellence. Content also includes: Safety-II Positivity language Negativity bias.
  4. Content Article
    In this article, published by Ayiecho Odembi Consultancy, the author draws on personal experiences as a Black nurse and Patient to illustrate the link between racism and patient safety. "Nursing while black on the NHS is a skill I had mastered but nothing had prepared me for being a patient while black on the NHS and how the system is stacked against you and how lonely, frustrating, anxious, helpless and dare I say angry you feel while also wrestling with the guilt of essentially raging against your employer and not wanting to cause a fuss because it is the NHS, you love the NHS, you are constantly reminded how lucky we are to have the NHS, so it would be in very bad faith to complain."
  5. Content Article
    In this episode of Radio 4's Women's Hour, presenter Emma Barnett discusses the health inequalities impacting on women in relation to medical understanding, funding and research.  Guests include: Women's Health Minister, Nadine Dorries Dr Elinor Cleghorn, cultural historian and author of 'Unwell Women - A journey through medicine and myth in a man-made world' Listener Judi who suffers from pelvic mesh complications Prof Hashim Hashim, a urological surgeon with specialist skill in mesh removal. Listen to the full episode here (you'll need a BBC Sounds account) Further reading Regulatory flaws: Women were catastrophically failed in the mesh, Primodos and Sodium Valproate tragediesDangerous exclusions: The risk to patient safety of sex and gender bias (Patient Safety Learning) Gender bias: A threat to women’s health (Sarah Graham) The normalisation of women’s pain (Lisa Rampersad) ‘Women are being dismissed, disbelieved and shut out’ (Stephanie O’Donohue)  Women’s Health Strategy: Call for evidence (Department of Health and Social Care) Improving hysteroscopy safety (Patient Safety Learning, November 2020)
  6. Content Article
    "In Unwell Women Elinor Cleghorn unpacks the roots of the perpetual misunderstanding, mystification and misdiagnosis of women's bodies, and traces the journey from the 'wandering womb' of ancient Greece, the rise of witch trials in Medieval Europe, through the dawn of Hysteria, to modern day understandings of autoimmune diseases, the menopause and conditions like endometriosis. Packed with character studies of women who have suffered, challenged and rewritten medical orthodoxy - and drawing on her own experience of un-diagnosed Lupus disease - this is a ground-breaking and timely exposé of the medical world and woman's place within it." Follow the link below to more information on the Amazon website.
  7. Content Article
    When Rupert was born he had to be immediately cooled after a difficult birth. Babies are cooled in certain circumstances in the hope of slowing down the processes that may cause brain damage. The Healthcare Safety Investigation Branch (HSIB) maternity investigators initiated an investigation to find out what went wrong. In this short video we hear from Rupert’s mum, Leila, who describes what it was like to be involved with a HSIB maternity investigation from a family point of view.  Leila shares why she and her family wanted to be involved, how HSIB’s approach to them was welcomed and how they felt this contributed to improving safety for the benefit of other families in the future.
  8. Content Article
    Approximately 1,000[1] UK health and care workers have died from Covid-19. Many were working with Covid-positive patients and with substandard Personal Protective Equipment (PPE). It is estimated that a further 122,000 health service workers who contracted Covid-19 are struggling with prolonged symptoms, often referred to as Long Covid. It has also become clear that a significant number of inpatients who had Covid-19, acquired the virus whilst in hospital.[2][3] In this opinion piece, Dr David Tomlinson argues that current PPE guidance still fails to adequately protect staff and patients against the airborne nature of the Covid-19 virus. David highlights the attempts made by many to raise their related safety concerns; arguing that the response to date has been inadequate, unsafe and unlawful.  
  9. Content Article
    In midwifery practice, skin assessment is an important element of any physical examination of women. Fundamentally, key practice recommendations are centred on visual and tactile cues to assist with the identification of changes in skin appearance. Although visual signals are more readily discernible in women with light skin tones, they may be more challenging to detect in women with darker skin tones. As a means of decolonising midwifery theory and practice, this article published in The Practising Midwife, highlights ways in which midwives can develop confidence in skin assessment when caring for women with dark skin tones. Read the full article Related content – Decolonising midwifery education part 2: neonatal assessment
  10. Content Article
    MASIC is the only charity in the UK dedicated to supporting women who have sustained serious childbirth injuries. It is run by a team of MASIC advocates who have experienced injury themselves and are led by a small Executive team and Board of Trustees who have all either worked with or represented women who have suffered an obstetric anal sphincter injury (OASI) injury and who are dedicated to treatment and prevention of these injuries. The link below will take you to a section of their website designed to help guide people looking for support after a birth injury, including: Support from your GP Helpline support NHS support Private support Mental health support Legal support Work and employment Psychological support.
  11. Content Article
    In this blog Patient Safety Learning outlines the key points included in its response to the consultation on a proposed Patient Safety Commissioner role for Scotland. This sets out their feedback to this consultation and describes the powers and resources this role will require if it is to effectively influence change and improve patient safety.
  12. Content Article
    This set of slides, developed by Dr Gillian Higgins for MedSupplyDrive UK, can be used by health and social care workers to advocate for better PPE protection locally.
  13. Content Article
    More than a million people in the UK are now living with prolonged symptoms of Covid-19,[1] also referred to as Long Covid, including at least 122,000 NHS staff.[2] With many struggling to come to terms with life-changing health challenges, Long Covid is considered by some to be the next pandemic. Good health information has the power to educate, influence and clarify; all of which are critical to effectively responding to public health crises and keeping patients safe. But the absence of good information can leave patients, staff and the wider public feeling confused and unsupported, and can widen health inequalities.  In this blog, Patient Safety Learning has identified four key areas where better information could help improve care for those living with Long Covid: Symptoms of Long Covid Long Covid assessment centres Education and awareness Performance and effectiveness.
  14. Community Post
    More than a million people in the UK are now living with prolonged symptoms of Covid-19, also referred to as Long Covid. In this blog (see link below), Patient Safety Learning have identified 4 key areas where better information around Long Covid could help to improve care and outcomes. Long Covid: Information gaps and the safety implications Are you living with Long Covid? Or perhaps you’re a healthcare professional supporting those who are struggling to recover? We want to know: What did you think of the points raised in the blog? What is your experience of accessing or delivering Long Covid services? What’s working well? What are the main challenges and barriers? What more needs to happen to support healthcare professionals and patients? Your perspectives are integral to developing this conversation, so please do share your insights by commenting below. You’ll need to sign up to the hub (its free and easy to do).
  15. Content Article
    This study, published in Women and Birth, aimed to: 1. analyse clinical outcomes for women experiencing CMC with CoCE by students 2. analyse clinical outcomes for women in a fragmented care model with CoCE by students; 3. compare clinical outcomes according to women’s primary model of care. Authors conclude that continuity of care experiences should be offered to all women early in their pregnancy to ensure optimal benefits. Acknowledging midwifery students’ potential to make positive impacts on women’s clinical outcomes may prompt more health services to reconceptualise and foster continuity of care experiences.
  16. Content Article
    Assessment of the skin is an important element of neonatal examination. Midwives need to develop knowledge and skills in this area to recognise changes in the skin and understand what these signify. Historically, teaching in this area has been skewed towards changes seen in newborns with light skin tones, resulting in a gap in clinical knowledge and resources on the assessment of skin in newborns with darker skin tones. This article, published in The Practising Midwife, on the decolonisation of midwifery education and practice, focuses on clinical assessment of the skin when examining newborns.
  17. Content Article
    The broad aim of the webinar, run by CloserStill Media, is to promote After Action Review (AAR) as a valuable tool to promote learning and patient safety improvement and to: show how AAR can support, empower and enable teams to identify learning and good practice share knowledge on how to apply AAR for impact excite potential new users to adopt this approach. Judy Walker, a leading expert in AAR and its adoption for impact in healthcare, will set the scene explaining "What is AAR, why is it so valuable and what helps successfully embed it in organisations.”
  18. Content Article
    Authors of this study conclude that among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care (continuous skin-to-skin contact) had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilisation. Follow the link below to access the paper in full via The New England Journal of Medicine.
  19. Content Article
    In this paper, authors review the thinking that underpins the use of safety cases across different safety-critical industries, and then reflect on their potential use for assuring the safety of digital health innovations. This builds in part on a previous review, but also considers the recent debate about the need for an evidence base for safety case adoption.
  20. Content Article
    In this reflection, published in the BMJ's Post Graduate Medical Journal, Dr John Launer talks about an exercise to help people to become better supervisors, to use peer supervision as a safe space for people to develop better interactional skills generally – and particularly to cultivate their curiosity.
  21. Content Article Comment
    Hi @Chedly, Thank you for your interest in volunteering. The two attachments above provide more information about the role and how to register your interest. We look forward to receiving your application and will be in touch shortly afterwards. Best wishes Stephanie
  22. Content Article
    This roadmap, published in Therapeutic Innovation & Regulatory Science, sets strategic goals for the patient engagement community to achieve meaningful and systematic engagement through changes in the culture, processes and resources of stakeholder organisations. It brings in key PARADIGM outputs to work in a coordinated fashion with existing frameworks and mechanisms to achieve system-wide sustained patient engagement. The roadmap provides a framework for all stakeholders to take collective action within their organisations and across Europe to implement patient engagement in a sustainable manner.
  23. Content Article
    Parkinson's UK have developed a number of training resources to help health and care staff provide safe care for patients with Parkinson's.
  24. Content Article
    BOB.health is a UK learning platform. Usually, content is only accessible to NHS staff, Academic Health and Science Networks and other verified and approved non-commercial organisations serving the NHS to ensure BOB remains a safe space to share. Given the importance of this topic and with Dr Obaro’s blessing, Bob.health has chosen to make this particular story accessible to readers beyond the NHS and the UK. "My impact story describes how I created the presentation, "Why I want to talk about racism" and how I approached sharing my experience and insight with colleagues. To date, the talk has been viewed over 4400 times and the far-reaching impact has been worth the journey it took to create. Talking about racism is painful, uncomfortable, and challenging but by tackling it, I hope we can make the NHS more equitable for staff and patients." Follow the link below to request access to the full impact story.
  25. Content Article
    This guide, developed by Parkinson's UK, tells you how to manage someone with Parkinson's in an emergency situation. It will be particularly useful for professionals who don’t see people with Parkinson's day-to-day.
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