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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This opinion piece for the BMJ is written by Miles Sibley, Director for the Patient Experience Library, and Rebecca Steinfeld, Head of Policy at National Voices. They highlight the avoidable harm that has impacted on thousands of women in recent years, drawing on several inquiries to evidence the need to put women's voices at the centre of their care (a core theme for the Women's Health Strategy). They argue that patient experience is too often undervalued when it comes to evidence gathering, and that supporting systems must be improved in order to make positive changes for patient safety.
  2. Content Article
    A hospital stay for a person with diabetes can be a frightening experience and it is easy to understand why. In 2017, an estimated 9,600 people required rescue treatment following a severe hypoglycaemic attack. 2,200 people suffered from Diabetic Ketoacidosis (DKA) because of under treatment with insulin. We can and must do better for people with diabetes in hospital.Diabetes UK have a number of resources and tools to improve inpatient and hospital care for people with diabetes.
  3. Content Article
    This research-based guide has been co-developed by Healthcare Improvement Scotland, the University of Dundee and the University of Glasgow to provide an overview of PROMs. It also aims to prevent the exclusion of people with low literacy skills and/or learning disabilities from PROM administration.
  4. Content Article
    Health inequalities are avoidable, unfair and systematic differences in health between different groups of people. There are many kinds of health inequality, and many ways in which the term is used. This means that when we talk about ‘health inequality’, it is useful to be clear on which measure is unequally distributed, and between which people.  The King's Fund have created a webpage to help people understand what health inequalities are.
  5. Content Article
    This article, published by WIRED, tells the story of Linsey Marr, an aerosol scientist at Virginia Tech and one of the few in the world who also studies infectious diseases. When the new coronavirus was discovered, Linsey and colleagues were deeply concerned that it had been labelled as 'not airborne'.
  6. Content Article
    In this comment piece, published by the Lancet, authors propose that it is a scientific error to use lack of direct evidence of SARS-CoV-2 in some air samples to cast doubt on airborne transmission while overlooking the quality and strength of the overall evidence base. There is consistent, strong evidence that SARS-CoV-2 spreads by airborne transmission. Although other routes can contribute, they believe that the airborne route is likely to be dominant.
  7. Content Article
    This guideline from The Centre for Perioperative Care (CPOC) provides recommendations to support delivery of quality perioperative care for people with diabetes undergoing surgery, from time of contemplation of surgery to discharge back to the community. The recommendations are supported by a set of practical and visual resources collated from units across the NHS, who have developed perioperative services for people with diabetes undergoing surgery.
  8. Content Article
    This investigation from the Healthcare Safety Investigation Branch, focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
  9. Content Article
    People in prison are significantly more likely to die by suicide. Samaritans work with prison services to reduce suicide and self-harm in prisons. Follow the link below to find out how people in prison, and prison staff, can access Samaritans' services.
  10. Content Article
    In this anonymous blog, the author argues that clinicians need to consider the impact of their words when they are communicating medical findings and diagnoses to patients. Drawing on her daughter’s experience of seeking psychiatric support, she explains how a more humane approach might have prevented additional harm. 
  11. Content Article
    If you think someone is in immediate danger, the quickest way to get help is to call an ambulance on 999.
  12. Content Article
    This course, run by Samaritans, will benefit anyone whose role brings them into contact with vulnerable customers or colleagues. Conversations with vulnerable people will equip you with the skills and confidence to handle challenging conversations in a sensitive and professional way.
  13. Content Article
    Samaritans have a confidential support line for health and social care workers and volunteers based in England and Wales.  Call: 0800 069 6222 All calls are answered by trained Samaritans volunteers, who provide confidential, non-judgmental support. Follow the link below to find out more about the service, and to download posters for your workplace.
  14. Content Article
    This research, published by PLoS ONE, highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. 
  15. Content Article
    Resuscitation Council UK’s Guidelines guarantee that health and care professionals across the UK share the same knowledge base surrounding teamwork and practice. The 2021 Guidelines contain detailed information about basic and advanced life support for adults, paediatrics and newborns, as well as information on the use of Automated External Defibrillators and other topics. 
  16. Content Article
    Think Aorta is a global campaign focused on the problem of misdiagnosis and delay in acute aortic dissection. It was created and is led by Aortic Dissection Awareness UK & Ireland. Think Aorta provides free, accredited learning resources for emergency medicine and radiology teams and for first responders, improving their ability to spot a time-critical, life-threatening aortic dissection and take appropriate action.
  17. Content Article
    The Aortic Dissection Charitable Trust aims to improve the diagnosis of aortic dissection and bring consistency of treatment across the whole patient pathway. They accomplish this through: Increased access to education for medical professionals and patients in the UK & Ireland Working with those responsible for Healthcare policy in the UK & Ireland to ensure that there is consistency in the provision of diagnosis for acute aortic dissection, specialised follow-up for survivors and access to clinical genetics for relatives Promoting funding for medical research into the detection, prevention, treatment and cure of aortic dissection. Follow the link below to access their resources.
  18. Content Article
    Paul Satori died as a result of a dissecting aortic aneurysm following a misdiagnosis, and being discharged from hospital.
  19. Content Article
    The national medical examiner system is being rolled out across England and Wales, initially on a non-statutory basis, and is part of the Death Certification Reform Programme for England and Wales. It also forms part of the NHS Patient Safety Strategy and the NHS Long Term Plan in England. The all-Wales Medical Examiner Service is a critical part of the long-established mortality review programme. Throughout 2020, medical examiner offices have been established at acute trusts in England and at regional hubs in Wales, initially providing scrutiny of non-coronial deaths in acute care. This remit is being expanded in 2021 and 2022 to cover non-coronial deaths that occur in other settings such as the community. A core part of the medical examiner role is to provide bereaved people with clear information about the cause of death, and an opportunity to raise any concerns they may have about the care and treatment provided to the deceased person. Medical examiners also carry out a proportionate review of patient records and discuss causes of death with the doctor completing the Medical Certificate of Cause of 5 | National Medical Examiner’s report 2020 Death (MCCD). They ensure concerns about patient care are identified promptly and referred for further investigation, to improve services and care for all patients. This report describes progress and next steps, building the foundations of a medical examiner system that will facilitate reflection, learning and improvement across the entire health system. 
  20. Content Article
    These coroner reports relate to two patients, Stephen and Peter, who both died as a result of complications from use of a nasogastric tube. The coroner notes concerns that this issue may be more widespread and has therefore highlighted the report to several relevant bodies who she advises to take action.
  21. Content Article
    NICE guidance on the management of chronic pain no longer recommends the initiation of many medications (e.g. NSAID’s, gabapentinoids etc) for primary chronic pain. However, there are many patients in the community who are already using these medications and it is important that when implementing this guideline, the recommendations are not used out of context.  This joint statement aims to provide information that will help doctors and patients when reviewing medications.
  22. Content Article
    Gary Day had a choroidal melanoma of the left eye. After discussing his treatment options with clinicians at Moorfields Eye Hospital, he elected to have that melanoma removed by an endoresection procedure at the hospital. Gary Day died less than 24 hours after the operation as a result of an air embolism. In the Coroner’s matters of concern, it was noted he was not advised beforehand of the potential risk of death, there was no check for an air embolism after the operation and he probably should have been kept in hospital overnight for observation. The report was sent to Moorfields Eye Hospital but has safety implications for all Trusts performing this procedure.
  23. Content Article
    Since Claire Griffiths underwent a rectopexy operation she has suffered almost constant, debilitating pain. In this article, published by Yahoo Style, she describes her experience and the devastating impact on her life. Also quoted in the article is Sling the Mesh’s founder Kath Samson, who says:"Nobody really knows how many are suffering because the NHS and the regulatory body the MHRA has not kept a database of how many women have had the operation and how many are suffering."
  24. Content Article
    Use of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.’ Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm.
  25. Content Article
    This article looks at NHS safety advice on reducing the harm caused by nasogastric feeding tubes that have been wrongly inserted. The alert, from the National Patient Safety Agency, followed 11 deaths of patients in two years, including that of one child.
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