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Content Article
WHO - Announcing World Patient Safety Day 2022 (4 March 2022)
Patient-Safety-Learning posted an article in WHO
The theme for World Patient Safety Day 2022 is Medication Safety. It will take place on 17 September 2022. Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare across the world. Medication errors occur when weak medication systems, and human factors such as fatigue, poor environmental conditions or staff shortages, affect prescribing, transcribing, dispensing, administration and monitoring practices. This can result in severe patient harm, disability and even death. The ongoing Covid-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm. The theme builds on the ongoing WHO Global Patient Safety Challenge: Medication Without Harm. It also provides much-needed impetus to take urgent action for reducing medication-related harm through strengthening systems and practices of medication use.- Posted
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- Pandemic
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Content ArticleIn this blog, Clare Rayner, an occupational physician, describes how an international collaboration to help understand Long Covid was established by harnessing the power of technology and social media. This collective, between a group of UK doctors experiencing prolonged health problems after Covid-19 infection and a globally renowned rehabilitation clinic at Mount Sinai Hospital in New York, aims to help both patients and healthcare professionals by disseminating learning about Long Covid from both sides of the Atlantic.
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- Long Covid
- Recovery
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Content ArticleHospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study from Richie et al. retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
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- Patient safety incident
- Health education
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Content ArticleIn this interview, Dr Alice Ladur talks about her experience of using the Whose Shoes? approach to increase male partners’ involvement in maternity care in Uganda. Whose Shoes? is a co-production tool that uses a board game to help participants share experiences and reflect on their experiences of services. Alice describes the importance and impact of involving partners and families in antenatal care and highlights the value of adapting interventions to specific cultures and locations.
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- Maternity
- Patient / family involvement
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Content ArticleIn response to growing pressures on healthcare systems, the advanced clinical practice (ACP) role has been implemented widely in the UK and internationally. In England, ACP is a level of practice applicable across various healthcare professions, who exercise a level of autonomy across four domains, referred to as the four pillars of practice (education, leadership, research and clinical practice). A national framework for ACP was established in 2017 to ensure consistency across the ACP role, however current ACP governance, education and support is yet to be evaluated. This study aimed to analyse data from a national survey of the ACP role to inform the development and improvement of policies relating to ACP in the National Health Service (NHS) in England.
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- Leadership
- Organisational development
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My Type 1 Diabetes - self-management education website
Patient-Safety-Learning posted an article in Diabetes
This public information website provided by the NHS is aimed at helping people with type 1 diabetes to effectively manage their condition.- Posted
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- Health education
- Diabetes
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Patient Safety Syllabus training
Mark Hughes posted an article in Specialist patient safety training
The National patient safety syllabus outlines a new approach to patient safety, emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors and applies to all NHS employees. This page provides access to learning materials (via the E-Learning for Health platform) for staff relating to Level one – Essentials for patient safety and Level two – Access to practice of the training associated with this.- Posted
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- Training
- Health education
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Content ArticleThis innovative educational initiative was developed as a direct and constructive response to the communication inadequacies exposed by the Montgomery case, and subsequent legislation. While it is not difficult to give ‘more information’ it is harder for surgeons and patients to achieve a decision partnership. The ICONS workshop content has been informed by internationally recognised experts in Shared Decision Making, by consensus among senior practising surgeons, by patients and by professional experts in risk management and risk communication. Delegates on the ICONS workshops will acquire skills and knowledge to implement best practice in sharing the complex decisions surrounding informed consent. By participating in a workshop, they will also contribute to the development of resources for future training in the important area of informed consent.
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Content ArticleThis YouTube channel contains video resources designed to raise awareness of falls and how to prevent them. The videos contain simple techniques to help prevent falls and promote healthy lifestyle choices. Videos include a daily 'Falls and management exercise class' and a weekly 'Functional Fitness MOT' for patients to use at home.
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- Falls
- Older People (over 65)
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Content ArticleThis paper from Parsons et al. looked at how patients prefer to be addressed by their healthcare providers and assessed their knowledge of their attending medical team's identity. The researchers conducted a survey which included 300 inpatients, with findings showing over 99% of patients prefer informal address and 57% of patients unable to correctly name a single member of their attending medical team.
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- Health education
- Patient identification
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Content ArticleMedical Errors: Promoting a Culture of Patient Safety is a course for continuing education relicensure requirements for Florida doctors. The purpose of this course is to promote patient safety and improving patient outcomes and is suitable for Allopathic Physicians, Osteopathic Physicians, Dentists, Podiatrists, Physician Assistants and Dietitians who are licensed in the State of Florida.
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- Health education
- Diagnostic error
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Imperial College London: MSc in Patient Safety
Patient Safety Learning posted an article in Medical students
A fully online Master’s in Patient Safety has been launched by Imperial College London and Bayer Pharmaceuticals. The course aims to develop global leaders and changemakers in patient safety who can catalyse improvements and innovation in healthcare practice across the globe. The programme, now open to UK and international applicants for the next academic year, is a refreshment of Imperial’s previous Patient Safety MSc offering, designed to enable a more flexible approach to learning and respond to emerging healthcare needs in light of the coronavirus pandemic. The new course aligns with the updated World Health Organization’s Patient Safety Curriculum. It features best-practice frameworks from healthcare systems around the world, as well as real-world insights and case studies from a pharmaceutical setting. The programme is delivered through a combination of online learning, group learning and live virtual teaching sessions from world-leading experts in the field. Students will also have the opportunity to apply their learnings through the completion of a research study addressing a patient safety challenge.- Posted
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Content ArticleHealth Education England (HEE) has published the first NHS-wide Patient Safety Syllabus which applies to all NHS employees and will result in all NHS employees receiving enhanced patient safety training. Written by the Academy of Medical Royal Colleges and commissioned by HEE the new National Patient Safety Syllabus outlines a new approach to patient safety emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors. Level one and two learning materials will be available on the E Learning for Health platform for staff to access and complete from August and September 2021.
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- Training
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Content ArticleSupport in clinical decision making is recognised as an educational development need for pharmacists. The health policy landscape puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. This is compounded by the COVID-19 pandemic, where healthcare environments have become more complex and challenging to navigate. In this environment, foundation pharmacists were unable to sit the GPhC registration assessment during the summer of 2020 but provisionally the registration assessment is due to take place online during the first quarter of 2021. In response to this, a suite of resources has been developed with collaboration between Chartered Institute of Ergonomics and Human Factors (CIEHF) and Health Education England (HEE). These resources are aimed in particular at early career pharmacists and their supervisors, especially those in foundation pharmacist positions managing the transition from education to the workplace environment.
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- Pharmacy / chemist
- Training
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Content ArticleHealthcare professionals are experiencing unprecedented levels of occupational stress and burnout. Higher stress and burnout in health professionals is linked with the delivery of poorer quality, less safe patient care across healthcare settings. In order to understand how we can better support healthcare professionals in the workplace, this study from Johnson et al. evaluated a tailored resilience coaching intervention comprising a workshop and one-to-one coaching session addressing the intrinsic challenges of healthcare work in health professionals and students. The authors found preliminary evidence that the intervention was well received and effective, but further research using a randomised controlled design will be necessary to confirm this.
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Content ArticleThis guidance from the Chartered Institute of Ergonomics and Human Factors (CIEHF) is aimed at early career pharmacists, especially those in foundation pharmacist positions managing the transition from education to the workplace environment. Support in clinical decision-making is recognised as an educational development need for early career pharmacists, making the transition from a university education where there is very little exposure to the clinical environment into the work environment. This situation is compounded by a policy landscape which puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. The guidance will also be of use to those involved in the education and mentorship of early career pharmacist.
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- Pharmacy / chemist
- Health education
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Content ArticleThe NHS Knowledge Mobilisation Framework is designed to help individuals to develop and use skills to mobilise knowledge effectively in their organisations – to help them to learn before, during and after everything that they do so that pitfalls can be avoided and best practice replicated. It is a re-working of an original concept devised by what was the Department of Health Connecting for Health Knowledge Management Team and the Kent, Surrey and Sussex Library and Knowledge Services Team. The modules introduce eleven techniques to help plan, co-ordinate and implement knowledge mobilisation activities in your organisation. Accompanying the framework are a set of quick reference cards.
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Content ArticleCreating a foundation for safe and reliable care requires more than just a small team in an organisation. This short video captures what the Patient Safety Movement Foundation has to offer healthcare organisations hoping to make their care better and safer from the ground up.
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Community PostWe should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. Cochrane Collaborate Report on Antenatal Massage https://pubmed.ncbi.nlm.nih.gov/23633325/ https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909
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Content Article
Health screening poster: Learning disabilities (MacIntyre)
Claire Cox posted an article in Learning disabilities
This poster from MacIntyre helps to raise awareness of health screening for people with learning disabilities among frontline staff. Giving an overview of relevant health checks depending on sex and age the poster serves as a quick visual reminder.- Posted
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- Learning disabilities
- Screening
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Content ArticleThe Keep Going…….Don’t Stop! (KGDS) group was formed in May 2016 with a focus of creating work (related to growing older, dementia and health) that is easily accessible to people with a learning disability in different formats, predominantly easy read. The aim is to ensure the documents will support people with a learning disability to have more of an understanding of what is happening with their changing health needs as they grow older. By making the documents accessible, MacIntyre can make sure they are involving the people they support as much as possible and staff can be confident that they have the tools to support such conversations.
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- Patient engagement
- Engagement
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Content ArticleThis innovative, practical guide introduces researchers to the use of the video reflexive ethnography in health and health services research. This methodology has enjoyed increasing popularity among researchers internationally and has been inspired by developments across a range of disciplines: ethnography, visual and applied anthropology, medical sociology, health services research, medical and nursing education, adult education, community development, and qualitative research ethics.
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- Research
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Content ArticleHelen is a Consultant Anaesthetist at the Oxford University Hospitals NHS Foundation Trust (OUHFT) and a Senior Clinical Research Fellow in the Nuffield Department of Clinical Neurosciences, University of Oxford. Here, Helen highlights the importance of support and training and gives an example of how the OxSTaR team are transforming staff teamworking skills and improving patient safety.
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- Anaesthetist
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Content Article
AWARE – Well-being resources
Patient Safety Learning posted an article in Good practice
A suite of resources designed to promote well-being among US residents, fellows, faculty members, and others has been created by the Accreditation Council for Graduate Medical Education. This initial set of AWARE resources focuses on individual strategies for cognitive skill building, and includes a video workshop, podcasts, and the ACGME AWARE app.- Posted
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- Fatigue / exhaustion
- Stress
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Community Post
National Safety Standards for Invasive Procedures
Annie Hunningher posted a topic in Surgery
- Pre-op period
- Intra operative
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How are people getting on with the NatSSIPs? PDF version to share NatSSIPs headline booklet.pdf- Posted
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- Pre-op period
- Intra operative
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