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Found 319 results
  1. Event
    until
    CORESS invites you to join their free educational webinar and hear from four speakers as they talk about their area of expertise in relation to patient safety. Programme overview: 14:00 - Introduction to CORESS and Welcome - Professor Frank Smith, Professor of Vascular Surgery & Surgical Education, University of Bristol and North Bristol NHS Trust and CORESS Past-Programme Director 14:03 - Symposium Programme Overview - Miss Harriet Corbett FRCS Paed Consultant Paediatric Urologist, Alder Hey Children’s Foundation NHS Trust, British Association of Paediatric Urologists and CORESS Programme Director 14:05 - SPOT Programme: The National inpatient PEWS Chart - Professor Damien Roland, Consultant in Paediatric Emergency Medicine, Head of Service Children's Emergency Department, University Hospitals of Leicester NHS Trust 14:30 - Championing Patient Safety with Evidence Based Medicine - Robotically Assisted Surgery - Dr John Burke, Chief Medical Officer, AXA Health 14:55 - What’s new at HSIB - Saskia Fursland, National Investigator, HSIB 15:20 - Patient Safety in a Medico-legal Context - Dr Michael Devlin, LLM, MBA, FRCP, FRCGP, FFFLM , Head of Professional Standards and Liaison, MDU 15:45 - Symposium Summary and Close - Harriet Corbett, CORESS Programme Director Intended Audience: This session is for Consultant Surgeons, medics, students with a surgical healthcare background and those in healthcare and insurance sectors with an interest in surgical improvement and patient safety. Register
  2. Content Article
    The World Health Organization (WHO) launched the Global Knowledge Sharing Platform for Patient Safety (GKPS) at the World Patient Safety Day 2023 Global Conference on 13 September 2023. GKPS is an online and public platform to facilitate systematic collection and sharing of patient safety knowledge by stakeholders in different geographic regions, economics and cultural settings. It promotes the sharing of best practices related to the theme of each World Patient Safety Day for implementing and learning, as well as sharing of experience in enhancing patient safety.  
  3. Content Article
    In this blog to mark World Patient Safety Day 2023, Patient Safety Learning sets out the scale of avoidable harm in health and social care, highlights the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, ‘Engaging patients for patient safety’.
  4. Content Article
    Chris Wardley has shared his useful summary of Learn Together's '5 stage process' in involving patients and families in patient safety investigations.
  5. Content Article
    This study, published by Applied Ergonomics, found that employing user experience design (UXD) could help to improve health education materials. Researchers looked at printed information about breast and cervical cancer screening and its perceived usability. 
  6. Content Article
    The NHS.uk website averaged over 2,000 visitors per minute in 2022 and, while websites are hardly considered cutting edge, this technology is important to help make trusted and reliable health and care knowledge easily accessible to patients and the public. Web-based information, alongside access to medical records and personalised care initiatives, means people are potentially more informed to make decisions and be actively involved in their own care. However simply having access to information doesn’t necessarily make it useable.
  7. Content Article
    To mark this year’s World Patient Safety Day (WPSD), the Royal College of Surgeons of Edinburgh (RCSEd) will be running a series of blogs and Talking Heads on key surgical and dental topics in this area. These have been provided by patients, families and carers, alongside members of the College’s Patient Safety Group, College Council and the wider College fellowship. The College’s eleven Surgical Specialty Boards (SSBs) have been asked to provide blogs on how patient involvement in their individual specialty has helped to drive up standards of care. The blogs will provide examples of how patients and carers can play vital roles in making decisions about their own individual care and also how they can enhance the safety of the healthcare system as a whole by contributing to strategic decisions at organisational level. Two blogs will be released on each day of the College’s week-long WPSD campaign, starting on Monday 11 September and leading up to WPSD on Sunday 17 September. Members and Fellows will have access to these through the College website following the campaign.
  8. Content Article
    Learn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. The resources have been designed, together with people who have experienced patient safety incidents and investigations, to provide the information and support patients might need following a patient safety incident. Information is provided in a range of formats including downloadable guides, videos and infographics. The site also provides information and resources for engagement leads. Learn Together is a partnership between Sheffield Hallam University, the University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford District Care NHS Foundation Trust, Leeds and York Partnership NHS Foundation Trust and York and Scarborough Teaching Hospitals NHS Foundation Trust, and is funded by the National Institute for Health and Care Research (NIHR).
  9. Content Article
    In this blog, Patient Safety Learning looks ahead to World Patient Safety Day 2023 and the theme of this year’s event, ‘Engaging patients for patient safety’.
  10. News Article
    Making data on medical interventions easier to collect and collate would increase the odds of spotting patterns of harm, according to the panel of a recent HSJ webinar When Baroness Julia Cumberlege was asked to review the avoidable harm caused by two medicines and one medical device, she encountered no shortage of data. “We found that the NHS is awash with data, but it’s very fractured,” says Baroness Cumberlege, who chaired the Independent Medicines and Medical Devices Safety Review and now co-chairs the All-Party Parliamentary Group which raises awareness of and support for its findings. And it is that fracturing that can make patterns of harm difficult to spot. The report concluded that many women and children experienced avoidable harm through use of the hormone pregnancy test Primodos, the epilepsy drug sodium valproate, and the medical device pelvic mesh – simply because it hadn’t been possible to connect the dots. “It’s very hard to collect things together and to get an overall picture. And one of the things that we felt very strongly about was that data should be collected once, but used often,” said Baroness Cumberlege at a recent HSJ webinar. Run in association with GS1 UK, the event brought together a panel to consider how better data might help address patient safety challenges such as problems with implants. “But the big problem was they couldn’t identify who had which implants. No doubt somebody somewhere had written this down with a fountain pen and then someone spilt the tea over it and the unique information was lost,” recalled Sir Terence Stephenson , now Nuffield professor of child health at Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England. The review he chaired therefore suggested establishing a concept of person, product place – “for everybody who had something implanted in them, we should have their name, the identifier of what had been put in, and where it had been put in. And one of my panel members said: ‘Well, how are we going to record this? We don’t want the fountain pen and the teacup.’” Ultimately the answer suggested was barcode scanning. By scanning the wristband of a patient, that on the product being implanted, and one for the hospital theatre or department at which it was being implanted, the idea was to create an immediate and easy-to-create record. For those long convinced of the virtues of barcode scanning in health, it is a welcome development Two years later, the then Department of Health launched the Scan4Safety programme, in which six “demonstrator sites” implemented the use of scanning across the patient journey. At these organisations, barcodes produced to GS1 standards – meaning they are globally unique – are present on patient wristbands; on equipment used for care, including implantable medical devices; in locations; and sometimes on staff badges. Link to full article here (paywalled)
  11. News Article
    Dr Penny Kechagioglou, Chief Clinical Information Officer and Deputy Chief Medical Officer at University Hospitals Coventry and Warwickshire, kindly shared her thoughts on digitising patient reported outcome measures in a blog for HTN. The UK digital transformation wave is mainly characterised by the roll-out of electronic health records and is an opportunity to transform patient care by collecting and analysing patient reported outcome measures digitally. A recent study at the European Society of Medical Oncology open journal (Modi, 2022) showed that patient reported outcome measures are predictive of cancer patient treatment response and quality of life for physical and mental parameters. The knowledge of patient reported outcomes (PRO) and experience (PRE) measures can be valuable in the monitoring of individual patient symptoms in clinic or remotely in the community and also for aggregating and interpreting population health data. To read the full article, click here
  12. News Article
    The NHS App will soon be updated with features to help offer people in England more personalised care. It is part of the government's plan for a digital revolution to speed up care and improve access while saving the health service time and money. By March 2023, more users will receive messages from their GP and be able to see their medical records and manage hospital elective-care appointments. By March 2024, the app should offer face-to-face video consultations. The government's ambition is for at least 75% of adults to be using it by March 2024. Currently, less than half - about 28 million - have it on their phone or tablet. The government also wants 90% of NHS trusts to have electronic patient records in place or be processing them by December 2023 and for all social-care providers to adopt a digital social-care record. And patients across the country should be able to complete their hospital pre-assessment checks from home by September 2024. Read full story Source: BBC News, 29 June 2022
  13. News Article
    More than three years into the Covid pandemic, there are a host of important unanswered questions about Long Covid, which significantly limit healthcare providers’ ability to treat patients with the condition, according to US physicians and scientists. That vacuum of information remains as much of the US has moved on from the pandemic, while Covid long-haulers continue to face stigma and questions over whether their symptoms are real, providers say. “We don’t quite have our finger on the pulse of what’s wrong, what biologically is causing it, and that’s a big problem,” said Dr Marc Sala, co-director of the Northwestern Medicine Comprehensive Covid-19 Center. “It’s hard to direct drugs or treatments without having the biological underpinnings for why someone is feeling so fatigued with exercise.” In addition to the ambiguity around the root causes of Long Covid, there are also challenges in research because of how Covid can produce so many different symptoms. The Centers for Disease Control and Prevention list includes fatigue, respiratory issues and difficulty thinking or concentrating but also states that “post-Covid conditions may not affect everyone the same way”. “Everyone has a different constellation of symptoms,” said Dr Steven Deeks, an infectious disease specialist at the University of California, San Francisco. “Some people get better over time, some people wax and wane, some people get worse,” and so it is difficult for researchers to determine when a study should end and compare a drug versus a placebo. Read full story Source: The Guardian, 6 March 2023
  14. News Article
    Women are being misled and manipulated about abortion by some crisis pregnancy advice centres in the UK, according to evidence from a BBC Panorama investigation. The centres operate outside the NHS and tend to be registered charities. Most say they don't refer women for abortions, but offer support and counselling for unplanned pregnancies. But the BBC's investigation reveals more than a third of these services give misleading medical information or unethical advice, and sometimes both. Pregnancy counselling is available through the NHS and regulated abortion providers, but searching online, Panorama identified 57 crisis pregnancy advice centres advertising. The BBC decided to investigate after hearing from women who had been to these centres. One said she had been "traumatised" and that the centre had tried to "manipulate" her into not having an abortion. Some 21 centres gave misleading medical information and/or unethical advice about abortion Seven centres said having a termination could lead to "post-abortion syndrome" - a mental health condition likened to post traumatic stress disorder, which is not recognised by the NHS. Eight centres linked abortion to infertility and problems carrying future pregnancies to term. Five centres linked abortion to an increased risk of breast cancer. Leading medic in the field of obstetrics, and director of an abortion provider, Dr Jonathan Lord, said women needed an "informed choice" which required "good quality unbiased information". Read full story Source: BBC News, 27 February 2023
  15. News Article
    Artificial hip and knee joints that have to be removed after failing early are to be examined routinely to save the NHS £200million a year – and reduce unnecessary pain for patients in future. Less than 1 in 100 removed implants are examined to see why they failed, so surgeons don’t learn what went wrong or pick up on potential scandals. Consultant orthopaedic surgeon Raghavendra Sidaginamale, of North Tees and Hartlepool NHS Trust, said: "Most removed implants are put in the bin. A wealth of information goes down the drain." Now the NHS is setting up an Implants Analysis Service, enabling hospitals to send them off to be analysed for signs of unusual wear or chemical degradation. Each year, 15,000 hip and knee replacements are replaced. If this happens within ten years, they are deemed to have failed early. Jason Wilson, of the IAS, said they are ‘like a black box flight recorder in a plane’, adding: "They hold a wealth of information we can learn from." Read full story Source: Daily Mail, 29 January 2023
  16. News Article
    Women who underwent mesh surgery were not given accurate information before the life-altering procedure, a case review has found. The study also said poor communication between patients and doctors led, in some cases, to mistrust. Medical notes were often misleading or did not detail the surgery that had occurred or its outcomes. The review spent two years looking at the cases of 18 women who received transvaginal mesh implants. It has now called for a comprehensive register to be set up to keep track of women who have had operations to remove mesh in Scotland, abroad and privately. The Transvaginal Mesh Case Record Review by Glasgow Caledonian University makes a series of other recommendations, including: Better aftercare following surgery Clear language so patients understand exactly what surgery is going to achieve. Read full story Source: BBC News, 21 June 2023
  17. News Article
    An integrated care board (ICB) has advised its GP practices not to give patients automatic access to their records, contradicting NHS England national requirements. Instead, North East London ICB has suggested practices only allow access where patients request it, and subject to conditions. The national go-live date for patients to be allowed automatic access to future entries in their records has been repeatedly delayed since initially being set at December 2021. GPs have argued they needed more time to redact sensitive information, ensure records are not inappropriately shared, and train staff. They have cited workload and safeguarding concerns. The ICB’s chief clinical information officer Osman Bhatti, who is a GP, told HSJ the ICB instead “wanted a process where patients could access both prospective and retrospective records safely, with less workload for GPs and so patients who actually want access can have it”. Read full story (paywalled) Source: HSJ. 1 June 2023
  18. News Article
    The US Food and Drug Administration has proposed to add to what you get with your prescription drugs. The proposed rule would require the prescriptions you get to come with a new kind of single-page medication guide with an easy-to-use set of directions and easy-to-understand safety information, a goal the FDA has been working toward for years. One study found that nearly 75% of Americans have had trouble taking their medicine as directed. A lot of that is due to cost – people might not be able to afford their medicine, so they don’t take it – but some is due to confusion. They might get more than one kind of written information with their prescription, or the information they receive can be conflicting, incomplete or repetitive, the FDA said. When people are confused or misinformed about their prescription, there is a good chance they will not take it or will stop taking it, and that can directly hurt their health. “Research suggests that medication nonadherence can contribute to nearly 25% of hospital admissions, 50% of treatment failures, and approximately 125,000 deaths in our country each year,” the FDA says. The agency said the new proposal is also meant to help fight the “nation’s crisis with health care misinformation and disinformation.” Read full story Source: CNN, 30 May 2023
  19. News Article
    A woman who had a hysterectomy has said she was discharged without sufficient information on its impact on her physical and mental health. Mechelle Davis, from County Down, said it was crucial women left hospital with appropriate medication and advice. Her operation involved removal of her womb, ovaries, fallopian tubes, and cervix. Ms Davis was 48 when she had her operation and said she had no option but to look online for advice, something she described as "unsatisfactory". "I had the operation in October 2022 and didn't go on HRT until the following February," she told BBC News NI. "Every woman who is going through the menopause - including surgically induced - needs support. In its online tool for clinicians, British Menopause Society advise that HRT plays a significant role in managing surgical menopause, especially in women under 45 - provided there are no contradictions such as personal history of hormone dependant cancer. It also adds that "all women undergoing surgical menopause should have counselling and be provided with information about the hormonal consequences of surgery and the role of HRT, both before surgery and before leaving hospital with clear communication to the primary care team." BBC News NI has spoken to other women who, after having a hysterectomy, were discharged without advice or a HRT prescription. Read full story Source: BBC News, 23 May 2023 Further reading on the hub: World Menopause Day 2022: Raising awareness of surgical menopause
  20. News Article
    Blind people are being put “at risk” when the NHS provides them with “inaccessible” information about their health, a charity has warned. People with sight loss have missed appointments, cancer screenings or been unable to use home test kits because of a lack of clear instructions in an accessible format, according to the sight loss charity RNIB. It warned that denying people access to their information can also “cause embarrassment and loss of dignity”. Linda Hansen, from Bradford, who is severely sight-impaired, said that she needed to get her daughter to read her the results of a medical exam which was sent to her in print format. Ms Hansen, 62, said: “I can get my bank statement or a gas bill in accessible formats, but yet I still receive health information that I can’t read. What could be more personal than your health status?” A new RNIB campaign – My Info My Way – has been launched calling for all blind and partially sighted people to be given accessible information. The charity said that a failure to provide information in an accessible format is putting blind and partially sighted people “at risk”. Read full story Source: The Independent, 16 May 2023
  21. News Article
    Cancer drug information leaflets for patients in Europe frequently omit important facts, while some are “potentially misleading” when it comes to treatment benefits and related uncertainties, researchers have found. Cancer is the biggest killer in Europe after heart conditions, with more than 3.7m new cases and 1.9m deaths every year, according to the World Health Organization. Medicines are a vital weapon against the disease. But critical facts about them are often missing from official sources of information provided to patients, clinicians and the public, according to a study led by researchers from King’s College London, Harvard Medical School and the University of Sydney, among others. “Regulated information sources for anticancer drugs in Europe fail to address the information needs of patients,” the study’s authors wrote in The BMJ journal. “If patients lack access to such information, clinical decisions may not align with their preferences and needs.” Read full story Source: The Guardian, 29 March 2023
  22. News Article
    The high-profile Australian neurosurgeon Charlie Teo admits making an error by going “too far” and damaging a patient, but maintains she was told of the risks. The doctor on Monday appeared at a medical disciplinary hearing to explain how two women patients ended up with catastrophic brain injuries. Teo also defended allegations that he acted inappropriately by slapping a patient in an attempt to rouse her after surgery, contrasting it with Will Smith’s notorious slap of Chris Rock at the Academy Awards last year. “It wakes them up and it wakes them up pretty quickly. And I will continue to do it.” Charlie Teo tells inquiry he ‘did the wrong thing’ in surgery that left patient in vegetative state One of the issues the panel of legal and medical experts is considering is whether the women and their families were adequately informed of the risks of surgery. Both women had terminal brain tumours and had been given from weeks to months to live. They were left in essentially vegetative states after the surgeries and died soon after. “We were told he could give us more time,” one of the husbands said, according to court documents. “There was never any information about not coming out of it". Read full story Source: The Guardian, 27 March 2023
  23. Content Article
    Community hospitals are an important part of local health and care systems, yet there has been very little shared on their role and contribution during the pandemic. This project from the Community Hospitals Association sought to redress this and highlight the role of these local hospitals. This two-year project enabled staff to reflect on their experiences and innovations in their community hospitals during the pandemic in a systematic way that facilitated wider sharing and learning. It captures the experiences of staff working in UK community hospitals during the COVID-19 pandemic, with a focus on positive impact changes. 
  24. Content Article
    Julie Smith, Topic Leader for the hub and Content Director at EIDO Healthcare, takes a look at how patient information can be used to help improve outcomes for those on long surgical waiting lists.
  25. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) aims to improve patient safety by supporting staff to access critical information about patients at their bedsides in emergency situations. It defines critical information as ‘information about patients that needs to be accessed rapidly and accurately to ensure correct care is delivered when it is required’. In this investigation, critical information was considered through a focus on patient identifiers (such as name and date of birth) and decisions relating to whether someone is recommended to receive cardiopulmonary resuscitation (CPR) if their heart stops (cardiac arrest). The reference event for this investigation was the care of a patient in a hospital who was found unresponsive in bed. A short time later, he stopped breathing and his heart stopped. Help was immediately sought from the ward staff and a team gathered around the patient’s bed, where they confirmed the patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. As a result, CPR was not started. Around 10 minutes later, a nurse who had previously been caring for the patient returned from their break and recognised that the patient had been misidentified as the patient in the next bed. The patient whose heart had stopped was recommended to receive CPR. CPR was immediately started, but despite this, the patient died.
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