Jump to content

All learn

Showing articles.

To sort the content by type, date or tags you will need to be logged into the hub. Join the hub today to enjoy full member benefits.

This stream auto-updates

  1. Yesterday
  2. Content Article Comment
    Got rid of Hsv, https://prefold2fitted.blogspot.com/2016/01/fold-in-fitted-variations.html
  3. Last week
  4. Content Article
    The Parliamentary and Health Service Ombudsman's annual report and accounts 2023 to 2024 gives details of its performance over the past 12 months, including financial reports and statistical information about the complaints received.
  5. Content Article
    The National Guardian’s Office (NGO) leads, trains and supports a network of Freedom to Speak Up (FTSU) Guardians in England. It also conducts speaking up reviews to identify learning and support improvement of the speaking up culture of the healthcare sector. This is their updated strategy to support cultural change in healthcare to improve worker experience and patient safety.
  6. Content Article
    Last year, before the publication of Labour's health mission, the Health Foundation set out five tests for political leadership on a whole-government approach to health inequalities. As Prime Minister Keir Starmer’s new government starts work, the Health Foundation looks back at those tests and asks: how far they have been met? And what further steps would the new government need to take to meet them? 
  7. Content Article
    The Nursing & Midwifery Council (NMC) are the independent regulator for nurses and midwives in the UK and nursing associates in England. Their annual report sets out their objectives, describes what they have achieved during the year and explains their governance, financial resources and future plans. 2023-24 was a difficult year for the NMC during which serious concerns were raised about its culture and regulatory decision making. A review was commissioned by Nazir Afzal OBE and Rise Associates, which highlighted safeguarding concerns and found that people working in the organisation have experienced racism, other forms of discrimination and bullying. The NMC also commissioned two independent investigations by Ijeoma Omambala KC into some of their fitness to practise cases and the way the NMC handled whistleblowing concerns being raised. These will be published later in 2024.
  8. Content Article
    In this article, Nicholas T H Farr, research fellow at the Department of Materials Science and Engineering at the University of Sheffield, looks at the need for improved preclinical testing methods to ensure the safety of new medical devices. He highlights cases where lack of testing has led to significant harm to patients and argues that to reduce the risk to patients, the research community needs rigorous and comprehensive testing methods that can more accurately predict how the human body will respond to implantable materials and devices. Nicholas has previously written for the hub, in this blog about the importance of investing in the development of testing methods to ensure medical devices are safe to use.
  9. Content Article Comment
    I can't find that document anymore on NHSE's website. They have a page of resources here: NHS England » Mental health nursing And a contact england.mhworksteams@nhs.net that might be able to help you. There's also the National Mental Health & Learning Disability Nurse Directors Forum, I don't know if they have something similar? MHForum If you do find it, please let us know and we'll update the page. Thanks Sam
  10. Content Article
    The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration it can be difficult for them to effectively contribute to escalation of care. This article looks at a process evaluation of the RESPOND quality improvement programme—Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration. It identifies enablers and barriers to the implementation of patient-led escalation systems found during the programme.
  11. Content Article
    Integrated care systems (ICSs) were created to increase collaboration in the health and social care sector and to enable the NHS, local authorities and other partners to take collective responsibility for improving health outcomes, reducing inequalities, delivering better value for money, and driving local social and economic development. This research from the King's Fund examines the development of ICSs by assessing their efforts to develop system-wide approaches to the recruitment, training and retention of staff. The findings are based on 24 in-depth interviews with local leaders in four case study sites plus a series of online workshops.
  12. Content Article
    Workers facing complex environments in the pharmaceutical industry could be helped to reduce risks by taking a different approach to human error. Instead of viewing people as the root of the problems and following a “blame, shame and retrain” model, companies could help to set them up for success using human factors thinking and working proactively. A recent CIEHF webinar on Human and Organisational Performance in Pharma explored the difference that could be made through steps including: Recognising risk and techniques for preventing error. Creating a roadmap for investigating human-related deviations. Improving communication, interviewing and coaching.
  13. Content Article
    The Covid-19 Inquiry published its first report and recommendations following its investigation into the UK’s ‘Resilience and preparedness (Module 1)’. The Chair of the Inquiry, Baroness Heather Hallett, set out her recommendations from the Module 1 report in a live streamed statement. It examines the state of the UK’s central structures and procedures for pandemic emergency preparedness, resilience and response. Reports related to the Inquiry’s further Modules will be published later.
  14. Content Article
    For the first time ever, the adult social care sector has come together, led by Skills for Care, to develop the Workforce Strategy it needs. Adult social care needs a workforce strategy to ensure we have enough of the right people with the right skills to provide the best possible care and support for the people who draw on it.
  15. Content Article
    Teamwork in the operating room is very important for high-quality patient care. It has been shown that increased team member familiarity predicts improved teamwork and is associated with shared mental models and mutual trust, which are in turn important factors for team effectiveness. The aim of this study in Surgery was to investigate the relationship between team member familiarity and perceived team effectiveness in operating room teams. The authors found that greater team member familiarity predicts greater team effectiveness, and this relationship is mediated by shared mental models. They concluded that training should be aimed at these aspects of team functioning to optimise team performance in the operating room.
  16. Content Article
    Listening to the voices of workers is essential for a safe and effective healthcare for workers, patients and the public. Freedom to Speak Up Guardians provide an opportunity for organisations to learn from these voices which may not otherwise be heard. Freedom to Speak Up Guardians are required to report non-identifiable information on the cases they receive both locally to their boards and senior leadership and to the National Guardian’s Office. This report summarises the data shared by Guardians about the speaking up cases they received between 1 April 2023 and 31 March 2024.
  17. Content Article
    Adverse childhood experiences (ACEs) are associated with poorer health outcomes. However, the association between ACEs and healthcare engagement remains relatively underexplored, particularly within the UK. This report presents the findings of an online survey of adults living in Wales and England which looked at the association between ACEs and healthcare engagement, including comfort in the use of healthcare services. The report highlights the following key findings: High ACE exposure is associated with greater medication use. Individuals with four or more ACEs were more likely to report having been prescribed antibiotics in the last 12 months and to be currently using prescription medicine.  Having two or more ACEs was associated with current use of prescription medicine for mental ill-health, with odds of reporting such a prescription being doubled in those with four or more ACEs. There is a relationship between ACEs and medication adherence, with individuals with two or more ACEs being more likely to report poor medication adherence. ACE exposure was linked to having not received all routine childhood vaccinations. Individuals with multiple ACEs were substantially more likely to perceive that professionals do not care about their health or understand their problems. People exposed to multiple ACEs were more likely to report a poor childhood experience with health services.
  18. Content Article
    The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. This study in the Journal of Patient Safety aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterise the nature of the risk controls proposed. The authors did a content analysis of 126 action plans of serious incident investigation reports from a multisite and multi-speciality UK hospital over a three-year period to identify the risk controls proposed. They found that: a substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. most of the proposed risk controls in action plans were assessed as weak, typically focusing on individualised interventions, even when the problems were organisational or systemic in character. They identified six broad approaches to risk controls: improving individual or team performance defining, standardising or reinforcing expected practice improving the working environment improving communication process improvements disciplinary actions. The authors concluded that advancing the quality of risk controls after serious incident investigations requires involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning. This should be supported by a common framework.
  19. Content Article
    In these presentation slides, Erik Hollnagel, Professor at the University of Southern Denmark, explains what is meant by the terms 'work as done' and 'work as imagined'. The presentation looks at the implications of designing with the two concepts in mind and highlights ways to better align system design with the realities of work as done.
  20. Content Article
    This is the tenth MBRRACE-UK Perinatal Mortality Surveillance Report. The report is divided into five sections: perinatal mortality rates in the UK; mortality rates for Trusts and Health Boards; mortality rates by gestational age; mortality rates by ethnicity and socio-economic deprivation; and a description of the causes of perinatal death. This report focuses on births from 24 completed weeks’ gestational age, with the exception of the section on mortality rates by gestational age, which also includes information on births at 22 to 23 completed weeks’ gestational age. This avoids the influence of the wide disparity in the classification of babies born before 24 completed weeks’ gestational age as a neonatal death or a late fetal loss. Terminations of pregnancy have been excluded from the mortality rates reported. Additional supporting materials to accompany this report include: a set of reference tables a data viewer with interactive mapping, which presents mortality rates for individual organisations, including Trusts and Health Boards a technical manual containing full details of the MBRRACE-UK methodology, including definitions, case ascertainment and statistical methods.
  21. Content Article
    This blog is part of a series written by Dr Charlie* taking a closer look at some of the patient safety issues affecting people's lives today.  In this blog, Dr Charlie describes how although digital prescribing can work well it needs all those involved in the system to put their heart and soul into it. Families and patients must be involved, drugs prescribed must be regularly reviewed and care must be joined up. *Names have been changed in this blog.
  22. Content Article
    Seminar from Tracey Herlihey, NHS England, on the Patient Safety Incident Framework (PSIRF).
  23. Content Article
    Patient safety is seen as implicit and complex, difficult to measure, difficult to engage with and the area of experts. This is very different from high safety industries that put safety at the centre of their activities, with a leadership intent to develop a just and learning culture. In this blog, Henrietta Hughes highlights the importance of leadership, not only of provider organisations but all the bodies that surround the NHS – the politicians, officials, inspectors, regulators, commissioners, representative bodies and patient groups. For frontline staff and patients alike, it is vital that leaders speak the same safety language, understand the impact that they have on the safety culture and embrace patient partnership.
  24. Content Article
    Safety is a core dimension of health care quality, and measurement of patient safety culture in Organisation for Economic Co-operation and Development (OECD) countries is increasingly conducted as part of efforts to monitor patient safety and to contribute to health system performance assessment. This Health Working Paper looks at the findings of the second OECD pilot on patient safety culture. This occurred in 2022-2023 and in total took data from 648,209 health care providers from 14 countries.
  25. Content Article
    A forgotten generation’s life chances are being harmed due to delays accessing care. The NHS is struggling to meet rapidly rising demand and increasingly complex and acute care needs among children and young people, a survey by NHS Providers highlights. There is deep concern among leaders of NHS trusts about the long-term harm caused by delays in services for children and young people (CYP), including a widening health inequalities gap.
  26. Earlier
  27. Content Article
    Surgical conditions are common in older patient and often require major surgery on frail patients. Strong understanding of the risks for different patients is crucial for decision-making and establishing goals of care. This study in the American Journal of Surgery aimed to find out which clinical factors increase the risk of older patients dying within 30 days of a colectomy or small bowel resection. The results showed that the highest predictors of mortality were American Society of Anesthesiologists (ASA) status 5, septic shock and dialysis. Without risk factors, mortality rates were 11.9% after colectomy and 10.2% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4% following colectomy and 100% following small bowel resection.
  28. Content Article Comment
    This gave me so much anxiety reading this. How we have got to this state is beyond me. How is this ok? How can we change this ? My heart goes out to this nurse and the thousands of others that work in these awful conditions.
  1. Load more activity
×
×
  • Create New...