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  2. Community Post
    Patients are increasingly being asked to access online systems to: request prescriptions or make medication requests access healthcare records and test results make appointments communicate health concerns sign consent forms. These developments can have a positive impact but they can also carry potential challenges, as highlighted in this recent blog - Digital-only prescription requests: An elderly woman sent round the houses. We'd like to hear your experiences of using online systems in healthcare. Have they made things easier? Does it feel like your care is more joined up for it? Have any of these changes been challenging? If so why? Comment below (sign up first for free) or contact us directly at content@patentsafetylearning.org to share your experience.
  3. Earlier
  4. Community Post
    @blueiii I am so sorry to hear about your painful and traumatic experience. The points that you and many others have raised, are incredibly important and we refer to this forum when we connect with others in the gynae space, highlighting the need for urgent improvement. More recently we have been seeking examples of good practice to share, with the aim of helping others learn from their work to provide safer care. We have also been working with researchers who have been exploring this area. I am including a few links below to content that may be of interest. Many of the issues raised by patients undergoing IUD procedures mirror those we have heard in relation to hysteroscopies. So I have also included a piece we wrote calling for action on that. Better data collection, patient reported outcomes and making sure women can have access to all of the available pain relief options (with the relevant information) would be a start to improving things. You'll see from the example in one of the links below that the team in Oxford also have a complex pathway for patients who they identify as having the potential to experience high levels of pain or trauma. It is a flexible system, based on listening to the patient - another key area for improvement. There is so much to learn in this space, to make sure patients don't continue to suffer as you have or lose trust. Fitting coils: developing a safe and supportive service Pain experiences during intrauterine device procedures: a thematic analysis of tweets (11 June 2024) Coil procedures: Exploring negative experiences through qualitative research (an interview with Sabrina Pilav) The ripples of trauma caused by severe pain during IUD procedures (BMJ Opinion, July 2021) Hysteroscopy: 6 calls for action to prevent avoidable harm
  5. Community Post
    A few years ago I was undergoing tests for coeliac disease. I was sent by my GP for an endoscopy with an independent provider. A couple of weeks after the procedure, I called my GP surgery to see if they had the results - the receptionist told me they had, and that they said the results were normal. To celebrate I went and enjoyed a blow-out wheaty weekend! But on the Monday morning I received a letter in the post that said the biopsy was positive for coeliac disease and I should follow a gluten free diet. I raised this with the GP, and they were apologetic, but said the results come in two stages - the letter the receptionist had seen referred only to visible signs of issues relating to other conditions, not the coeliac biopsy. I didn't came to any major harm as a result of being given the wrong diagnosis, but I do wonder what would have happened if I hadn't received the second letter myself.
  6. Community Post
    Hi @DKJoker84 You can email enquiries@ukcvfamily.org if you are interested in joining UKCVFamily's support forum for people who have experienced vaccine injury. They may be able to offer some signposting to research regarding your symptoms and services that can offer further support.
  7. Community Post
  8. Community Post
    Hi, we at patient Safety Learning are looking to hold a virtual round table in the last week of June to look at how to improve patient safety related to the implementation of EPRs. If you are a clinician who has been directly involved with the roll out of an EPR, then you could be part of the event. All notes taken at the event will follow Chatham House rules and your participation will not be disclosed outside the round table group if that is your preference. If you'd like to be involved, please contact me (Clive Flashman) directly at support@pslhub.org Many thanks, Clive
  9. Community Post
    A short report and approach to understanding thinking errors in a PSII Understanding Thinking Errors within a PSII.pdf
  10. Community Post
    In 2010, it emerged that implants manufactured by the French company Poly Implant Prothese (PIP) had been made with cheap silicone that had not been approved for cosmetic surgery, and had a high splitting rate. The French authorities closed PIP and the company's founder was convicted of aggravated fraud and imprisoned. Patient groups say there has been little support, recognition or information for those affected in the UK, and that thousands of women continue to experience health problems.[1] Have you had a PIP implant? What has your experience been? What could be done now to make sure those affected are supported? Please comment below (sign up here first, for free) or get in touch with the team at content@pslhub.org [1] Woman pays £11,000 to fix ruptured breast implant
  11. Community Post
    I mainly object to the name; Physician Associate infers that the person is a physician. It should be Physician's Associate or Physician's Assistant. Many patients have told me they think PAs are junior doctors, training to be GPs I have also heard of PAs overstepping the work they are legally qualified & allowed to do and speaking as if they are doctors. They are not. They are helpers. They earn a very good salary. (£40,000+) I would never see one if I needed a doctor.
  12. Community Post
    I’m so sorry that you have joined the ranks of those of us who were not given the correct information about hysteroscopy, and have suffered. The lack of care, respect, honesty and professionalism is truly shocking. You may be interested in The Campaign Against Painful Hysteroscopy, which has a Facebook and web page, as well as @HysteroscopyA on Twitter. CAPH has a survey, completed by over 5,000 women, detailing their awful experiences, and you may wish to complete one. If you feel up to it, put in a complaint. Another good way of highlighting your traumatic experience, is to detail it on Care Opinion, which is an independent organisation that highlights people’s experiences of health care, unlike the NHS which marks its own homework. The hospital concerned will be highlighted, and you may post anonymously. Sadly, so many of us understand and are able to empathise.
  13. Community Post
    Today's medical system totally overlooks one of the most horrifying patient safety issues. That issue is when patients declared dead REVIVE. In my 80+ year lifetime, two doctors have blown the whistle in this arena, reporting that there are quite a few more instances of reviving than make it into public media. The concern among doctors and institutions is the appearance of medical malpractice. (It's only the appearance, doctors aren't God and can't be sure in just the short time they are given.) If you're lucky, you may revive in a morgue. If not, you may revive in the cremation oven or underground. Those "unlucky" cases WILL NEVER BE KNOWN. but statistically, we can be sure they happen more or less regularly. Keep in mind that determination of death is VERY skimpy, requiring only a few minutes of no heartbeat and breathing. There have been studies finding that the brain can actually keep working for some HOURS. Victorian era evidence showed coffin linings being ripped by the occupant. The main reason for this callous disregard of patient safety may well be that a fictitious "brain dead" declaration, applied to patients who are still artificially breathing and circulating blood, is used to HARVEST VALUABLE ORGANS. Big Bucks Bend Rules. The true state of the patient is hidden by NOT keeping an EEG unit connected and monitored throughout the 3-4 hour procedure. Far more cruel, the patients are ONLY GIVEN PARALYSIS DRUGS, NO PAINKILLING ANESTHETICS. If they start feeling pain during organ harvesting, nobody will know except the torture victim. So reader, remember that ALL of us can be subject to this form of potential torture and we ALL should be helping to require making reviving impossible, at least when a patient requests it. To me, this should be right at the TOP of the patient safety topic lists. I suggest it's about time for medical professionals to acknowledge that there is an unknown number of revive-after-declared death cases which, due to fears of being called out for malpractice, never get made known to the public. Thus, the public does not have a fair picture of how serious this problem may be. I suggest that it's long overdue for medicine to adopt methods where a patient is assured that once death has been declared, a method of preventing reviving will be applied, probably on request. I suggest that a simple way might be to inject a couple of hundred milligrams (in solution) of morphine into the heart or major artery. This can be done with materials on hand and is minimally inconvenient for the attending physicians. A really sure method would be the draining of blood. Autopsy facilities should be able to accomplish that without a lot of difficulty. I suggest that the current practice of telling the patient "The mortuary will take care of that" is INSUFFICIENT - a patient has no way of knowing what will happen once they are shipped out of the hospital morgue. So I say "C'mon doctors! You are highly educated in physiology -- DO YOUR PATIENTS A GREAT KINDNESS AND SET UP A SYSTEM FOR THIS NEED." Thanks for all the medical system does, in spite of this one failing, Eleanor Weiss
  14. Community Post
    This new qualitative study might be of interest to those who have experienced dental diagnostic error or diagnostic failure. It's a start in building research evidence around the harms that can be caused. Patients’ experiences of dental diagnostic failures: A qualitative study using social media (April 2024)
  15. Community Post
    Ugh, that sounds frustrating! Dealing with unnecessary hoops for a simple inhaler replacement can be a real hassle. The idea of classifying experienced patients as 'expert patients' is brilliant – could save a lot of time and streamline the process
  16. Community Post
    Reaching out to NHS professionals involved in transporting and delivering drugs is a smart move. Collaborating with them can provide valuable insights and help streamline procedures.
  17. Community Post
    Last week in Geneva the World Health Organisation Executive Board approved the “draft global action plan for infection prevention and control, 2024‒2030: draft global action plan and monitoring framework” and this will now proceed to the World Health Assembly in May for ratification by all WHO Member States. This very detailed action plan with its set of indicators, outlines a plan for countries and health care facilities to achieve the global vision that by 2030, everyone accessing or providing health care is safe from associated infections. A set of annexes go into the detail on the indicators and key players that will be instrumental in implementation of the plan once it has been ratified. There's a big focus on ensuring that in each country, IPC programmes are aligned with and contribute to other complementary national programmes’ strategies and documents, this is where the IPC-patient safety-quality-AMR interlinkages, relationships and collaborations (to name but a few programmes) come into play. The plan also addresses the need for political commitment, health worker knowledge, data for action, advocacy and communications, research and development and collaboration and stakeholders’ support. A theory of change is available. 2024 offers to be an interesting year for those working to improve infection prevention and control as one part of patient and health worker safety and quality.
  18. Community Post
    The latest stat I heard is that each hospital generates more information than the Library of Congress. That is meant to store all media created (although I think that excludes Tik Tok videos and social media). I don't have a timescale for this but, if true, it's pretty impressive and also somewhat intimidating.
  19. Community Post
    I have created a policy using the templates. I've submitted it but had no feedback as yet. Will report back on my success/failure
  20. Community Post
    I agree and will look into these issues
  21. Community Post
    This case study focuses on a North Staffordshire Combined NHS Trust project. The lead consultant for the service was concerned that the clinical pathways were not optimised and bottlenecks were delaying access, assessment and diagnosis of patients. As a result there were delays to initiating treatment. In addition to potential harm to patients this was resulting in inefficient and wasteful use of resources. Following pathway changes, value and efficiency impact was noted in the following areas: Because head CT scans are provided by a neighbouring acute trust, reducing the number of patients referred had a direct impact on service cost as well as releasing capacity in the wider system. Comparing baseline activity with the review period showed a 30% reduction in CT scan referrals and a £7,800 direct cost saving. The number of patients not attending appointments reduced from 572 in the baseline period to 379 after implementing pathway changes. While not a cash releasing saving this improved overall efficiency and productivity for the service and contributed to a reduction in overall unit price per attendance. At the start of the project, the average unit price for patients attending the memory service was £280.93. Through a combination of direct cost savings and efficiency and productivity gains arising from the revised pathway, this figure had reduced to £205.12 in the review period. Do you have a cost-saving or efficiency case study to share? What were the patient safety implications? Do you have resources or knowledge to share that can help others make positive changes? Comment below (sign in or register here for free first), or get in touch with us at content@pslhub.org to tell your story.
  22. Community Post
    Hi Fiona, As you are already a member of the hub, please email support@PSLhub.org with a request to be added to the group.
  23. Community Post
    "One of the best examples I saw involved a case in which a worker was about to move a vehicle and trailer. The keys were in the ignition, but before starting the vehicle, he decided to perform a walkaround and discovered a mechanic was working underneath the trailer. Together, they agreed to take the keys out of the ignition and established a tagging system to ensure nobody else would inadvertently move the equipment while it was being worked on."[1] According to this article by Safety Management Group, just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns an organisation's safety philosophy into a clear reality. Do you use a 'good catch' reporting system in your health and social care setting? Has it made a difference to safety culture or behaviour? How easy was it to implement? Do you recognise and/or celebrate staff for reporting incidents? Or perhaps this is something you'd like to implement. What would you like to ask others who have tried it? Share your experiences and questions in the comments below. You'll need to register for free first. Related reading: Near-Miss and Good-Catch Reporting Promote a culture of safety with good catch reports Using good catches to increase worker ownership of safety 5 Examples of good catches in healthcare and how to implement a near miss campaign [1] SMB. Using good catches to increase worker ownership of safety. Accessed online 9/08/23.
  24. Community Post
    Strategy - NHS Culture Change.pdf
  25. Community Post

    Better use of data for medication safety in hospitals

    Kenny Fraser

    Kenny Fraser replied to Kenny Fraser's topic in Medicine management

    Thanks Clive - love to hear thoughts from those dealing with this in clinical practice
  26. Community Post
    @Tom Rose @Rosanna Hunt @JonathanK @Pramjit @Avashinee @Emma W I am sorry I have not followed this up. Please get in touch with me at perbinder@gmail.com or my LinkedIn profile www.linkedin.com/in/perbindergrewal. I am very interested in how behaviours and culture impacts on PS. Thanks
  27. Community Post
    @BDF @Jo Griffin @Greenfingers @Stefanie If any of you would be interested in sharing your perspectives as a parent in a blog about these issues, please do get in touch with us at content@patientsafetylearning.org. We can offer editorial support and blogs can be anonymous
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