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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The use of non-medics in clinical roles is leading to deaths and missed diagnoses, senior doctors have warned. Hundreds of doctors have signed an open letter to the leadership of the Royal College of Physicians (RCP), urging them to take a stand over the rollout of physician associates (PAs). PAs are a newer type of medical role that involves significantly less training than doctors receive. The NHS has used PAs since 2003 but concerns have emerged in recent months about them taking on more advanced work than is appropriate. NHS England set out plans earlier this year to expand their numbers significantly amid ongoing staff shortages. Now an open letter to the RCP’s council, to date signed by 46 fellows of the college and 194 other doctors, sets out concerns ranging from patient safety and liability to the fact that newly qualified PAs can earn more than newly qualified doctors. They say: “There have been several high-profile incidents in which serious illness was missed by a PA when undertaking a role that would normally be filled by a doctor. In some cases, avoidable deaths have resulted. “Given that some of these conditions required more advanced training than the PA had received, the implication is that rare avoidable deaths are a price society must pay for the replacement of medical staff with non-medical staff. We believe this trade-off must be debated widely not just by doctors but also by the lay public.” Read full story (paywalled) Source: The Times, 5 October 2023
  2. News Article
    The number of doctors seeking help for mental health issues has risen by more than three quarters within two years, according to figures from a specialist treatment service for NHS staff. For one GP, the relentless stress of the job led to him taking three months off work with burnout. David Triska is no stranger to high-pressure situations. As an army medic, he served two tours of Afghanistan. But mounting workloads at his village GP surgery left him feeling "hollowed out and spent". Simple tasks, like unlocking his car or making a meal, became a challenge - an experience he describes as leaving him feeling "like a husk of a human". "At that extreme point, I couldn't see why I needed to be here anymore," Dr Triska said. He is not alone. Since the year ending March 2021, there has been a 77% rise in the number of doctors seeking help for mental health issues, according to figures shared with the BBC by a confidential support service for NHS staff. More than 5,600 doctors used the NHS Practitioner Health programme in England in 2022/23, with about a third having thought about taking their own lives. Read full story Source: BBC News, 5 October 2023
  3. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organisation. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches Facilitated by: Andrew Harvey IG Consultant BJM IG Privacy Ltd Register hub members receive a 20% discount code. Email info@pslhub.org for discount code.
  4. Event
    This virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. Knowing things may have gone wrong can feel a heavy burden and a complex emotional situation to be managing. Often, we avoid visiting difficult emotions in others, as well as ourselves, because we don’t feel confident or skilled, or we feel fearful of not doing it perfectly. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  5. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture. Register hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  6. Event
    The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members will receive 20% discount. Email info@pslhub.org for a discount code.
  7. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on non-technical skills to improve patient safety. Key learning objectives: Task analysis Cognitive overload Reliability Non-technical skills Examples Register hub members receive 20% discount. Email info@pslhub.org for discount code.
  8. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider work stream and tips for avoiding them. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
  9. Event
    Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. There will be an extended focus on the role of human factors in patient safety investigation in line with the new National Patient Safety Incident Response Framework (PSIRF). For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/human-factors-in-healthcare or email kate@hc-uk.org.uk Follow this conference on Twitter @HCUK_Clare #HumanFactors hub members receive a 20% discount. Email info@pslhub.org for discount code.
  10. Event
    The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on safety actions for improvement. There will also be an extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. The conference update delegates on the new Patient Safety Incident Response Standards and how to review your current practice against these standards. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/serious-incident-investigation-patient-safety or email kerry@hc-uk.org.uk Follow this conference on Twitter @HCUK_Clare #NHSSeriousIncidents hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  11. Event
    This Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night, and supporting the wellbeing of those working at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night and transforming out of hours services and roles to improve patient safety. The 2023 conference will focus on the developing an effective Hospital at Night service, and focus on the practicalities of supporting staff at night, improving wellbeing and fighting fatigue. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/hospital-at-night-summit or email frida@hc-uk.org.uk Follow on Twitter @HCUK_Clare #HospitalatNight hub members receive a 20% discount. Email info@pslhub.org for discount code.
  12. Event
    This conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to that insight to ensure patient feedback is translated into quality improvement and assurance. Through national updates and case study presentations the conference will support you to measure, monitor and improve patient experience in your service, and ensure that insight leads to quality improvement. Sessions will include learning from patients, improving patient experience, practical sessions focusing on delivering a patient experience based culture, measuring patient experience, using the NHS Improvement National Patient Experience Improvement Framework, demonstrating insight and responsiveness in real time, monitoring and improving staff experience, the role of human factors in improving quality, using patient experience to drive improvement, changing the way we think about patient experience, and learning from excellence in patient experience practice. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-insight or email aman@hc-uk.org.uk Follow on Twitter @HCUK_Clare #PatientExp hub members receive a 20% discount. Email info@pslhub.org
  13. Event
    This conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit. Twitter @HCUK_Clare #DeterioratingPatient hub members receive a 20% discount. Email info@pslhub.org
  14. Event
    This conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  15. Event
    This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview Using a structured hierarchy of questions to facilitate comprehensive, accurate information Asking system-focused questions Closing an interview Register
  16. Event
    This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview Using a structured hierarchy of questions to facilitate comprehensive, accurate information Asking system-focused questions Closing an interview Register
  17. Event
    This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview Using a structured hierarchy of questions to facilitate comprehensive, accurate information Asking system-focused questions Closing an interview Register
  18. Event
    This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points. Register
  19. Event
    until
    This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points. Register
  20. Event
    until
    This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points. Register
  21. Event
    until
    This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points.
  22. Content Article
    For innovation to be successful it must be developed in collaboration with those set to use or benefit from it. Involvement and co-production with people, public, carers, and communities is a growing and thriving agenda across the AHSN Network, and is even more important than it has ever been, given the experiences of the COVID-19 pandemic. With this in mind, during 2020/2021 the Network reviewed activity across AHSNs to support a more strategic approach to involvement and co-production of innovation and developed its co-production strategy. Read more about their approach to co-production and patient and public involvement and view the AHSN Network Involvement Strategy.
  23. News Article
    Thousands of people unaware they have type 2 diabetes could be diagnosed and avoid serious complications if screening was introduced in emergency departments, a study suggests. The prevalence of the disease has risen dramatically in countries of all income levels in the last three decades, according to the World Health Organization. More than 400 million people have been diagnosed, but millions more are estimated to be in the dark about the fact they have the condition. A study that took place in an NHS trust in England suggests 10% more cases could be picked up with the use of a simple blood test. Screening could also pick up 30% more cases of pre-diabetes – a serious condition where blood sugar levels are higher than normal. The findings are being presented at the annual meeting of the European Association for the Study of Diabetes (EASD) in Hamburg, Germany. “Early diagnosis is the best way to avoid the devastating complications of type 2 diabetes, and offers the best chance of living a long and healthy life,” said Prof Edward Jude, of Tameside and Glossop integrated care NHS foundation trust. Read full story Source: The Guardian, 3 October 2023
  24. News Article
    A district general hospital has accused a major teaching trust of ‘failing to adhere to arrangements’ made around the provision of acute stroke services, sparking patient safety warnings in a local integrated care board’s (ICB) risk register. Harrogate and District Foundation Trust’s accusation that its neighbour, Leeds Teaching Hospitals Trust, is failing to comply with protocol around acute stroke pathways was published in West Yorkshire ICB’s risk register. The ICB’s September risk register also said the “risk to patient safety is significant and probable if the situation remains unresolved”. The issues centre on the provision of hyper-acute stroke unit beds, which provide the first two to three days of care for patients with newly diagnosed strokes, and what happens to patients requiring acute stroke care following their initial HASU stay. West Yorkshire ICB said in its September’s performance report that the problem had “grown due to two recent clinical incidents,” but added “there is no quick solution to this problem”. Harrogate has raised concerns with the ICB in recent months that “a number of patients are not receiving HASU level care at Leeds”. Read full story (paywalled) Source: HSJ, 3 October 2023
  25. News Article
    Doctors missed a man’s stroke which led him to suffer another one and go temporarily blind. The man said that the experience had changed him from ‘an outgoing social person, to a sheltered man living in fear that he is not being looked after competently’. The 75-year-old visited his GP in Darlington complaining of dizziness, light-headedness, and a numb foot. He had experienced a stroke and should have been immediately sent to hospital. But doctors missed the signs, diagnosed him with a ‘dropped foot’ and requested an urgent MRI scan. However, due to an administrative error the referral wasn’t made and the scan never happened. A month after visiting the GP, the man suffered a blinding headache and diminished vision. He saw an ophthalmologist who referred him to a specialist team. He had suffered another stroke. He also paid for a private scan which confirmed the first stroke happened a month earlier. Distressingly, the man lost vision in his right eye, which he was told could be permanent. Fortunately, his sight returned eight weeks later. His daughter, who described the experience as ‘horrendous’, complained to the Parliamentary and Health Service Ombudsman (PHSO) about her father’s care. The PHSO found that the initial symptoms were signs of a problem with nerve, spinal cord, or brain function. Doctors should have suspected a stroke and immediately sent him to hospital. If that had happened, the second stroke and sight loss would likely have been avoided. Ombudsman Rob Behrens said: “Having a stroke and then being told you could be permanently blind must have been incredibly frightening. The impact on the man, and his family who supported him through the ordeal, will have been deep and long-lasting. “Mistakes like these need to be recognised and acted upon so that they are not repeated.” Read full press release Read case file Source: PHSO, 4 October 2023
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