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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This is the first episode in a series of podcasts by Natasha Loder, Health Policy Editor at The Economist, about the care backlog currently facing the health service. After more than two years battling Covid-19, the NHS is struggling through its worst winter crisis in living memory and is facing a daunting task to clear the huge backlog exacerbated by the pandemic. Nearly six million people are on the NHS waiting list for routine treatment in England alone. As patients, often with worsening conditions, pour back into the NHS after putting off treatment, health secretary Sajid Javid warns waiting lists could top thirteen million. In this first episode, Natasha speaks to frontline workers, managers, policy experts, and patients to assess the pressure created by the unprecedented demand on the different areas of the NHS from emergency services to GP surgeries.
  2. Content Article
    In this article in The BMJ, Farah Hameed highlights that the backlog of care in the aftermath of the Covid-19 pandemic is having a significant and detrimental effect on primary care services, not just elective hospital treatment. The combined impact of patients not coming forward for treatment during the pandemic, and hospitals having to cancel non-urgent procedures and routine clinics, has led to a huge backlog of patients living with conditions that are gradually getting worse. It is primary care that has to support these patients in the absence of capacity in secondary care. Consultant-led hospital services rejecting GP referrals due to lack of capacity is a major problem, with the number of GP referrals rejected due to lack of slots jumping from 238,859 in February 2020 to 401,115 in November 2021.  Farah argues that emphasis must be placed on how tackling the build-up of care in our communities can help the wider system. For example, making GP continuity of care a policy priority would be a cost-effective way of improving patient outcomes and reducing the burden on other parts of the healthcare system, including secondary care.
  3. Content Article
    This qualitative study in Antimicrobial Resistance & Infection Control aimed to identify institutional actions, strategies and policies related to healthcare workers’ safety perception during the early phase of the Covid-19 pandemic at a tertiary care centre in Switzerland. The authors interviewed healthcare workers from different clinics, professions, and positions. The study identified transparent communication as the most important factor affecting healthcare worker's safety perceptions during the first wave. This knowledge can be used to help hospitals better prepare for future infectious disease threats and outbreaks.
  4. Content Article
    This report describes an adverse incident at Queen's Medical Centre in Nottingham in 2001, when a male patient being treated for leukaemia died after being mistakenly given the chemotherapy drug Vincristine intrathecally (into the spine). Vincristine should be administered intravenously, and accidental intrathecal administration of Vincristine is almost always fatal.
  5. Content Article
    This training video illustrates guidance from the Department of Health on safe administration of intrathecal medications.
  6. Content Article
    This study in the International Journal for Equity in Health aimed to listen to the views of community leaders from seven diverse urban communities in Minneapolis-Saint Paul, Minnesota, around quality healthcare and financial reimbursement. In the US, healthcare quality is measured by insurers, professional organisations and government agencies, with little input from diverse communities. The researchers found that community leaders identified several ideal characteristics of quality primary healthcare, most of which are not currently measured. Community leaders expressed concern that health inequalities are perpetuated when social and structural determinants of health are not considered in determining quality.
  7. Content Article
    This investigation by the Healthcare Commission examined the cases of ten women who died during pregnancy or within 42 days of delivery at Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005. This number of maternal deaths was significantly higher statistically when compared with other trusts that serve similar populations.
  8. Content Article
    This study in Occupational Medicine examined the impact of the introduction of face masks during the Covid-19 pandemic on D/deaf healthcare professionals (HCPs). The study found that D/deaf HCPs felt left behind, isolated and frustrated by a lack of transparent masks and reasonable adjustments to meet their communication needs. This resulted in some leaving their roles, and loss of experienced, qualified HCPs has a significant economic and workforce impact, particularly during a pandemic. The authors call for urgent action to ensure D/deaf HCPs are provided with the workplace support required under the Equality Act (2010).
  9. Content Article
    This resource from the Health Foundation includes data, insights and analysis exploring how the circumstances in which people in the UK live shape their health.
  10. Content Article
    The Covid-19 pandemic has had a significant impact on the amount of planned care the NHS has been able to provide. This delivery plan sets out how the NHS will recover elective care over the next three years. It has been developed with a wide range of expert partners and explains how the NHS will capitalise on current success and embed new ideas to ensure elective services are fit for the future.
  11. Event
    The National Comparative Audit of Blood Transfusion is the largest programme of clinical audits of blood transfusion in the world and is funded by NHS Blood and Transplant. It began in 2002 and audits the administration of blood and blood components as well as assessing appropriate use of blood in various clinical settings. It is concluding its work on three National Comparative Audits: 2018 audit of the use of fresh frozen plasma, cryoprecipitate and transfusions for bleeding in neonates and other children 2019 Re-audit of the medical use of red cells 2021 audit of NICE Quality Standard 138 This webinar includes a 40 minute presentation by experts from NCA and SHOT teams. Register
  12. Content Article
    In this blog, Dr Charlotte Paddison, Senior Fellow at the Nuffield Trust, discusses whether the shift towards digital primary care risks making access easier for people with less need and harder for those more likely to be in poorer health. She also describes the actions that would help make access to primary care easier for different groups of patients.
  13. Content Article
    This is the first in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Josie tells us about the nursing error that first sparked her interest in patient safety, how a just culture helps healthcare workers and systems learn from their mistakes, and how her love of skiing has inspired her to think differently about risk in healthcare.
  14. Content Article
    The British Association of Perinatal Medicine is inviting parents of babies who have spent time in a neonatal intensive care unit (NICU) to submit questions for neonatal research to the Neonatal Priority Setting Partnership. The partnership is made up of healthcare professionals and parent representatives that have come together to oversee a process to identify and prioritise research questions that can be tested in randomised trials in UK neonatal care. Answers to the questions submitted should improve neonatal care and reduce unwanted variations in practice. Questions can be submitted until 28 February 2022.
  15. Content Article
    This resource by the mental health charity Mind is for people who want to change the practice of restraint in mental health services and end reliance on force, particularly on adult mental health wards. It is mainly aimed at people who use mental health services, carers, advocates and campaigners. It provides information about restraint, people’s experiences, official guidance, good practice and campaigners’ stories.
  16. Content Article
    The Muckamore Abbey Hospital Public Inquiry is a statutory inquiry established under the Inquiries Act 2005, to examine the issue of abuse of patients at Muckamore Abbey Hospital (MAH). It aims to determine why the abuse happened and the range of circumstances that allowed it to happen. The purpose of the Inquiry is to ensure that such abuse does not occur again at MAH or any other institution in Northern Ireland which provides similar services. This website contains all documentation, reports and news about the inquiry.
  17. Content Article
    Very preterm infants are at increased risk of adverse outcomes in early childhood. This study in The Lancet Child & Adolescent Health assessed whether delayed clamping of the umbilical cord reduces mortality or major disability at two years. The authors found that clamping the umbilical cord at least 60 seconds after birth reduced the risk of death or major disability at two years by 17%, reflecting a 30% reduction in relative mortality with no difference in major disability.
  18. Content Article
    This report presents the findings and conclusions of an independent review into clinical governance arrangements within maternity services at The North West London Hospitals NHS Trust. The independent review was set up following three maternal deaths in one year and two other serious untoward incidents (SUIs) in the Trusts's maternity unit.
  19. Content Article
    In this blog, a patient who experienced life-changing surgical complications describes the process of reconciliation between medical staff and patients when harm has occurred in healthcare. She highlights the need for both the patient and healthcare professional to be engaged and open in the process. She also looks at how different human factors can negatively impact on the duty of candour process, and why they need to be acknowledged. These factors include lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and norms.
  20. Content Article
    In this blog for Refinery29, Sadhbh O'Sullivan looks at the issues faced during antenatal care by pregnant women who are overweight. She recounts the perspectives of several pregnant women who felt dehumanised and blamed for their weight during pregnancy. She also highlights issues with the way in which risks are communicated to pregnant women, with overcommunication and overestimation of risk causing anxiety and sometimes making women reluctant to engage with maternity services. She also discusses failures of informed consent, the role of comorbidities and the impact of wider health inequalities.
  21. Content Article
    This blog by the Institute for Safe Medication Practices identifies ten medication safety concerns in the US from 2021 that still need to be addressed. These concerns are: Mix-ups between the paediatric and adult formulations of the Pfizer-BioNTech COVID-19 vaccines Mix-ups between the COVID-19 vaccines or boosters and the 2021-2022 influenza (flu) vaccines EPINEPHrine administered instead of the COVID-19 vaccine Preparation errors with the Pfizer-BioNTech purple cap or grey cap COVID-19 vaccines Errors and delays with hypertonic sodium chloride Errors with discontinued or paused infusions Infection transmission with shared glucometers, fingerstick devices, and insulin pens Adverse glycaemic event errors Every organisation needs a medication safety officer Increasing error reporting
  22. Content Article
    This non-statutory guidance from the UK Government aims to support education, health and care settings and services in putting in place measures which will help them: understand the needs of children and young people, including the underlying causes of and triggers for their behaviour. develop strategies and plans to meet those needs and regularly review them as children change. adapt the environments in which children and young people are taught and cared for so as better to meet their needs. provide appropriate support for children and young people whose behaviour challenges, without the use of restraint or restrictive intervention. It sets out relevant law and guidance and provides a framework of core values and key principles to support: a proactive approach to supporting children and young people whose behaviour challenges. a reduction in the need to use restraint and restrictive intervention.
  23. Content Article
    In this editorial in the Journal of Health Services Research & Policy, Professor Brendan McCormack, Associate Director of the Centre for Person-centred Practice Research at Queen Margaret University Edinburgh, looks at the role of person-centred care in improving quality in health systems. He argues that there is a need to demonstrate the value of person-centred cultures and the significance of person-centred outcomes to healthcare organisations. In order to achieve this, researchers need to utilise theory-driven and mixed-methodology evaluation designs that demonstrate effectiveness and capture the diversity of experiences among all stakeholders.
  24. Content Article
    This study in the International Journal for Equity in Health used an online survey to measure and assess relationships between health behaviours and outcomes, and measures of wealth and civic engagement. The relationships found in the survey results support the interrelationships of constructs within the conceptual model. The model can serve as a guide for future equity research, encouraging a more thorough assessment of equity.
  25. Content Article
    This guidance from the Chartered Institute of Ergonomics and Human Factors (CIEHF) outlines how human factors as a discipline can help address issues relating to equality, diversity, and inclusion (EDI). It looks at situations that cause EDI issues, including: confusing user interface language and terminology. ill-fitting personal protective equipment (PPE). biases in equipment design. It also examines the role of human factors in overcoming these issues, by: adopting a systems approach. using a participatory design process. applying specific HF methods to enhance EDI delivery.
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