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Patient-Safety-Learning

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  1. Content Article
    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the prescribing of medicines for children based on their weight. This HSIB investigation reviewed the case of a four-year-old child who was diagnosed with a blood clot in her leg following a surgical procedure in hospital. She was prescribed an anticoagulant medicine using an electronic prescribing and medicines administration (ePMA) system. Errors in the prescription, dispensing and administration processes meant that the child received ten times the intended dose on five separate occasions over three days. A scan of the child’s brain showed evidence of a bleed and she was admitted to the paediatric intensive care unit. Following three months in hospital, the child was discharged home with an ongoing care plan.
  2. Content Article
    This white paper documents a roundtable discussion held at the International Forum on Quality and Safety in Health Care in Europe 2021. Participants discussed how smart medication management can be improved to optimise healthcare quality and efficiency. The meeting was chaired by Yu-Chuan (Jack) Li, a researcher of artificial intelligence (AI) in medicine and medical informatics, and editor-in-chief of BMJ Health and Care Informatics.
  3. Content Article
    In this blog for the Hospital Times, Tracy Bignall, Senior Policy and Practice Officer at the Race Equality Foundation, writes about how ethnicity impacts on women's health experiences. She argues that the The Department for Health and Social Care (DHSC) Vision for the Women's Health Strategy released in December 2021 does not give adequate attention to the influence that ethnicity has on women's experience of, and outcomes in healthcare. The article outlines instances in healthcare where ethnicity has an impact on women's health and calls for specific action to address how ethnicity influences health inequalities.
  4. Content Article
    This study in BMJ Quality & Safety aimed to determine whether areas with higher levels of socioeconomic deprivation or larger ethnic minority populations saw larger falls in emergency and planned admissions in England during the Covid-19 pandemic. The study found that Covid-19 did not have an evenly spread impact on NHS hospital care for non-Covid patients, with disparities corresponding to deprivation and ethnicity. Although it is hard to determine the mechanisms behind these differences, the authors argue that they could make pre-pandemic health inequalities worse.
  5. Content Article
    This self-assessment tool has been developed by the British Lung Foundation for people with Long Covid symptoms. It aims to help patients identify and prioritise their needs, signposts them to further information and outlines the help they should get in dealing with Long Covid. It is anonymous and takes 5-10 minutes to complete. Patients can also print out their answers and share them with healthcare professionals an employers to clearly highlight an individual's needs.
  6. Content Article
    This report by the Commission for Health Improvement (CHI) sets out what the CHI has found out about the involvement of patients and the public from more than 300 inspections and from its research into the topic. It discusses what CHI looks for when assessing patient, service user, carer and public involvement (PPI), examples of how organisations are tackling this agenda and messages for the NHS in taking PPI forward.
  7. Content Article
    This resource by The Health Foundation provides a timeline of national policy and health system responses to Covid-19 in the UK. Themes include: Policy narrative Measures to limit spread Health and social care response Research and development Broader policy Policy history
  8. Content Article
    Non-communicable diseases (NCDs) including cardiovascular disease, cancer, chronic respiratory disease and diabetes, are leading causes of morbidity, disability and mortality in the WHO European Region, causing nearly 90% of all deaths and 67% of premature deaths. The World Health Organization (WHO) Regional Office for Europe has released the WHO Europe NCD Dashboard, which provides graphical data on NCDs in the 53 Member States of the Region and makes comparisons between them. The dashboard enables analysis of a country’s health situation and its progress towards meeting NCD health targets. It includes standardised data from national and international registries and surveys collected by countries, WHO and other international organisations
  9. Event
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    Would you like to collaborate across the South West to identify, learn and share best practice for managing deterioration? Join us at our next Deteriorating Patient Safety Network (DPSN) Workshop on 4 March 2022. Be inspired – come and listen to our inspirational speakers! Make connections and build new relationships – get to know others in the Deteriorating Patient Safety Network in our ‘chat over a coffee’ sessions. Learn more about our work to improve patient safety – find out more about the focus of the regional patient safety collaborative run by the South West Academic Health Science Network, our focus and our principles Network co-production – have the opportunity to co-design our DPSN in a targeted brainstorming session. Let’s work together to build a network which focuses on our collective priorities, which builds and harnesses our skills and experiences and improves patient safety In our DPSN sessions throughout 2021 we had identified the challenges in managing deterioration that you are facing within your settings and determined priorities for future work. The following are key themes that have come out of these sessions. Why not join us to continue exploring these themes? Improving staff confidence and skills to prevent, identify and escalate deterioration Improving response times so that the patient/person receives the right care in the right place at the right time Having sufficient staffing levels in all settings to maximize patient safety Reducing inequalities – access to care no matter who you are Communicating effectively so you are heard Who is invited? Our DPSN workshops are open to those who work in integrated care system organisations across Somerset, Devon and Cornwall, who are involved in patient deterioration in non-care home settings: Commissioners County Council Leads Domiciliary care providers – care @ home including care for people with a learning disability Mental health settings Prisons Primary care Ambulance Services Informal carers Acute Trusts Community Hospitals and nursing teams delivering care in community settings Register to attend About the Deteriorating Patient Safety Network The Deteriorating Patient Safety Network (DPSN) is hosted by the South West AHSN and supports its members to plan, deliver and monitor deteriorating patient and resident projects. Projects in the region have a variety of settings and support patient pathway collaboration between partners from acute and community hospitals, community services in the home, primary care services, care homes, clinical commissioning groups, councils and other partners across the region. Quarterly DPSN events bring teams together to collectively learn from good practice, share resources and support each other on their improvement journey. Bespoke quality improvement methodology and culture training assist the teams to collectively sculpt solutions to common problems and create a thriving and active regional support network. Find out more on our webpage.
  10. Content Article
    This study in the BMJ Open examines the links between between adverse childhood events and trust in Covid-19 health information, attitudes towards and compliance with Covid-19 restrictions and vaccine hesitancy. The study found correlations between adverse childhood events and: low trust in NHS Covid-19 information feeling unfairly restricted by government supporting removal of social distancing and ending of mandatory face coverings breaking Covid-19 restrictions vaccine hesitancy. The authors concluded that as adverse childhood events are common across many populations, there is a need to understand how they impact trust in health advice and uptake of medical interventions. This could play a critical role in the continuing response to Covid-19 and approaches to controlling future pandemics. In addition, as individuals with adverse childhood events suffer greater health risks throughout life, better compliance with public health advice is another reason to invest in safe, secure childhoods for all children.
  11. Content Article
    'The Theatre: Surgical Learning & Innovation Podcast' is a podcast by the Royal College of Surgeons of England. This episode features a panel discussion on the nature of “human factors” in surgery, presented by Peter Brennan, consultant oral and maxillofacial surgeon, Louise Cousins, trainee general surgeon, Neil Tayler, British Airways pilot and trainer, and Graham Shaw, also a British Airways pilot and Director of Critical Factors, a consulting and training service for professionals operating in safety-critical environments.
  12. Event
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    In this webinar from Learning Disability Today, Alexis Quinn, autistic woman and author; Dr Jeremy Tudway, Clinical Director for Dimensions, and Max Green, Ambassador for the National Autistic Society, talk about how communication is key to providing good care to people with a learning disability and/or autism. It looks at how professionals communicate with the people they are supporting, what they do and don’t say, and how they say it. This webinar is for: GPs Psychiatrists Practice managers Professionals working with people with a learning disability and/or autism People with a learning disability and/or autism The panellists will discuss how communication is essential to improve the care and quality of life of people with a learning disability and/or autism. In the first part of this talk, Alexis Quinn talks about her experience in an Assessment and Treatment Unit (ATU) where she was over-medicated and subjected to restraint and seclusion. She will also discuss how support in the community could have prevented her hospital stay. In the second part of the talk, Dr Jeremy Tudway, Clinical Director for Dimensions, and Max Green, Ambassador for the National Autistic Society, will talk about how communication is key, looking at how professionals communicate with the people they are supporting, what they do and don’t say, and how they say it. Register
  13. Content Article
    This study in Scientific Reports aimed to understand the current situation of occupational exposure to blood-borne pathogens in a women's and children's hospital in China. The authors analysed the causes of exposure to provide a scientific basis for improving occupational exposure prevention and control measures.
  14. Content Article
    This article in the British Journal of General Practice examined GP perspectives and concerns about safeguarding during the Covid-19 pandemic, focusing on the challenges and opportunities created by remote consultation. GPs interviewed for the study expressed concern about missing observational information during remote consultations, with pooled triage lists seen as further weakening safeguarding opportunities. They were also worried that conversations might not be private or safe. Remote consultations were seen as more ‘transactional’, with reduced opportunities to explore ‘other reasons’ including new safeguarding needs. Remote consultation was seen as more difficult and draining and associated with increased GP anxiety and reduced job satisfaction. However, GPs also recognised opportunities that remote consulting offers, including providing more opportunities to interact with vulnerable patients.
  15. Content Article
    This study in the International Journal for Equity in Health aimed to understand the care experiences of people with learning disabilities, and explore the potential patient safety issues that they and their carers raised. The authors examined the lived experience of care for people with learning disabilities through focus groups and narratives posted on the public platform Care Opinion. The study identified a series of safety inequities and gaps in systems affecting people with learning disabilities. The authors recommend considering interventions to protect against these inequities at a policy and organisational level and highlight that policy needs to span both health and social care.
  16. Content Article
    This scoping review in JMIR Human Factors looked at existing research into how including the reason for use on a prescription impacts pharmacists. It suggests that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counselling, impact communication and improve patient safety. Concerns about workflow and patient privacy may be factors that prevent the inclusion of use information. The review identified that more research is needed to better understand how the inclusion of use information affects pharmacists.
  17. Content Article
    This index of medications provides evidence-based patient leaflets about the use of different medicines in pregnancy. The leaflets are produced by the UK Teratology Information Service (UKTIS). Women can look up medications to understand their impact on pregnancy and how they may affect the chances of miscarriage and birth defects, and provide information on their own pregnancy to add to the knowledge base around medicines in pregnancy.
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    Join the #SolvingTogether Connect Sessions, virtual sessions that anyone can attend where people share their ideas for addressing the challenges.  They are informal opportunities to put forward ideas, and have discussion. Patients and health and care staff are all invited to attend. The MSTeams link to the session will be added to the event page at 9am on Thursday 2nd February.
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    In this online event, the Chartered Institute of Ergonomics & Human Factors will be launching their new guidance packed with information on how human factors as a discipline can help address Equality, Diversity and Inclusion (EDI) issues. You’ll learn: How human factors can support the different protected characteristics under the Equality Act 2010. How human factors techniques and approaches contribute to EDI by increasing buy-in and engagement. How storytelling of lived experiences helps build a stronger sense of empathy. Who will this be of interest to? Are you an EDI or human factors professional eager to learn more about the relationship between these two areas? Are you a policy maker? Are you involved in dealing with human resources, UX and workplace issues that touch on EDI? If so, this webinar will be of interest to you. About the presenters Courtney Grant is a Senior Human Factors Engineer with twenty years’ experience across industry, consultancy and public service. Amanda Widdowson is Head of Human Factors Capability, Thales UK and Past President of the CIEHF. Abigal Wooldridge is Diversity lead at the US Human Factors & Ergonomics Society. How to book Register for your free place
  20. Content Article
    In this blog, Roohil Yusuf, Global Pharmacy Advisor at Save the Children, looks at the different factors involved in providing access to life-saving medication, including planning, sourcing, use and management of medicines. She tells the story of Habibah, a three-year-old girl from Nigeria, who was able to access medication for Severe Acute Nutrition and tuberculosis at one of Save the Children's treatment centres. She also looks at the dangers of counterfeit and expired medicines, and explores how organisations can take steps to prevent poor quality, counterfeit or expired medicines being given to patients.
  21. Content Article
    This report by The Patients Association is based on information gathered from more than 1,000 patients in a survey carried out in December 2021, just before the omicron wave of the Covid-19 pandemic hit the UK. The results of the survey highlight that patients found it hard to access care during this period, with pressures affecting the NHS compromising their care. They also show that the worst affected patients were those whose illness or care needs seriously affect their day-to-day lives.
  22. Content Article
    This toolkit has been created for NHS organisations to help them implement the Living Wage. It includes the accreditation process as well as case studies and advice from existing accredited NHS organisations.
  23. Content Article
    This report looks at research commissioned by the Juvenile Diabetes Research Foundation (JDRF) to understand the varying pandemic experiences of different people affected by type 1 diabetes in the UK. It highlights an enormous withdrawal of NHS services during the pandemic, leading to highly unequal access to type 1 diabetes care.
  24. Content Article
    In this blog for the King's Fund, Toby Lewis examines the need for NHS organisations to ensure its staff members in lower-paid roles are paid enough to meet their living costs. He calls for organisations to pay the real Living Wage, a figure based on actual living costs, rather than the National Living Wage. Currently, NHS pay scales at and below Band 2 spine point 3 do not reach the real Living Wage. He argues that adopting a real Living Wage policy results in a return on investment in the form of fewer vacancies, smaller staff turnover and less sickness - 60% of real Living Wage employers state that it improves recruitment, quality of applicant, and retention in lower-paid roles.
  25. Content Article
    Barrie Housby had a medical history that included frailty, Parkinson’s disease and macular degeneration. During a stay at Clifton Hospital he was known to be at high risk of falls and at the beginning of the nightshift on 12 July 2021, it was advised that he should be cared for on a one to one basis and not left unattended. During the shift, a member of staff allocated to monitor him left the bay to attend to other duties, and in this time Mr Housby left his bed and fell. He was transferred to a hospital emergency department but subsequently died on 13 July 2021 as a result of a traumatic subdural haemorrhage following a fall. In his report, the Coroner Alan Wilson highlights the impact of staffing shortages at the Trust and their contribution to Mr Housby’s death, stating that this poses an ongoing risk to patient safety.
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