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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This article in the British Journal of General Practice looks at what will happen to public engagement in healthcare following the Covid-19 vaccine rollout. The author, Datapwa Mujong, argues that the successes of community-centred approaches employed in response to the pandemic could be lost without sustained funding and policy to embed these services in healthcare provision. He warns of the dangers of 'initiative decay' and expresses concern that disadvantaged groups may be further disenfranchised by the short-term nature of engagement for the purpose of the vaccine rollout. He argues that in order to tackle inequalities, sustainable solutions are needed, rather than short-term interventions, even though these may require fewer resources.
  2. Event
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    Voices for Improvement: Facilitating the co-existence of Lived and Learned Experience Rachel Matthews, Head of Experience at National Voices and Associate Lived Experience Leader Keymn Whervin have co-designed and developed a prototype programme of coaching and mentoring, which will bring mutual benefit to those with Lived and Learned Experience and improve health and social care. We know that people with Lived Experience bring important insight to the design and delivery of care, and understand how resources can be directed for better value. However, they do not often get the opportunity to work alongside system leaders to support improvement. Voices for Improvement, a National Voices project in partnership with Q Community, offers Lived Experience Partners the opportunity to provide coaching and mentoring to those in senior positions in health and care. Through 1 to 1 coaching in action learning groups, Lived Experience Partner participants are trained to bring their perspective and insights to support leaders to develop their personal and organisational practice. We really believe that this has the potential to help to enact meaningful change through strategic co-production. The event This event will share our learning from this project as we prepare to launch. We want to bring you along for the journey, and allow you the chance to meet those who have contributed along the way. We are excited to share our methodology and invite participants to ask questions to see what getting involved in this work could look like for them, their organisations and their networks. Who is this event for? We are excited to welcome a wide range of people to this event: If you are a person with Lived Experience who is interested in becoming a Lived Experience Partner through the programme, or someone who knows people who may find this experience to be beneficial do come along and learn about what is involved. If you are a system leader or hold a position of influence within healthcare and you’d like to learn more about how to embed Lived Experience in your work through the expertise of a Lived Experience coach, we will explain more about the programme and open the floor to additional questions. If you are part of a larger charity with your own Lived Experience networks and want to learn about what makes our approach different, and how this could potentially help you do come along. Register for this event. If you have any questions, please email info@nationalvoices.org.uk Agenda to follow soon. Voices for Improvement builds on the exploration conducted in 2020 with the Voices for Improvement Advisory group including two representatives from the Rosamund Snow Community and with support from the Health Foundation.
  3. Event
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    This webinar delivered by the East Midlands Patient Safety Collaborative and The AHSN Network will provide an introduction to safety culture and the impact it can have. To register, email kursoom.khan@nottingham.ac.uk
  4. Content Article
    This report by The Health Foundation reviews attempts to tackle inequities in the supply of general practice services in England over the past 30 years. The ‘inverse care law’ was first defined by the GP Julian Tudor Hart 50 years ago and describes how people who most need health care are least likely to receive it. The report looks at policies on general practice funding, workforce, premises, contracts and commissioning, examining recent evidence on differences in GP services between more and less deprived areas of England and assessing past national policies to reduce inequities. The report then looks at the implications of this analysis and outlines policy recommendations for addressing the inverse care law in general practice.
  5. Content Article
    This campaign from Kit Tarka Foundation aims to remind anyone coming into contact with a young baby to remember their T-H-A-N-K-S: Think Hands And No Kisses. Young babies are particularly susceptible to infections, but many people are unaware of the risks and what they can do to reduce them.
  6. Content Article
    In this article for Nature, Aris Katzourakis, Professor of Evolution and Genomics at the University of Oxford, highlights misconceptions around the word 'endemic' that have arisen during the Covid-19 pandemic. He defines an endemic infection as "one in which overall rates are static — not rising, not falling," and highlights that we have come to associate this with less harmful illnesses such as the common cold, when in fact it can also be applied to deadly diseases including malaria, polio and tuberculosis. He argues that the word has been misused by policymakers to indicate that the virus poses less threat and therefore no action needs to be taken. In order to tackle the ongoing threat of Covid-19, the author suggests the following four actions: Set aside lazy optimism Be realistic about the likely levels of death, disability and sickness. Targets set for reduction should consider that circulating virus risks giving rise to new variants Use the weapons we have available, globally: effective vaccines, antiviral medications, diagnostic tests and a better understanding of how to stop an airborne virus through mask wearing, distancing, and air ventilation and filtration Iinvest in vaccines that protect against a broader range of variants
  7. Content Article
    This Prevention of Future Deaths report relates to the death of four patients who all died from endoscopic retrograde cholangio-pancreatography (ERCP) related complications, within a six-month period. All four patients had their treatment carried out by the same doctor during his training for this high-risk procedure. In her report, the Coroner Laurinder Bower raises concerns about the systems in place to gain consent and inform patients of the risks of these procedures.
  8. Content Article
    This is the recording of a webinar given on 19 January 2022 for the International Shared Decision Making Society by Professor Kirsten McCaffery from the University of Sydney and Marie Anne Durand from the University of Lausanne. It covers the following topics: What is health literacy and why does it matter Conceptualising health literacy and shared decision making Findings from recent health literacy and shared decision making reserach What can we do better?
  9. Content Article
    This study in the British Journal of General Practice looked at the association between continuity of GP care and potentially inappropriate prescribing in patients with dementia, as well as the incidence of adverse health outcomes. The study authors found that for patients with dementia, consulting with the same doctor consistently, resulted in: 35% less risk of delirium 58% less risk of incontinence 10% less risk in emergency admission to hospital less inappropriate prescribing. The results demonstrate that increasing continuity of care for patients with dementia could improve their treatment and outcomes.
  10. Content Article
    This qualitative study in Research in Social and Administrative Pharmacy examined how staff working in UK community pharmacy during the first waves of the Covid-19 pandemic in 2020 responded and adapted to new pressures on their services to maintain patient safety. From responses gathered from 23 community pharmacy staff in England and Scotland, the authors identified five themes: Covid-19, an impending threat to system Patient safety stressors during the first waves of Covid-19 Altering the system, responding to system stressors Monitoring and adjusting Learning for the future. They found that pharmacy staff responded and adapted to the evolving situation, monitoring the success of measures and protocols adopted in response to the pressures of the pandemic.
  11. Content Article
    This study in JAMA Network Open sought to determine whether limited English proficiency (LEP) is associated with not reporting a history of cardiovascular disease among patients with angina symptoms. The study found that patients reporting symptoms of angina were more likely to not report having cardiovascular disease if they had limited English proficiency. This discrepancy may be because of higher rates of undiagnosed cardiovascular disease or lower awareness of such diagnoses among individuals with LEP. The authors highlight the importance of finding effective communication strategies for people with LEP in order to make prevention and treatment for cardiovascular disease more effective.
  12. Event
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    This is the third in a series of online lectures organised by the International Shared Decision Making Society (ISDM). This lecture will be hosted by Kristen Pecanac, UW-Madison School of Nursing. Join the webinar
  13. Content Article
    This study in the International Journal of Nursing Studies looked at the role of primary care nurses in coaching patients in shared decision making about their treatment. It evaluated an approach to support nurses in coaching patients, which was found to have a positive impact overall. Nurses became more aware of their own attitudes and learning needs and reported more in-depth discussions with patients. However, nurses struggled to integrate the approach in routine care and highlighted the need to receive support from their practice to implement the new approach.
  14. Content Article
    This report by The Health Foundation looks at the relationship between debt problems and health, and the impact of the Covid-19 pandemic on increasing the burden of debt that UK households experience. The authors highlight the two-way relationship between debt burden and health issues, with poor health likely to cause an increase in debt, and debt having an impact on health and wellbeing. Those most exposed to deprivation are more likely to experience a higher burden of debt, adding to health inequalities. The report also demonstrates that the pandemic has particularly affected those on low incomes and the self-employed, in terms of debt burden, and public sector debt collection has added to debt pressures for many. They argue that resilience to future financial shocks has been reduced for a significant proportion of the population and that taking action to offset the impact of rising energy bills should be an immediate priority.
  15. Content Article
    In this article in Inforisk Today, Marianne McGee looks at warnings from patient safety experts and federal authorities around cyberattacks on the public health sector. She looks at emerging trends in the way that cybercriminals target healthcare, recent work to bring down cybercriminal gangs and the impact of ransomware attacks on healthcare systems.
  16. Content Article
    In this article for The Independent, Hannah Fearn looks at the issues women face when seeking treatment for urinary tract infections (UTIs). New research from Garmin has found that 40% of young women say they have been accused of over-exaggerating symptoms or being “over dramatic” about their wellbeing when seeing a doctor. The author highlights several personal stories of women who have experienced debilitating recurring urinary tract infections (UTIs), describing dismissive and discriminatory treatment from both GPs and secondary care doctors. She also looks at the work of the UK's only dedicated research centre focused on recurrent UTIs for women, based at London’s Whittington Hospital, and highlights new treatments that are becoming available for women with recurrent UTIs.
  17. Event
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    From Wednesday 26th January 2022 until February 3rd 2022, NHS England and NHS Improvement will be running daily drop-in Vaccine confidence Q&A sessions. These sessions are for all NHS staff to attend and will be an opportunity for you to ask any specific questions you might have regarding Covid-19 vaccines. Each of these drops-in sessions will be tailored towards a specific audience and hosted by a relevant clinical professionals who will answer any questions and signpost you to any additional information. These sessions will provide a safe and supportive environment to ask any questions you may have about the COVID-19 vaccines. Dates, times and themes are: Wednesday 26 January: 12:00 pm – 1:00 pm - Primary Care Thursday 27 January: 3:00 pm – 4:00 pm - Vaccines and Fertility Friday 28 January: 10:00am – 11:00 am - Vaccines and the Science Saturday 29 January: 7:00pm – 8:00 pm - Vaccines and Your Faith Sunday 30 January: 7:00pm - 8:00pm - Vaccines and Your Faith Monday 31 January: 12:00 pm – 1:00 pm - Vaccines for Nursing and Midwifery Staff Tuesday 1 February: 1:00 pm – 2:00 pm - Vaccines and Fertility Wednesday 2 February: 12:00 pm – 1:00 pm - Vaccines for Healthcare Students Thursday 3 February: 4:00 pm – 5:00 pm - Vaccines and the Science Please note that registration for each session will close three hours before each session begins. You will need to register with your NHS email address. Joining instructions will be send to registered delegates two hours before each session begins. For further information contact Erika Ottley at erika.ottley@nhs.net or on 0779 913 3321
  18. Content Article
    This study in the Journal of Patient Safety assessed the occurrence of incidents in inter-hospital transport for critically ill patients, their potential consequences, and whether they are actually reported. Two different services in Norway were asked to self-report incidents after every inter-hospital transport of critically ill patients. The study found that only 1% of incidents were actually reported in the hospital’s electronic incident reporting system. It also highlighted that experts who examined the incidents were inconsistent in which incidents should have been reported and to what degree different interventions could have prevented them. The study results show the existing quality and safety challenges relating to inter-hospital transport of critically ill patients.
  19. Content Article
    Mollie Daisy Dimmock died from perinatal asphyxia due to hypoxia 34 minutes after being delivered. This was caused by umbilical cord compression from shoulder dystocia which lasted for five minutes before Mollie was fully delivered. In his report, the Coroner Crispin Butler raises concerns about the NICE guidance in relation to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
  20. Content Article
    In this primer for Patient Safety Network, the authors examine the issues surrounding diagnostic error and delay during the Covid-19 pandemic. They discuss the following issues: Biases in the diagnostic process - availability bias, anchoring bias, implicit biases Diagnostic testing for active SARS-CoV-2 Infection Clinical implications of diagnostic error
  21. Content Article
    This systematic analysis in The Lancet used data covering 471 million individual records from systematic literature reviews, hospital systems, surveillance systems and other sources. The authors, an international research collective called the Antimicrobial Resistance Collaborators, used this data to estimate deaths and disability-adjusted life-years (DALYs) that have come about as a result of bacterial antimicrobial resistance (AMR). They estimated that, in 2019, 1.27 million deaths were directly attributable to AMR, with the three primary infections involved being lower respiratory and thorax infections, bloodstream infections and intra-abdominal infections. Their analysis shows that AMR death rates were highest in some lower- and middle-income countries, making AMR not only a major health problem globally, but a particularly serious problem for some of the poorest countries in the world.
  22. Content Article
    'Support after Covid-19' is a series of short podcasts exploring Long Covid and work. It was developed by Professor Cathy Bulley and Dr Eleanor Curnow at Queen Margaret University in response to research insights from the ‘Support After Covid Study,’ which was carried out between May 2020 and June 2021. It focuses on the experiences of people working in health services who are living with Long Covid, offering resources, insight and advice.
  23. Content Article
    Serious Hazards Of Transfusion (SHOT) is the UK's independent, professionally-led haemovigilance scheme. This guidance replaces previous versions and provides information for healthcare professionals on reporting serious adverse reactions and serious adverse events to SHOT.
  24. Content Article
    This article by the Royal College of Obstetricians & Gynaecologists and The My Body Back Project provides tips for healthcare professionals to make cervical cancer screening attendees feel as comfortable as possible during their appointments. Cervical screening can be very daunting for some women, and for those who have experienced sexual violence it can be triggering and cause emotional distress. The article provides the following tips, with more detailed guidance: Communication – language and listening - build trust by listening and acknowledging rather than downplaying any concerns. A sense of calm – how can you can make the environment feel calm and safe? Share control – Consider how you can demonstrate shared control within the consultation and examination. Position – a good position can make all the difference to their comfort and your ability to visualise the cervix. It’s about time…. Offer a double appointment so there is time to check in, build trust and for the woman or person with a cervix to feel ready to be examined.
  25. Content Article
    This study in Social Science & Medicine looked at access to mental healthcare services in the UK during the Covid-19 pandemic. It examined changes to the idea of candidacy, a concept used to describe people's perceptions about their eligibility and entitlement to care. The authors found that the pandemic had a significant effect on patients' ideas about their candidacy, and state that their findings affirm the value of the candidacy framework for mental health contexts.
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