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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this opinion piece for The Hill, the authors argue that urgent action is needed to prevent huge amounts of avoidable harm in the American healthcare system. They point to successful strategies under the Obama administration to demonstrate that the right political will can both improve patient safety and save money. They highlight actions that policy makers, official bodies and patients should take to promote the patient safety agenda.
  2. Content Article
    This Annual Report provides an overview of independent investigations commissioned by regional independent investigation teams, primarily relating to homicides committed by patients in receipt of mental health services. Focusing on financial years 2019/20 and 2020/21, it details the key findings from investigations and the performance of the commissioning arrangements.
  3. Content Article
    This study in Clinical Child Psychology and Psychiatry assessed feedback from paediatric diabetes patients and their parents or carers regarding virtual consultations, using a solution focused approach, in a hospital setting. Patients completed an electronic survey following their virtual consultation, and of those surveyed, 86% recommended video consultations to be part of their diabetes care. Qualitative data showed reduced travel time, comfort, reduced need for parking and convenience as the major benefits to patients. The results demonstrated that clinical care was shown to be positive and addressed patients concerns, the majority of respondents (84%) reported that the appointment was about what they wanted it to be about. Using the solution focused model helped overcome the challenges faced with virtual consultations particularly with concerns surrounding safeguarding issues, confidentiality, audio/video difficulties and also helped to support the patient journey.
  4. Content Article
    This guide by the University of Birmingham's Institute for Mental Health is designed to help young people prepare to talk with their GP about self-harm and suicidal experiences. It contains advice about what to do before, during and after a GP visit.
  5. Content Article
    In this interview Kathryn Marszalek, Senior Analytical Manager at the Health Foundation and Dr Jessica Butler from the Institute of Applied Health Sciences at the University of Aberdeen, discuss the Health Foundation's Networked Data Lab (NDL). They describe how linking data across the whole health and care system improves care and safety outcomes for patients, and how the programme has been used so far to identify clinically extremely vulnerable patients during the Covid-19 pandemic. They talk about what's next for the NDL and describe key success factors in achieving the the programme's fundamental goal of improving health inequalities in the population.
  6. Content Article
    A midwife in England shares their experiences of working in the NHS in 2021. They describe the mental and physical impact of having to work beyond capacity on a daily basis, a situation caused by a staffing crisis in the midwifery workforce. The impact of this is that more midwives are leaving the NHS as they are unable to cope with these pressures, which makes the workload for remaining staff even heavier.
  7. Content Article
    This report by the Health and Social Care Commons Select Committee looks at the catastrophic impact of the Covid-19 pandemic on patients waiting for NHS care and outlines the findings of the Select Committee's inquiry. Waiting lists are at their highest since records began, and the 5.8 million patients waiting to start treatment in September 2021 may be only the tip of the iceberg, with missing patients meaning that the true waiting list could be as high as 13 million. The report highlights the need to carefully plan how to tackle the elective care backlog. It outlines the risks involved, including the danger of prioritising areas that are well suited to numerical targets to the detriment of other areas of care, such as mental health, general practice and community services. It also highlights that the challenges the NHS faces are greater than just tackling elective care. With a record number of 999 calls and waiting times in emergency departments at record levels, work to tackle the backlog is being threatened by pressure on emergency care.
  8. Content Article
    In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, looks at some of the patient and staff safety issues surrounding insulin delivery. These issues have been identified by a new working group set up by the Safer Healthcare and Biosafety Network (SHBN), and she also highlights potential solutions the group will explore. The SHBN is an independent forum focused on improving healthcare worker and patient safety. It has established a working group on improving injection technique and delivering dual safety in diabetes care. The working group consists of clinicians, policy-makers, charities, manufacturers and patients who are concerned about high numbers of preventable safety incidents related to diabetes treatment.
  9. Content Article
    This article in The BMJ discusses the consequences for practising doctors of the 2015 Montgomery v Lanarkshire Case. The case was brought by Nadine Montgomery, a woman with diabetes and of small stature, after she delivered her son vaginally and experienced complications during the birth which resulted in her son having cerebal palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby’s size was a potential problem. The Supreme Court ruling in her favour established that a patient should be told whatever they want to know, not what the doctor thinks they should be told.
  10. Event
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    Join us for a series of free online webinars brought to you by Bolt Burdon Kemp’s specialist Women’s Health Team to help raise awareness of racial inequality in maternal healthcare. Hear from leaders and influencers in maternal healthcare, focusing on changes required across the profession to improve the level of care provided to those who identify as ethnic minority mothers and birthing people. We have a fabulous line up of expert speakers and each webinar will be followed by a Q&A session. Come and join us for a chance to contribute to the discussion and share experiences. This webinar will be led by Natasha Smith, Founder of Eden’s Script and Benash Nazmeen, Practising Midwife. To register, please email webinars@boltburdonkemp.co.uk - you will be sent a Zoom invite with joining details nearer the time.
  11. Event
    until
    Join us for a series of free online webinars brought to you by Bolt Burdon Kemp’s specialist Women’s Health Team to help raise awareness of racial inequality in maternal healthcare. Hear from leaders and influencers in maternal healthcare, focusing on changes required across the profession to improve the level of care provided to those who identify as ethnic minority mothers and birthing people. We have a fabulous line up of expert speakers and each webinar will be followed by a Q&A session. Come and join us for a chance to contribute to the discussion and share experiences. This webinar will be led by Mars Lord, Doula Educator and Birth Activist. To register, please email webinars@boltburdonkemp.co.uk - you will be sent a Zoom invite with joining details nearer the time.
  12. Event
    until
    Join us for a series of free online webinars brought to you by Bolt Burdon Kemp’s specialist Women’s Health Team to help raise awareness of racial inequality in maternal healthcare. Hear from leaders and influencers in maternal healthcare, focusing on changes required across the profession to improve the level of care provided to those who identify as ethnic minority mothers and birthing people. We have a fabulous line up of expert speakers and each webinar will be followed by a Q&A session. Come and join us for a chance to contribute to the discussion and share experiences. This webinar will be led by Dr Christine Ekechi, Consultant Obstetrician and Gynaecologist and Co-chair of the Race Equality Taskforce at the Royal College of Obstetricians and Gynaecologists and spokesperson for racial equality. To register, please email webinars@boltburdonkemp.co.uk - you will be sent a Zoom invite with joining details nearer the time.
  13. Event
    until
    Join us for a series of free online webinars brought to you by Bolt Burdon Kemp’s specialist Women’s Health Team to help raise awareness of racial inequality in maternal healthcare. Hear from leaders and influencers in maternal healthcare, focusing on changes required across the profession to improve the level of care provided to those who identify as ethnic minority mothers and birthing people. We have a fabulous line up of expert speakers and each webinar will be followed by a Q&A session. Come and join us for a chance to contribute to the discussion and share experiences. This webinar will be led by Elsie Gayle, Midwife and will include lived experience from a Pakistani mother To register, please email webinars@boltburdonkemp.co.uk - you will be sent a Zoom invite with joining details nearer the time.
  14. Event
    until
    Join us for a series of free online webinars brought to you by Bolt Burdon Kemp’s specialist Women’s Health Team to help raise awareness of racial inequality in maternal healthcare. Hear from leaders and influencers in maternal healthcare, focusing on changes required across the profession to improve the level of care provided to those who identify as ethnic minority mothers and birthing people. We have a fabulous line up of expert speakers and each webinar will be followed by a Q&A session. Come and join us for a chance to contribute to the discussion and share experiences. This webinar will be led by Kate Brintworth, Chief regional Midwife for London and Wendy Olayiwola, National Maternity Lead for Equality NHS England and NHS Improvement To register, please email webinars@boltburdonkemp.co.uk - you will be sent a Zoom invite with joining details nearer the time.
  15. Content Article
    This poster from the Royal College of Midwives (RCM) provides information for midwives and midwife support workers on appropriate PPE for different scenarios in maternity care. It covers what to wear in different stages of care in both hospital and community settings if a patient has, or does not have, confirmed or suspected Covid-19.
  16. Content Article
    In this interview with the journal International Politics and Society, Brendan Delaney, professor at the Faculty of Medicine at Imperial College London discusses the impact of Long Covid on individuals and society. He describes his own experience of Long Covid, which rendered him unable to work for months, and highlights that we should not be surprised by the prevalence of Long Covid, as all epidemics result in long-term illness for many people. He draws attention to parts of the political system 'not believing in' Long Covid and highlights the damage caused by psychologising the condition. Finally, he points to the need for more research to better understand Long Covid symptoms.
  17. Content Article
    This population-based cohort study in JAMA Surgery aims to determine the association of surgeon and patient sex concordance with postoperative outcomes. The authors found that worse outcomes, including death and complications, were more likely among female patients treated by male surgeons. The authors highlight the need for further research to understand the underlying mechanisms causing this trend.
  18. Content Article
    This guidance will help Local Maternity Systems align their Equality and Equality Action Plans with Integrated Care Systems health inequalities work. The guidance includes an analysis of the evidence, interventions to improve equity and equality, resources, indicators and metrics.
  19. Content Article
    This study in the Journal of Health Services Research & Policy examines healthcare workers' ideas of what counts as 'voiceable concern'. It demonstrates that identifying whether a concern should be voiced often involves personal judgement, exercised in highly specific organisational and cultural contexts. The authors conclude that understanding how those who work in health care organisations come to recognise what counts as a voiceable concern is critical to understanding decisions and actions about speaking out. They highlight that the concept of voiceable concern may help to explain aspects of raising concerns in organisations, as well as informing interventions to improve voice.
  20. Content Article
    In this article in Becker's Hospital Review, Mackenzie Bean highlights five of the most pressing safety issues for healthcare systems and hospitals to address in 2022:Foundational safety workSupporting the healthcare workforceIntegrating equity into safety workDiagnostic harmHealthcare-associated infections
  21. Content Article
    This study in The Journal of Minimally Invasive Gynecology applied a structured human factors analysis to understand the factors that contribute to vaginal retained foreign objects (RFOs). Trained human factors researchers looked at 45 incidents that occurred between January 2000 and May 2019 at an academic medical centre in Sothern California. The narrative of each incident was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). The authors of the study concluded that the top two contributing factors in vaginal RFO incidents were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.
  22. Content Article
    15 year-old Mary Bush had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, and on 6 August 2020, Mary took her own life. In her report, the Coroner raises a number of concerns and highlights action that needs to be taken to prevent future deaths.
  23. Content Article
    This short animation looks at the importance of healthcare professionals routinely asking patients, "What matters to you?" Understanding an individual patient's needs, wants and hopes results in empowered patients, improved outcomes and improved relationships between patients and healthcare professionals.
  24. Content Article
    In this report, the Care Quality Commission (CQC) comments on progress following publication of its 'Out of sight – who cares?' report in October 2020, and highlights the main areas where further work is still needed.
  25. Content Article
    Although research has focused on safe disposal of sharps in healthcare settings, the issue of disposal by patients in the home setting has not often been addressed. This US study in the journal Diabetes Spectrum aimed to evaluate methods of disposal and patient demographic factors associated with correct disposal of diabetes-related sharps in the community.
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