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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This article in BMJ Quality & Safety looks at letters of compliment from patients to NHS staff, recognising their role in identifying and encouraging high quality healthcare. The authors examined compliment letters from patients and identified: why patients wrote them which activities they complimented which members of staff the feedback was aimed at. The study found that 77% of letters complimented staff on their relationship with the patient, 50% on clinical work and 30% on management. Many letters commented on staff going above and beyond their role to help patients and most letters had the joint aims of acknowledging and promoting good practice.  The authors conclude that by acknowledging, rewarding and promoting positive practice, compliment letters can contribute to healthcare services by promoting positive behaviours and giving staff social recognition.
  2. Content Article
    This blog for the High Reliability Organizing website looks at the implications of 'preoccupation with failure' for individuals and organisations. The author highlights examples of how preoccupation with failure, as first described by Karl Weick and Kathleen Sutcliffe, can improve outcomes and reduce costs in healthcare organisations and in other sectors. She identifies barriers to organisations engaging with the process, including reluctance to look for 'hidden failures' and poor communication.
  3. Content Article
    This toolkit from the Department of Veterans Affairs (VA) National Center for Health Promotion and Disease Prevention contains tools that help promote patient engagement in healthcare settings. It was developed in consultation with VA staff and veterans and is based on the Patient Aligned Care Team (PACT) model.
  4. Content Article
    This guidance from the Care Quality Commission is aimed at adult social care services managers and staff. It explains the care needs associated with type 1 and type 2 diabetes.
  5. Content Article
    This article by Lauren McGIll in The Walrus looks at how design changes to the trauma bay at St Michael's Hospital in Toronto are saving lives. Lack of intentional design in hospitals, new technologies and a culture that celebrates adaptability all contribute to what the author describes as "a piecemeal approach" to emergency medicine workspaces. The outcome of this is ultimately higher mortality rates as staff do not have an optimum working environment. The article describes a research project set up in 2015 by doctors Christopher Hicks and Andrew Petrosoniak, which aimed to identify and remove latent hazards and obstacles that cost trauma staff time in emergency situations. They redesigned the trauma bay at St Michael's hospital as a result of their findings, and early reports are that dramatic rescues have been possible thanks to the new layout. Petrosoniak says, “You cannot remove the stress of someone dying in front of you, but we can remove the stress of not being able to find equipment.” Further reading Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review (BMJ Quality & Safety) Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST) (BMJ Open) Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department (AEM Education and Training) Health professionals' experience of teamwork education in acute hospital settings: a systematic review of qualitative literature (JBI Evidence Synthesis)
  6. Content Article
    This cross-sectional study in BMJ Quality & Safety examines the association of hospital nursing skill mix with patient mortality and quality of care. The study analysed patient discharge data, hospital characteristics and nurse and patient survey data from adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. The authors found that a bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. They suggest that having a higher proportion of assistive nursing personnel without professional nurse qualifications reduces the skill mix and may: contribute to preventable deaths erode quality and safety of hospital care contribute to hospital nurse shortages.
  7. Content Article
    This YouTube channel contains video resources designed to raise awareness of falls and how to prevent them. The videos contain simple techniques to help prevent falls and promote healthy lifestyle choices. Videos include a daily 'Falls and management exercise class' and a weekly 'Functional Fitness MOT' for patients to use at home.
  8. Content Article
    This article lists some of the top chronic pain and illness blogs on the internet, with a short description of each one.
  9. Content Article
    This article in Age & Ageing describes a quality improvement project at Leeds Teaching Hospitals Trust (LTHT) that aimed to achieve timely Parkinson’s disease medication administration.
  10. Content Article
    This webinar from the Chartered Institute of Ergonomics & Human Factors is about boosting organisational and personal performance by recognising, measuring and promoting wellness. It describes the development and application of indices to measure wellness using a 'Whole Life - Whole Organisation' approach.  Topics include: Ways for organisations to improve key performance indicators such as sales, productivity, customer service, reduction in accidents, quality, safety/liability, people retention, absence, presenteeism and levels of engagement/motivation Access to new software and management intelligence to support and implement a 3D next generation organisational improvement approach New certifications such as Certificate in Personal Performance - Wellness Management Global Wellness Indices for Healthcare, Hybrid Workers, Hazardous Industries and Universities (staff and students) New research and development and the growing international community of organisations and people active in Performance – Wellness – Health
  11. Content Article
    In this blog for NHS Providers, National medical director's clinical fellow Cian Wade writes about his work with the NHS Improvement national patient safety team on reducing healthcare inequalities. Responding to commitments in the NHS Long Term Plan, this work focuses on two main areas: Determining the extent and causes of unequal experiences of clinical harm among different patient groups. This involved working with patient groups and system leaders to map patient journeys that demonstrate how and why some patients are at heightened risk of harm. Identifying areas for development that may help reduce health inequalities around patient safety. This second phase is in progress and involves gathering input on specific interventions that may reduce the risk of harm.
  12. Event
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    We are delighted to announce our Women’s Rights in Healthcare conference will be back in London on Thursday 7 October, followed by networking. Following the COVID-19 pandemic, we will be exploring the effect this has had on maternity services, the NHS and pregnant women as well as how women specifically may be affected by the onset of Long COVID. The headline talk will look at domestic violence and the impact of brain injury in women and we will also explore delays in diagnoses for women and girls with Autism. Our expert panel includes: Suzanne White, Leigh Day | Chair Harriet Harman, MP | Opening address Jocelyn Gaynor, The Disabilities Trust | Brain injury and domestic abuse: An Invisible Impact Maria Booker, Birthrights | The impact of COVID on maternity services Ernest Boateng, Husband of Mary Agyapong | I AM MARY - Widower’s campaign to protect the rights of pregnant women during the COVID-19 pandemic Dr Louise Newson, Newson Health Research and Education | Gender inequality in a pandemic Margaret O’Hara, Long Covid Support | Whose disease is it anyway? How false narratives and exclusion of the patient voice create stigma and barriers to healthcare Claire Farmer, Co-chair of Autistic Girls Network | Neurodivergence and the urgent need for a shift in understanding, training, and culture Andy and Amanda McCulloch, Leigh Day Clients | WHY CAN’T YOU HEAR ME? We are pleased to invite participants to attend the event in person or online via zoom for those who would prefer to participate remotely. Lunch will be provided before the conference commences. Register for this event
  13. Content Article
    This new book by Professor Harold Thimbleby of Swansea University tells stories of widespread problems with digital healthcare and explores how they can be overcome. "The stories and their resolutions will empower patients, clinical staff and digital developers to help transform digital healthcare to make it safer and more effective."
  14. Event
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    Human performance in pharmaceutical and biopharmaceutical manufacturing: successes and challenges to meaningful industry change Adopting the principles and practices of human performance has led to valuable business and safety performance improvements in high-risk high-consequence industry sectors, such as energy and aviation. Eager to realise similar levels of improvement, several companies in the pharmaceutical and biopharmaceutical manufacturing sector have begun the adoption of human performance within their operations. However, the unique industry context and regulatory environment of this sector has proven the adoption of human performance principles and practices to be more challenging and complex than simply copying from the successes of other industries. In this webinar, you’ll hear from industry professionals who will share their experiences and perspectives on human performance adoption value, successes and challenges. Register now for free Topics and presenters Chairs Dr Brian Edwards trained at Guy’s Hospital, London in hospital medicine and clinical research. He has worked for the Medicines Control Agency, Parexel and Johnson & Johnson, there as a deputy qualified person for pharmacovigilance. For the last 13 years, he was Principal Consultant in Pharmacovigilance at NDA Regulatory Science based in the UK. Brian is Director of ISoP Secretariat Ltd and co-chairs the ISOP Medication Error Special Interest Group, Vice President Pharmacovigilance & Drug Safety in the Alliance Clinical Research Excellence and Safety (ACRES) and Chair of the UK Pharmaceutical Human Factors Group. He has recently been awarded a Fellowship with the International Society of Pharmacovigilance. Currently he consults for his own company, Husoteria Ltd. Julie Avery is former Global Lead for human factors at GSK, with over 20 years in Quality and Operational Excellence. As an independent practitioner, Julie now integrates human performance into existing systems strategically and tactically supporting business goals and KPIs. Julie leads the CIEHF Human Factors Pharmaceutical Manufacturing COP and is a Trustee of the CIEHF representing Associate Members. Topic 1: Why we focus on human performance James Morris, executive director at NSF Health Sciences, has over 30 years’ pharmaceutical operations experience in quality and manufacturing; He’s often leading consulting and training projects in investigation and CAPA management. Topic 2: How human performance reflects a way of thinking – beliefs and principles Amy Wilson has more than 20 years’ experience in biopharma manufacturing, focusing on human and organisational performance, operational excellence, risk management and technical training. John C Wilkes is Human Performance lead for biologics at AstraZeneca. He has more than 25 years’ experience in industry, in manufacturing operations, operational excellence, quality systems and quality control. Topic 3: In terms of internal challenges, how can we get out of our own way? Clifford Berry is head of business excellence for Takeda at its Massachusetts Biologics Operations site. He’s been a human and organisational performance practitioner for over 20 years, with experience in commercial nuclear electrical generation, electric transmission and distribution, and biopharma.
  15. Content Article
    In this article in the Anesthesia Patient Safety Foundation Newsletter, Katsuyuki Miyasaka talks about the history of the pulse oximeter in Japan and celebrates one of it's earliest developers, Takuo Aoyagi. The author recognises the life-saving impact of pulse oximeters, but talks about the need for more education and regulation around the use of this readily available device. Miyasaka highlights that the quality of devices is variable and that when patients attempt to interpret the numbers they see, it may lead to harm.
  16. Content Article
    The Anesthesia Patient Safety Foundation Newsletter is the official publication of the non-profit Anesthesia Patient Safety Foundation and is published three times per year in Wilmington, Delaware, USA. Download all copies of the newsletter
  17. Content Article
    This video presents some highlights of the HSJ Patient Safety Awards on 20 September 2021 at Manchester Central, and includes short interviews with some of the judges and award winners. The HSJ Patient Safety Awards were set up to recognise and celebrate projects that improve patient safety and quality of care. This year, the judges commented that nominees across 23 categories were all of a very high quality and presented innovative projects that made real improvements to patient safety in the NHS. "The quality of this year was quite phenomenal - we were really impressed at how inventive people had been in coming up with solutions to COVID as part of safety strategies," said Lesley Durham, President of the International Society of Rapid Response Systems and member of the awards judging panel. The awards showcase excellent projects and ways of working that have potential to be replicated in other areas. A team from Devon Partnership Trust/Royal Devon and Exeter Foundation Trust won the award for Mental Health Initiative of the Year for their project 'Connecting physical and mental health services in Gastroenterology'. A representative from the team said, "What we want to do now is take this, shout about it and make it happen elsewhere." Many award winners commented on the importance of teamwork across services and trusts and recognised that collaboration was a key part of the success of their projects. View the full list of award winners
  18. Content Article
    Clinical guidelines advise GPs in England which patients need urgent referral for suspected cancer. This study in BMJ Quality & Safety used linked primary care, secondary care and cancer registration data to assess: how often GPs follow the guidelines on cancer referral whether certain patients are less likely to be referred how many patients were diagnosed with cancer within one year of non-referral. The study included patients who presented for the first time with blood in the urine, breast lump, difficulty swallowing, iron-deficiency anaemia and post-menopausal or rectal bleeding during 2014–2015. The authors found that the majority of patients presenting with common possible cancer symptoms were not being referred by GPs in line with clinical guidelines. They also found that a significant number of these patients went on to develop cancer within a year, and suggest that improvement is needed in the cancer diagnosis process.
  19. Event
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    NHS Long Term Plan Webinar Series NHS waiting lists have hit record levels across the UK as a result of the Covid-19 pandemic and the numbers are continuing to rise, with some experts warning 14 million people could be waiting for treatment by the end of 2022. Many hospital groups have turned to digital technology to increase clinical capacity, help safely manage patients and detect deteriorating patients, but are these short term saviours or long-term solutions? New NHS funding has been created to support innovation and the introduction of digital tools, so we have brought together an expert panel to share evidence-based examples of how digital technology is supporting the NHS waiting list challenge and helping to shape the future of healthcare and discuss: What impact has remote patient monitoring already made for patients and clinicians dealing with waiting list backlogs? How can experiences in surgical waiting lists and COVID-19 care guide other clinical pathways? How does this offer a way to increase engagement with patients and improve outcomes? Book a place
  20. Content Article
    This systematic review published in BMJ Global Health looks to identify the nature, frequency and causes of long-COVID symptoms by reviewing data from existing research studies into long-COVID. It aims to regularly synthesise evidence on long-COVID characteristics to help improve long-term outcomes. From the data provided by 39 studies, the review found that: long-COVID affects both patients who were hospitalised and those managed in the community patients with long-COVID display a wide range of symptoms including weakness, general malaise, fatigue, concentration impairment and breathlessness research currently available on long-COVID is vulnerable to bias, so caution should be used when interpreting data. The authors also identify areas where further research is needed to help define long-COVID symptoms, identify risk factors for different populations and assess the impact of variants of concern and vaccination on long-term outcomes.
  21. Content Article
    This study in Jama Network Open examines the health outcomes of patients who were hospitalised with COVID-19 in two Wuhan hospitals between February and April 2020. The authors found that: 45 percent of patients reported at least one symptom one year after hospitalisation the most common symptoms that patients reported were fatigue, sweating, chest tightness, anxiety and muscle pain patients who experienced severe disease during hospitalisation were more likely to experience more symptoms of long-COVID one year on patients who experienced severe disease were likely to have higher chronic obstructive pulmonary disease (COPD) assessment test scores that patients with less severe disease.
  22. Content Article
    Research shows that peer support is an effective way to help healthcare staff recover when something goes wrong in patient care. The Betsy Lehman Center for Patient Safety has developed a toolkit that aims to help healthcare organisations create or expand peer support opportunities for staff. Each section of the online toolkit focuses on key elements of a successful peer support program - from gaining leadership buy-in to creating policies and collecting data.
  23. Content Article
    Health Education England, Loughborough University and a range of partners have developed the new Human Factors Healthcare Learning Pathway in response to the NHS Patient Safety Syllabus 2021. It is the first ever system-wide Patient Safety Syllabus and is available as e-learning short courses that can be completed as a Learning Pathway (Levels 1-3) or individually. Fully accredited by the Chartered Institute of Ergonomics and Human Factors (CIEHF) and the CPD Certification Service, the Pathway offers a complete programme for health and social care staff to: develop competence and capability in Human Factors (Ergonomics) focus their knowledge on patient safety and staff wellbeing. Level 1 is available for free on the NHS Education for Scotland TURAS system and Health Education England's e-Learning for Healthcare platform Selected Level 2 modules are available to book on the Loughborough University Healthcare Learning Pathway webpage
  24. Content Article
    In this article for the Evening Standard, journalist Susannah Butter talks to Caroline Criado Perez about her book, 'Invisible Women, Exposing Data Bias in a World Designed for Men'. Criado Perez discusses inequalities faced by women in healthcare, including delayed diagnosis, misdiagnosis and exclusion from medical research. The article also looks at tech solutions being founded by women to fill gaps and address these inequalities.
  25. Content Article
    This research by the Nuffield Trust, commissioned by NHS England and NHS Improvement, explores the business case for overseas recruitment and looks at the factors that attract or deter nurses from choosing to work in the UK. With a current NHS nursing vacancy rate of 10% and ambitious national goals to expand the workforce, recruiting nurses from overseas is an essential part of the picture. In this research, the authors look at the costs and benefits of overseas recruitment and present their findings as a briefing paper, research report and review on factors that attract or deter staff from moving to the UK.
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