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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Mary Anne Mellor died from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent inserted four years previously.
  2. News Article
    After concerns were raised regarding safety and quality of care for women and babies at the Jessop Wing maternity unit in a Sheffield Teaching Hospital, an unannounced inspection found the unit to be 'inadequate'. Whilst the Care Quality Commission found the maternity service had some good areas which included staff feeling respected and supported, there were concerns raised regarding midwife shortages and whether the staff had the knowledge and experience to run the service appropriately. As a result of the report, several actions were taken to impose conditions on the maternity unit which included proper training of staff, improving infection control and ensuring staff were able to follow the correct safety procedures regarding urgent or serious incidents and proper storage of medicines. Read full story (paywalled) Source: HSJ, 9 June 2021
  3. News Article
    New data has found patients in ambulances experienced significant delays in hospital admissions before the pandemic began. The data revealed patients were waiting for up to an hour or more before they were given to the care of A&E staff and may have had to wait in the ambulance or A&E corridors before they could be admitted to the hospital. It has also been found that in the midst of the Covid-19 pandemic, patients were having to wait even longer before they could be admitted into hospital. A case report by West Midlands Ambulance Service detailed how a woman in her nineties experienced worsening health whilst waiting for treatment and died a short time later. Read the full story. Source: The Independent, 08 June 2021
  4. News Article
    Watchdog has warned the NHS that patients experiencing significant waiting times may be at risk amid fear patients health could worsen whilst waiting for surgery. Read full story Source: The Independent, 7 June 2021
  5. News Article
    A new report commissioned by the House of Commons finds NHS staff and social care workers are suffering from burnout at 'emergency levels'. The report has said problems with burnout among the NHS and care staff already existed but was increased due to the Covid-19 pandemic. Staff shortages have been indicated as one of the causes of burnout as the work days became longer and the pressure on staff grew. It was also found that staff felt overwhelmed after lockdown ended as patients who had not been to see their GP during lockdown were now coming in with an array of health problems. NHS and care staff felt insufficiently equipped to deal with the incoming patients due to a lack of proper staffing support in the workforce. Read the full story Read the full report here Source: BBC News, 8 June 2021
  6. Event
    until
    A multidisciplinary webinar organised by the MASIC Foundation with leading speakers, reflecting the diverse professional roles required to coordinate and deliver effective and individualised care for women experiencing Obstetric Anal Sphincter Injury (OASI). Discussion topics include: The importance of listening to women PTSD Psychosexual issues Body image and sex How a GP can help Q & A session to follow with all speakers, Professor Pauline Slade, Dr Rebecca Moore, Kate Walsh, Lucy Theo, Dr Sarah Hillman, a MASIC Ambassador and Professor Mike Keighley. Co-hosted by Dame Lesley Regan and Debra Bick OBE. For more details and interest in attending, please click here
  7. Content Article
    Workforce burnout and resilience in the NHS and social care report describes the causes and effects of burnout among staff working within the National Health Service as well as the impact of Covid-19 on burnout. 
  8. Content Article
    This narrative review in BMJ Quality & Safety argues that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error and to initiate quality improvement projects aimed at reducing the risk of error and harm. It highlights three approaches that may help with measuring the incidence of diagnostic error: Using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error Using standardised patients (secret shoppers) to study the rate of error in practice Encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process
  9. Content Article
    This guide provides guidance for hospital clinical staff and managers in the secondary care of COVID-19 patients, based on the experience of hospital trusts that performed well during the early phase of the pandemic. It summarises the challenges faced by, and responses of, several high performing trusts visited as part of the GIRFT cross-specialty COVID-19 deep dives, as well as identifying successful innovations they implemented.
  10. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
  11. Content Article
    External clinical harm reviews aim to give assurance to patients, patient groups, commissioners and the public as to whether any patients have been harmed as a result of an incident, as well as to avoid future harm to patients. This handbook by Dr Henrietta Hughes, NHS Medical Director for London North, Central and East, outlines an approach to conducting clinical external harm reviews. It identifies the factors which make external clinical harm panels successful and provides example agendas and terms of reference for the process.
  12. Content Article
    This guide for people who inject insulin or GLP-1 to treat diabetes includes information on: how to correctly inject insulin where to inject to ensure insulin and GLP-1 medication enter the body correctly how to avoid ‘Lipos’ how to store medication correctly how to dispose of needles safely.
  13. Content Article
    This checklist is for people who inject insulin or GLP-1 medication to treat their diabetes. It details the steps patients should take to ensure they inject their medication correctly and explains the impact of failing to take certain steps - such as moving injection sites and changing needles - on blood glucose control.
  14. Content Article
    This webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch  Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust
  15. Content Article
    This report by The Right Reverend James Jones KBE aims to provide an insight into what the bereaved Hillsborough families experienced in the years following the Hillsborough disaster in April 1989. It seeks to place their insight on the official public record in the hope that their suffering and experience will bring about changes to the way in which public institutions treat people who have been bereaved. It records family members' experiences of interacting with the authorities after the disaster and around the different inquests, and highlights 25 points of learning for public institutions.
  16. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
  17. Content Article
    This short article describes how maternity and neonatal teams across Herefordshire and Worcestershire Local Maternity and Neonatal System (LMNS) have been using video conferencing technology to drive safety improvements for mothers and babies, thanks to the launch of their new daily digital safety huddles.
  18. Content Article
    This manual by the Healthcare Quality Improvement Partnership provides an overview of the basic clinical audit process for non-clinician members of a clinical audit team. Topics include: What is Clinical Audit? How to Set Objectives How to Select an Audit Sample Clinical Audit Confidentiality and Ethics Comparing Performance Against Criteria and Standards Writing an Audit Report Implementing Change and Action Plans
  19. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
  20. Content Article
    This review in the World Journal of Nephrology assesses the value of clinical audit in nephrology settings. It looks at areas where the use of clinical audit has been effective, such as hypertension and mineral metabolism control in haemodialysis patients. The authors suggest ways to make the process effective and recommend that clinical audit is used more widely within the field of nephrology.
  21. Content Article
    Variation in healthcare processes is widespread in mental health care and can lead to inefficient processes and unnecessarily long inpatient stays. This study in The British Journal of Healthcare Management aimed to identify sources of variation and introduce a huddle intervention to increase system efficiency on a psychiatric inpatient ward in London. The study found that huddles are a useful way to improve staff communication and increase ward efficiency without taking up a significant amount of clinicians' time.
  22. Content Article
    This toolkit created by The National Academies of Sciences, Engineering and Medicine contains information and resources to help patients learn about and engage in the diagnostic process. There are many barriers to patients fully engaging in their diagnosis, and this toolkit aims to help patients take control of their role in the process, as well as equipping healthcare providers to create an atmosphere that allows patients to contribute meaningfully.
  23. Content Article
    In this blog for medical education website Intensive, Chris Nickson shares advice on running a 'hot debrief' after a critical incident. A hot debrief is a short conversation that allows staff involved in an incident to gather as a team and share their perspectives and concerns, as well as coming up with ways to prevent similar incidents happening again. This blog details practical methods for planning, facilitating and concluding a hot debrief and provides resources for further reading.
  24. Content Article
    This study in the International Journal for Quality in Health Care aimed to develop and test a handover performance tool (HPT) able to help clinicians to systematically assess the quality and safety of shift handovers. The study was conducted in the paediatrics, obstetrics and gynaecology wards of a UK district hospital. 30 human factor experts participated in the development phase and 62 doctors from various disciplines were asked to validate the tool. The authors found that, according to the HPT, communication determined the majority of handover quality, with teamwork and situation awareness also important factors in the overall quality rating. They found that the HPT demonstrated good validity and reliability and can be easily used by raters with different backgrounds and in several clinical settings.
  25. Content Article
    This study in the Joint Commission journal on quality and patient safety examines the impact of using unclear or misleading abbreviations on medication prescribing errors. This study analysed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.
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