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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Increasing diversity amongst surgeons results in a wide range of sizes and strengths. There are many types of biases affecting women surgeons. This study evaluates what challenges women surgeons may have with surgical equipment. Key findings include: 89% of women surgeons report difficulty with surgical instruments due to size. 71% of women surgeons report difficulty with surgical instruments due to grip strength. The study highlights a potential source of gender bias which could be addressed to improve equity for women surgeons.
  2. Content Article
    Data federation is a process that uses software to connect many existing systems so that they can function as one. It was recently announced that the contract to develop the NHS Federated Data Platform (FDP).has been awarded to US analytics and AI firm Palantir. This blog explains what the FDP is and what it will do, as well as outlining issues surrounding data privacy that have been raised with the Department of Health and Social Care and NHS England by National Voices and other organisations.
  3. Content Article
    Increasing interest in general surgery from students who are Under-Represented in Medicine (URiM) is vital to advancing diversity, equity and inclusion efforts. This study in The American Journal of Surgery examined medical student third year surgery clerkship evaluations quantitatively and qualitatively to understand the experiences of URiM and non-URiM learners. The authors found that URiM students are less likely than non-URiM students to see surgical residents and faculty as positive role models. They highlight that integrating medical students into the team, taking time to teach and allowing students to feel valued in their roles improves the clerkship experience for trainees and can contribute to recruitment efforts.
  4. Content Article
    Conflicts and wars contribute substantially to the development and spread of antimicrobial resistance (AMR). War-related factors that contribute to AMR include restricted resources, high casualties, suboptimal infection prevention control, and environmental pollution from infrastructure destruction and heavy metals release from explosives. This article in The Lancet looks at the impact of the war in Gaza on AMR. It highlights that access to essential antibiotics, primarily through donations, has been a continuous challenge due to the blockade of Gaza and that Gaza's already restricted national surveillance system for AMR adds to the challenges.
  5. Content Article
    Paediatric health research is fraught with both ethical and practical challenges that can prevent the successful completion of research studies. Listening to, and acting on, the voices of children and young people in the design and delivery of paediatric health research (otherwise known as Patient and Public Involvement) is one way to overcome these challenges. This paper describes the authors' experiences of working directly with children and young people in various health research initiatives. They outline the journey of involving children and young people as partners and give examples to demonstrate the unique knowledge and insights gained in the production of high-quality research.
  6. Content Article
    In this video and accompanying transcript, clinical decision support researcher F Perry Wilson looks at the importance of health records and databases indicating whether or not a patient is deceased. If they are not up to date and sharing this information with the right staff and processes, inappropriate messages can be sent to healthcare professionals or the deceased patient's family. He argues that as well as being a waste of resources, sending communications requesting procedures or offering appointments in this situation undermines confidence and trust in health systems, in both staff and members of the public.
  7. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tracey talks about how her lived experience of navigating the criminal justice and healthcare systems as a victim of serious violent crime has shaped her role as a Patient Safety Partner. Tracey is passionate about speaking up for patients and families, and she highlights the need to prevent compounded trauma by ensuring services meet their needs. She calls for a more joined-up approach between public services and outlines the importance of clear, compassionate communication following a patient safety incident or other traumatic event.
  8. Content Article
    With around half a million people receiving homecare medicines services at a cost that is likely to be between £3billion and £4billion each year, there are questions over what the NHS is getting for its money and how governance and accountability within the system could be improved. This article outlines an investigation by The Pharmaceutical Journal that has revealed hundreds of patient safety incidents caused by problematic homecare medicines services.
  9. Content Article
    Social prescribing can be life changing for many children and young people, allowing them to have a voice about what matters to them, access the things they enjoy and can give them a route to achieve their ambitions. The greater choice and control that social prescribing brings also empowers them to make positive decisions, build confidence and increase self-esteem. This toolkit has been developed collaboratively by the charity StreetGames, the South West Integrated Personalised Care Team and other key partners across the UK. It is a guide to developing, implementing and delivering high quality social prescribing for children and young people. It provides a framework to help providers assess what is needed and examples of what others have achieved through social prescribing, and how. It also demonstrates how partnership working allows organisations to achieve more and support young people to have truly great lives.
  10. Event
    This conference focuses on patient involvement and partnership for patient safety including implementing the National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework. Book a place
  11. Content Article
    This video explains why Patient Safety Learning set up the hub, how you can join for free and the benefits of becoming a member.
  12. Content Article
    Martha Mills was 13 when she tragically died due to a series of medical errors. In this video by the Patient Safety Movement Foundation (PSMF), Martha's mother Merope Mills tells her story and aims to raise awareness about the consequences of medical errors. Merope advocates for improved patient safety measures including the introduction of Martha's Rule, which will allow patients and their families to trigger an urgent clinical review from a different team if they are in hospital, are deteriorating rapidly and feel they are not getting the care they need.
  13. Content Article
    This book sets out what the terms governance and leadership mean, and how thinking about them has developed over time. Using real-world examples, the authors analyse research evidence on the influence of governance and leadership on quality and safety in healthcare at different levels in the health system: macro level (what national health systems do), meso level (what organisations do) and micro level (what teams and individuals do). The authors describe behaviours that may help boards focus on improving quality and show how different leadership approaches may contribute to delivering major system change.
  14. Content Article
    The Covid-19 pandemic increased the sense of urgency to advance understanding and prevention of infectious respiratory disease transmission. There are extensive studies that demonstrate scientific understanding about the behaviour of larger (droplets) and smaller (aerosols) particles in disease transmission as well as the presence of particles in the respiratory track. Methods for respiratory protection against particles, such as N95 respirators, are available and known to be effective with tested standards for harm reduction. However, even though multiple studies also confirm their protective effect when N95 respirators are adopted in healthcare and public settings for infection prevention, overall, studies of protocols of their adoption over the last several decades have not provided a clear understanding. This preprint article demonstrates limitations in the methodology used to analyse the results of these studies. The authors show that existing results, when outcome measures are properly analysed, consistently point to the benefit of precautionary measures such as N95 respirators over medical masks, and masking over its absence.
  15. Content Article
    In this blog, Dr Nadeem Moghal looks at the recent case of a 30 year-old patient who died after a physician associate (PA) at her GP surgery failed to diagnose her with a pulmonary embolism. He outlines a recent debate about the role of PAs in general practice and why employing them has become an attractive option for GP partnerships, which run as businesses. He highlights the need for PAs to be adequately trained and supervised to ensure patient safety and argues that the role is here to stay as PAs play an important role in tackling gaps in the NHS workforce.
  16. Content Article
    The Patients Association has been working with NHS England and the Royal College of Physicians on the development of an outpatient strategy for the past year. In this series of three blogs, they discuss what they have heard from patients about the state of outpatient care and what patients would like to see change. What patients want from an outpatient strategy Kindness, reasonable adjustments and consistency needed across outpatients Personalising care and offering patients choice
  17. Content Article
    In this blog, journalist Rory Cellan-Jones reflects on some major challenges the NHS currently faces. Sharing insights from a recent meeting with medtech companies and a lecture by economist Professor Diane Coyle, he shares concerns that productivity in the health service has decreased as a result of the pandemic, and that medtech companies face barriers in selling their solutions to the NHS. He highlights a growing consensus that policymakers need to think beyond immediate firefighting and look at how to transform the NHS over the long term.
  18. Content Article
    Leadership walkarounds (LWs) have been promoted in practice as means to drive operational, cultural and safety outcomes. This systematic review in BMJ Open Quality aimed to evaluate the impact of LWs on these outcomes in the US healthcare industry. The authors found only positive association of LWs with operational and perception of cultural outcomes.
  19. Content Article
    The Government's 10-year vision set out in People at the Heart of Care, published in 2021, focuses on three objectives for people who draw on formal care and support, their families, unpaid carers and the social care workforce:   People have choice, control and support to live independent lives. People can access outstanding quality and tailored care and support. People find adult social care fair and accessible.  In April 2023, the Department of Health and Social Care (DHSC) announced that it would establish an innovation and improvement unit to develop and define clear priorities for innovation and improvement across adult social care. This document sets out the Government's priorities for innovation and scaling in care and support, including identifying, recognising and supporting unpaid carers.
  20. Content Article
    In this episode of the Medicine and the Machine podcast, Scottish GP Gavin Francis talks about the need to reconsider the importance of convalescence. He discusses the role of GPs in supporting patients through recovery after a hospital admission or period of illness and talks about a lack of awareness of the principles of convalescence amongst patients.
  21. Content Article
    Physician associates (PAs) support doctors in the diagnosis and management of patient. They are often employed in general practice as members of the multidisciplinary team, trained in the medical model. This update outlines the Royal College of General Practitioners' (RCGP's) policy position on PAs. The RCGP sees PAs as having an enabling role to play for general practice, but highlights that they must always work under the supervision of GPs and must be considered additional members of the team, rather than a substitute for GPs.
  22. News Article
    One of the biggest challenges facing clinicians who treat Long Covid is a lack of consensus when it comes to recognising and diagnosing the condition. But a new study suggests testing for certain biomarkers may identify Long Covid with accuracy approaching 80%. Effective diagnostic testing would be a game-changer in the Long Covid fight, for it’s not just the fatigue, brain fog, heart palpitations, and other persistent symptoms that affect patients. Two out of three people with Long Covid also suffer mental health challenges like depression and anxiety. Some patients say their symptoms are not taken seriously by their doctors. And as many as 12% of Long Covid patients are unemployed because of the severity of their illness and their employers may be sceptical of their condition. Researchers at Cardiff University School of Medicine in Cardiff, Wales, United Kingdom, tracked 166 patients, 79 of whom had been diagnosed with Long Covid and 87 who had not. All participants had recovered from a severe bout of acute Covid-19. In an analysis of the blood plasma of the study participants, researchers found elevated levels of certain components. Four proteins in particular—Ba, iC3b, C5a, and TCC—predicted the presence of Long Covid with 78.5% accuracy. "I was gobsmacked by the results. We’re seeing a massive dysregulation in those four biomarkers," says study author Wioleta Zelek, PhD, a research fellow at Cardiff University. "It’s a combination that we showed was predictive of Long Covid.." Read full story Source: Medscape, 29 November 2023
  23. Content Article
    Hospitalised adults whose condition deteriorates while they are on hospital wards have considerable morbidity and mortality. Early identification of patients at risk of clinical deterioration has traditionally relied on manually calculated scores, and outcomes after an automated detection of clinical deterioration have not been widely reported. The authors of this article published in The New England Journal of Medicine developed an intervention program involving remote monitoring by nurses who reviewed records of patients who had been identified as being at high risk. Results of this monitoring were then communicated to rapid-response teams at hospitals. They compared outcomes among hospitalised patients whose condition reached the alert threshold at hospitals where the system was operational, with outcomes among patients at hospitals where the system had not yet been implemented. The authors found that using an automated predictive model to identify high-risk patients, for whom interventions could then be implemented by rapid-response teams, was associated with decreased mortality. 
  24. Content Article
    This presentation was given at the WHO Global Conference: Engaging patients for patient safety that took place in September 2023. Maki Kajiwara, technical officer at the World Health Organization's (WHO's) Patient Safety Flagship and Sue Sheridan, a founding member of Patients for Patient Safety US (PFPS-US), gave the presentation to introduce the new WHO Patient Safety Storytelling toolkit. The presentation outlines the need for a storytelling toolkit and provides questions and guidance to help storytellers share their experience.
  25. Content Article
    Patient safety incidents, including medical errors and adverse events, frequently occur in intensive care units, leading to a significant psychological burden on healthcare professionals. This burden results in second victim syndrome, which impacts the psychological and psychosomatic wellbeing of these staff members. This systematic review and meta-analysis aimed to examine the occurrence of second victim syndrome among intensive care unit healthcare workers, including the types, prevalence, risk factors and recovery time associated with the condition.
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