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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    From Autumn 2023, NHS organisations in England are changing the way they investigate patient safety incidents. NHS England has introduced this new approach, which is called the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. However, discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident.
  2. Content Article
    The Patient Safety Incident Response Framework (PSIRF) is a new approach to responding to patient safety incidents. NHS organisations in England have been implementing the framework since September 2023 and, as part of this, each trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder, available below. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. As well as sourcing PSIRPs that are easily accessible in the public domain, we submitted a Freedom of Information (FOI) request to all NHS trusts in England in November 2023. We will continue to add links to plans as they become available. If you are aware of a PSIRP that has been published that isn't yet featured, please get in touch and we will add it to the finder.
  3. Content Article
    In May 2021, the Irish public health service was the target of a cyber-attack. The response by the health service resulted in the widespread removal of access to ICT systems. While services including radiology, diagnostics, maternity and oncology were prioritised for reinstatement, recovery efforts continued for over four months. This study describes the response of health service staff to the loss of ICT systems and the risk mitigation measures introduced to safely continue health services. It also explores the resilience displayed by frontline staff whose rapid and innovative response ensured continuity of safe patient care.
  4. Content Article
    This study in BMC Health Services Research mapped healthcare workers’ experiences with patient safety incidents during the second wave of the Covid-19 pandemic in Slovakia. The authors found that healthcare workers with patient safety incident experiences reported poor hospital management of patient safety culture. This might reflect missed the opportunities to strengthen their resilience during the Covid-19 pandemic.
  5. Content Article Comment
    Hi @FIONA ELLWOOD, if you have permissions for the PSEN, you will be able to access the notes here: https://www.pslhub.org/forums/forum/311-drop-ins-and-chats/ If you're still having problems, please email us at content@pslhub.org
  6. Content Article
    Digital health inequality, observed as differential utilisation of digital tools between population groups, has not previously been quantified in the NHS. But recent developments in universal digital health interventions, including a national smartphone app and online primary care services, allow measurement of digital inequality across a nation. This study in BMJ Health & Care Informatics aimed to measure population factors associated with digital utilisation across 6356 primary care providers serving the population of England. The authors concluded that the study results are concerning for technologically driven widening of healthcare inequalities. They highlight the need for targeted incentives to digital in order to prevent digital disparity from becoming health outcomes disparity.
  7. News Article
    A 45-year-old mother who almost died after injecting herself with a life-threatening amount of insulin she thought was Ozempic is calling on the Government and social media companies to crack down on the online counterfeit weight-loss jab trade. Michelle Sword, a receptionist from Carterton, Oxfordshire, first took Ozempic without any issues after she was prescribed it by a legitimate online pharmacy in early 2021. Ms Sword said she completed an online questionnaire and gave a false BMI that she knew would qualify her the drug. “I just told them what they wanted to hear,” she said. Ms Sword said she takes responsibility for her actions, but criticised rogue sellers for taking advantage of people with insecurities and selling a product that “can kill you”. She also wants the Government and social media companies to step in to tackle the trend. “I think the drug was in such infancy in what we knew about it that they weren’t able to “police” who got it, who took it, who sourced it. I think they [the Government] need to look at that.” Read full story (paywalled) Source: inews, 26 November 2023
  8. Content Article
    The Sentinel Stroke National Audit Programme (SSNAP) measures the quality and organisation of stroke care across England, Wales and Northern Ireland. The overall aim of SSNAP is to provide timely information to clinicians, commissioners, patients and the public on how well stroke care is being delivered. Processes of care are measured against evidence-based quality standards referring to the interventions that any patient may be expected to receive. This report presents data from more than 91,000 patients admitted to hospitals between April 2022 and March 2023 and submitted to the audit, representing over 90% of all admitted strokes in England, Wales and Northern Ireland. This data is summarised in key messages for both those who provide and those who commission stroke care in hospitals and the community, and presented in tables and charts.
  9. Content Article
    This report published by the National Audit of Inpatient Falls (NAIF) includes information on multi-factorial risk assessments and post fall management, and contains five recommendations as well as resources to support improvement.
  10. Content Article
    This report published by the National Vascular Registry (NVR) contains information on emergency (non-elective) and elective procedures for the following patient groups: patients with peripheral arterial disease (PAD) who undergo either (a) lower limb angioplasty/stent, (b) lower limb bypass surgery, or (c) lower limb amputation patients who have a repair procedure for abdominal aortic aneurysm (AAA) patients who undergo carotid endarterectomy or carotid stenting.
  11. Content Article
    This study in the American Journal of Surgery aimed to understand the impact of operating room temperature and humidity on surgical site infection (SSI). The authors found that large deviations in operating theatre temperature and humidity do not increase the risk of SSI.
  12. Content Article
    This resource published by pharmaceutical company BD provides information on common complications of IV catheter therapy, including signs and symptoms and prevention. It covers the following complications: Catheter-related bloodstream infection Dislodgement Extravasation Infiltration Occlusion Phlebitis Thrombosis
  13. Content Article
    This study in the Journal of Applied Research in Intellectual Disabilities aimed to  share rich detail of the emotional and physical impact on children and young people with intellectual disabilities of attending hospital, from their own and their parent's perspective. The authors found that the multiple and compounding layers of complexity surrounding hospital care of children and young people with intellectual disabilities resulted in challenges associated with loss of familiarity and routine, undergoing procedures, managing sensory overload, managing pain and having a lack of safety awareness. They concluded that an individualised approach to care is needed to overcome these issues.
  14. Content Article
    The harsh reality of surgery often involves grappling with the distressing and emotionally taxing aspects of human suffering that many people outside of healthcare never witness. When complications occur, surgeons feel the weight of their responsibility and are often alone to ruminate with negative thoughts of self-doubt, sometimes leading to anxiety and depression. This article in The American Journal of Surgery examines existing literature on Second Victim Syndrome (SVS) specifically focusing on prevalence among surgeons and factors related to different responses. The authors identify women and junior surgeons at particularly high risk of SVS and peer support as a preferred method of coping but an overall lack of institutional support highlighting the need for ongoing, open conversations about the topic of surgeon well-being.
  15. News Article
    A 10-year-old boy with severe asthma died as a result of multiple failings by healthcare professionals amounting to neglect, a coroner has concluded. William Gray, from Southend, died on 29 May 2021 from a cardiac arrest caused by respiratory arrest, resulting from acute and severe asthma that was “chronically very under controlled”. His death has led to calls to improve asthma treatment for children nationwide. The court heard that William’s death was a “tragedy foretold” having previously suffered a nearly fatal asthma attack on 27 October, 2020, which he survived. The coroner said that William’s death was avoidable, his symptoms were treatable, and he should not have needed to use 16 reliever inhalers over 17 months, but instead his condition should have been treated with preventer medications and should have been controlled. Julie Struthers, a solicitor at Leigh Day who represented the family, said, “In an inquest involving concerns with medical treatment it is rare for a coroner to find neglect, and even rarer for a coroner to find Article 2, a person’s right to life, to be engaged. This reflects the real tragedy of what happened to William, the substantial number of failures by multiple healthcare professionals in his care, and the importance of improving asthma treatment for children nationwide.” Read full story (paywalled) Source: inews, 22 November 2023
  16. Content Article
    In this opinion piece for the BMJ, Partha Kar looks at the current debate surrounding the role of medical associate professionals (MAPs) in the NHS. He highlights the concerns raised by many that MAPs are “doctors on the cheap” and outlines the reasons for friction between junior doctors and MAPs, which include the issues of pay, training and regulation. He also outlines issues facing locally employed doctors (LEDs), international medical graduates (IMGs) and specialist, associate specialists (SASs) including lack of access to training, supervision and career progression. He makes five suggestions to improve the situation and calls for a pause to consider how these different roles can interact and work together, for the good of both staff and the health service.
  17. Content Article
    This report by the Royal College of Emergency Medicine presents insights about Emergency Department (ED) crowding in England. It highlights that overcrowding is a major threat to public health and outlines the reasons for overcrowding - primarily increasing patient demand coupled with high hospital bed occupancy, which has resulted in exit block.
  18. Content Article
    TrialResults.com present the results of completed clinical trials in an easy to understand format. The site allows you to search for clinical trials related to different areas and conditions, and filter results by country and sponsor. You can they view and download a Plain English summary of each trial. It was set up by TrialAssure, a global company committed to clinical trial and human health data transparency for the entire pharmaceutical industry.
  19. Content Article
    Professor Jane Somerville, emeritus professor of cardiology at Imperial College, talks about the issues facing doctors who raise concerns about patient safety issues in the NHS. She shares her views on the risks facing doctors who speak up and the ways that healthcare managers treat whistle blowers. She also highlights issues in the employment tribunal system and outlines the need to regulate NHS managers. In the video, Jane mentions the employment tribunal of Dr Martyn Pitman. Since this interview was recorded, Dr Pitman lost the case he brought for retaliatory victimisation.
  20. Content Article
    The scale of the health inequalities challenge can often feel daunting and overwhelming for system leaders, but tackling health inequalities is one of the four statutory purposes of integrated care systems (ICSs) to support communities to live long, healthy lives. This article outlines a project the NHS Confederation has launched to support healthcare leaders adopt best practice to address this issue.
  21. Content Article
    The UK’s healthcare systems are experiencing a prolonged period of high pressure, with industrial action, backlogs in elective care persisting, and a shortage of doctors that ongoing high vacancy rates evidence. This report by the GMC analyses trends in the medical workforce across the UK. It uses a variety of sources to provide insights for policymakers and workforce planners, as well as offering deeper analysis on specific themes.
  22. Event
    until
    In this first webinar of the Changes in Primary Care series, Dr Claire Fuller, Medical Director of Primary Care at NHS England will discuss the new reception team alongside frontline general practice staff. Register for the webinar
  23. Content Article
    e-Bug, operated by the UK Health Security Agency, is a health education programme that aims to promote positive behaviour change among children and young people to support infection prevention and control efforts, and to respond to the global threat of antimicrobial resistance. e-Bug provides free resources for educators, community leaders, parents, and caregivers to educate children and young people and ensure they are able to play their role in preventing infection outbreaks and using antimicrobials appropriately.
  24. Content Article
    Incivility in the workplace, school and political system in the United States has permeated mass and social media in recent years and has also been recognized as a detrimental factor in medical education. This scoping review in BMC Medical Education identified research on incivility involving medical students, residents, fellows and faculty in North America to describe multiple aspects of incivility in medical education settings published since 2000. The results of the review highlight that incivility is likely to be under-reported across the continuum of medical education and also confirmed incidences of incivility involving nursing personnel and patients that haven't been emphasised in previous reviews.
  25. Content Article
    Patient experience is deteriorating across the NHS, so hearing from users should be of the utmost importance as the NHS looks to improve, yet too often those leading work on patient experience feel that it is not prioritised. The King’s Fund has been working with the Heads of Patient Experience (HOPE) network to design and develop projects to better understand how people and communities are experiencing health and care services. This article outlines learning and recommendations from this work.
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