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Content ArticleThis report summarises the findings of an evaluation conducted by Health Innovation East and Health Innovation Manchester on behalf of the national Innovation Collaborative for digital health. It presents findings from an evaluation of a chronic obstructive pulmonary disease (COPD) virtual ward that falls within a virtual hospital managed by South and West Hertfordshire Health and Care Partnership. It aims to inform the potential wider adoption of the virtual ward model across the UK and understand the model’s potential to support people with other health conditions. It also considers the success of South and West Hertfordshire Health and Care Partnership Virtual Ward objectives to improve patient care, clinical outcomes, healthcare utilisation, and patient and staff satisfaction.
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Content ArticleThis is the recording of a presentation given by Niall Downey at a recent Patient Safety Management Network (PSMN) meeting. Niall considered why error is inevitable, how it affects many different industries and areas of society and, most importantly, what we can do about it.
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Content ArticleInvestigative journalist and medical researcher Maryanne Demasi interviews Phillip Buckhaults, a cancer genomics expert and professor at the University of South Carolina. Professor Buckhaults describes how he decided to test for DNA contamination in vials of Pfizer and Moderna’s bivalent booster shots, hoping to debunk myths about contamination. However, his research revealed that billions of tiny DNA fragments are present in Pfizer’s mRNA vaccine. He highlights the need for further research to find out whether this poses any risk to people who have been given the vaccine, particularly around whether these fragments of DNA could trigger people developing cancer or autoimmune conditions.
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Content ArticleThese videos posted by Melissa Sheldrick tell the story of her son Andrew, who died aged eight from a medication error. The investigation into Andrew's death found that he had been given baclofen by his pharmacy instead of the tryptophan he had been prescribed. When tested, the dose of baclofen in the bottle given to Andrew contained three times the lethal dose of baclofen for adults. PSMF Melissa's story. In this video, Andrew's mother Melissa talks about what happened to Andrew and how it led to her campaigning for mandatory reporting of medication errors by pharmacists across Canada, Australia and the US. Patients taking the lead: Collaborating for safer healthcare. This presentation was originally given at the World Health Organization's (WHO's) World Patient Safety Day conference on 12 September 2023 in Geneva, Switzerland. Melissa tells Andrew's story and talks about how she has raised awareness of gaps in accountability for pharmacies and pharmacists. She describes how she was invited to be part of a taskforce to improve safety in pharmacy by the pharmacy regulator in her home state of Ontario—this was the first time a member of the public had been included in such a taskforce.
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Content ArticleThis article published by the Betsy Lehman Center looks at the benefits of real-time monitoring of electronic health records (EHRs). Early adopter hospitals have demonstrated dramatic gains in safety by monitoring patients' EHR's in real time for signals of potential safety events, allowing providers to more quickly and effectively address safety gaps and improve outcomes. This monitoring is carried out by automated safety surveillance software that continuously runs in the background of EHR systems and can detect hundreds of categories of adverse events as they occur. Expert analysis then quickly helps organisations gain insight from the data, which can be used to proactively reduce safety risks and reliably measure incidence of harm over time.
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Content Article Comment
Patient Safety Education Network
Patient-Safety-Learning commented on Chris Elston's article in Specialist patient safety training
@Daniel Hodgkiss Thanks for flagging this, I've sent your request to a member of the team, who will make sure you are added to the list.- Posted
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Content Article
This year’s World Patient Safety Day on Sunday 17 September 2023 focused on engaging patients for patient safety, in recognition of the crucial role that patients, families and caregivers play in the safety of healthcare. This webinar provided an opportunity for those involved in patient safety to hear from patient safety leaders and discuss the opportunities and barriers to increased patient engagement. It was co-hosted by the Patient Safety Commissioner for England and the charity Patient Safety Learning. -
Content ArticleThe relationship between patients and their data is deeply personal. This report by The Patients Association shows that patients recognise that the potential for data use to improve care is huge, and that there is widespread support for realising this potential if patients’ concerns are acknowledged and addressed. It proposes the development of a data pact to outline the relationship between patients, their data and the health system. This could be a useful first step in informing patients about how data is used in the health and care system and a starting point in improving patient confidence. To do this, the pact needs to acknowledge that the system is not perfect, as one part of building public confidence is acknowledging the reasons why at present, confidence may be low.
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Content Article
This report from Asthma + Lung UK highlights that lung diseases such as COPD, asthma and pneumonia are the third leading cause of death in England, whilst the UK as a whole has the worst death rate from lung disease in Europe. Hospital admissions for lung diseases have doubled in the last 20 years and lack of proper testing for lung diseases is having an impact on patient safety, as GPs have to "guess" diagnoses. The report highlights three areas where policy changes should be implemented in order to improve care for people affected, reduce pressure on services and deliver massive savings for the NHS: Diagnosing lung disease early and accurately Keeping people healthy and out of hospital Providing treatments that work -
Content ArticleIf you are throwing up, having diarrhoea, drinking less water and/or have a fever, you can become dehydrated. Being dehydrated means your body doesn't have enough fluids. When you're dehydrated, some medications used to treat certain health problems may cause unwanted side effects, such as harm to your kidneys. It is important to have a plan to prevent these side effects in case you should become sick and dehydrated. The authors of this guidance learned about a person who died in hospital as a result of side effects of taking a particular medication while dehydrated. They were taking a diabetes medication called empagliflozin and kept taking the same dose after becoming sick. This medication is helpful for people with diabetes, but it can cause serious side effects if it's taken when the person is dehydrated. This guidance offers advice on how to reduce the risk of side effects from your medications when you are sick and dehydrated.
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Content ArticleThe Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. This multisite case study in BMJ Quality and Safety examined the first documented attempt to apply the Safety Case methodology to clinical pathways. The study found that the Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.
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Content ArticleThe idea of patient feedback as an essential tool for improving the safety of services is a familiar one. In recent years there has been a more fundamental shift towards recognising patients not just as commentators on the safety of the healthcare they experience, but as contributors to improving the safety of care. In this blog, Kate Eisenstein, Director of Strategy at the Parliamentary and Health Service Ombudsman (PHSO) looks at the ways in which patients and their families contribute to safe care. She also highlights the fact that in many cases, their voices are still being ignored, with catastrophic consequences for individual patients and the system as a whole.
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Content ArticleThe Patient Safety Partner (PSP) is a new and evolving role developed by NHS England to help improve patient safety across health care in the UK. This web page outlines Mersey Care NHS Foundation Trust plans to develop a team of PSPs to work alongside staff, patients, service users and families to influence and improve safety within its services. PSPs can be patients, service users, carers, family members or other lay people (including NHS staff from another organisation). The page contains answers to frequently asked questions (FAQs) about the PSP role, including: What is the role of a Patient Safety Partner? What kinds of projects will I get involved with? Will I have any support? How much will I get paid for this role? What training will I receive? What is the time commitment? How long will I hold this role for? Do I need any experience? How will my work help the NHS? Do I have to live locally? Who should apply for this role?
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Content ArticleIn this opinion piece for the BMJ, Partha Kar, NHS England National Specialty Advisor for Diabetes, shares his observations on why leaders fail to speak out on things that clearly aren't good for patient care. He identifies five key reasons: Keeping the job Fear Rhetoric about 'the bigger picture' The idea that 'I'll be rewarded' Genuine belief that the issue isn't real Partha highlights that speaking up about issues needs to become the norm if we are to see a culture shift in healthcare. Leaders need to be at the forefront of this, using their privilege to bring about change.
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Content ArticleEngland is well on the way towards its goal of eliminating hepatitis C; with over 84,000 patients treated and cleared, there are now more people that have been treated than are left to treat. However, there are still up to an estimated 70,000 people left to find—and what has worked to find patients so far, might not work so well for those that remain to be found. This is where former patients, also known as peers, come in. In this blog, Hepatitis C Trust CEO Rachel Halford and Mark Gillyon-Powell, Head of programme for hepatitis C at NHS England, look at how patient engagement has been essential to efforts to eliminate Hepatitis C in England.
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Content Article
Harry's Story website
Patient-Safety-Learning posted an article in Inquests
Harry's Story is a website set up by Derek Richford, the grandfather of Harry Richford, who died in November 2017 at just a week old following failures in care during and after his birth. The site outlines how Harry's family worked tirelessly to uncover what happened to Harry and the poor standard of care at the maternity unit at East Kent University Hospitals Foundation Trust (EKUHFT). It covers the following aspects of the family's experience: Our Investigation The Inquest Cover Up? - You Decide HSIB Involvement What Happened Next The Kirkup Inquiry Accountability Harry's Legacy The site also contains a section offering advice for parents whose babies die or suffer harm in hospital during the perinatal period. -
Content ArticleDementia remains the biggest killer in the UK and is on track to be the nation’s most expensive health condition by 2030. This report by the charity Alzheimer's Research UK sets out a series of calls for party leaders ahead of the next general election, all of which are underpinned by an urgent recommendation for greater investment in dementia research.
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Content ArticleThis checklist has been developed by the Alzheimer’s Society to allow patients to check symptoms that could be a possible sign of dementia. Endorsed by the Royal College of General Practitioners (RCGP), it is a simple tool to help patients and their families clearly communicate their symptoms and concerns to a GP or other healthcare professional. It is not a diagnostic tool, but aims to provide a basis for helpful conversations.
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Content ArticleThis blog from the Institute for Healthcare Improvement (IHI) looks at the importance of embedding quality control (QC) measures into everyday work. QC methods sustain improvements for the long-run and promote stable systems to produce reliable outcomes. When effectively used, they can internally monitor performance, assess progress towards goals and allow systems to direct improvement resources to where they are needed most.
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Content ArticlePeople rely on prescription medication to treat and manage their conditions and keep well. Based on analysis of public feedback from local Healthwatch and from a webform on pharmacies, this blog by Healthwatch England highlights the challenges people face when trying to get prescription medication. It outlines the following key issues: Shortages of medication Delays in getting repeat prescriptions issued Shortages of staff Closed pharmacies
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Content ArticleOvercrowding in the emergency department (ED) is a global problem that causes patient harm and exhaustion for healthcare teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. This study in BMJ Open Quality looked at a quality improvement project that aimed to ensure that no patients were lying in bed awaiting care or referral outside a care area. Several plan–do–study–act (PDSA) cycles were tested and implemented to achieve and maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: No patients lying down outside of a care unit Forward movement Examination room always available Team huddle An organisation overcrowding plan The researchers found that the PDSA strategy based on these five measures removed in-house obstacles to the internal flow of patients and helped avoid them being outside the care area. These measures are easily replicable by other management teams.
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Content ArticleThis article in the Nursing Times looks at how a sincere and prompt apology, using appropriate language and tone, can help those involved come to terms with something that has gone wrong. Nurses may be concerned that saying sorry will make litigation more likely, but the evidence is that patients are less likely to resort to the courts if they feel they have been listened to and have been offered a "proper" apology.
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Content ArticleIn this article, inews columnist Kate Lister looks at the andropause, sometimes called the 'male menopause' that can affect men in their later 40s and early 50s. A gradual decline in testosterone levels can contribute to some men developing depression, loss of sex drive, erectile dysfunction and other physical and emotional symptoms. She looks at current research and views around the issue, highlighting her own bias in initially dismissing the idea and linking this to the societal notion that 'only women are hormonal'. She highlights that although the drop in testosterone men experience is not like the sudden hormonal changes that causes the menopause, men can still experience severe symptoms that require treatment with hormone therapy. "Despite my scoffing at the idea, it turns out that the andropause is very much a real thing that can impact some men very badly. The treatment is exactly the same as it is for women struggling with menopause and perimenopause. It’s hormone replacement therapy: this time in the form of testosterone."
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Content ArticleIf the NHS doesn't fund the medical treatment you need in your area, or you are unhappy about where you are going to be treated on the NHS, you have the legal right to go elsewhere and still be treated by the NHS, even if it's outside your local NHS Trust area. In this short blog, patient Verite Reily Collins writes about the rights patients have to choose where they receive their care, and how this may help overcome barriers in access to treatment.
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Content ArticleWhen it comes to your health, it's easy to fall into the mindset that unless you are having signs or symptoms of an illness, you can put off going to see your doctor and skip yearly exams or tests. But preventative care—such as blood tests, cancer screening, mental health check-ins, vaccinations and tests for genetic conditions—can help keep you from developing a serious illness or having to receive care at the hospital. Speak Up™ To Prevent Serious Illness is a patient safety campaign from The Joint Commission designed to educate patients on how to find preventative care services, get past barriers and try to avoid reaching a crisis point with their health. The Joint Commission has produced a video, infographic and distribution guide as part of the campaign.
