Patient-Safety-Learning
PSL ModeratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleIn this blog, Paul Whiteing, Chief Executive of Action Against Medical Accidents (AvMA), highlights how proposed changes to the UK legal system will affect people who have been harmed by healthcare and their families' access to justice. He describes the negative impact of legislation that would make claims less than £100,000 subject to a fixed cost regime. Paul writes, "The consequence of a fixed cost regime is that where the patient wins their case against the healthcare provider, the costs awarded will be capped at the rates set by Parliament." Related reading Read our Patient Safety Spotlight interview with Paul.
-
Content Article
The National Vascular Registry (NVR) has published a report on the impact of the Covid-19 pandemic on vascular surgery in the UK, presenting key findings from NVR data throughout 2020 and 2021. NVR previously reported on data as at 25 September 2020, which showed that Covid-19 infection in patients undergoing vascular surgical procedures significantly increased the risk of respiratory complications and mortality. Here, they update this analysis, using data through to the end of 2021, and explore whether the Covid-19 vaccination programme provided protection to patients against this life-threatening complication. One finding is that, between March 2020 and Dec 2021, confirmed postoperative Covid-19 diagnoses were most common among non-elective procedures, ranging from 18.4% (non-elective AAA repair) to 27.5% (major lower limb amputation). For elective procedures, the reported rates of confirmed postoperative Covid-19 diagnoses were lower, ranging from 1.6% (elective AAA repair) to 4.1% (lower-limb bypass). Other key findings include: There was only a modest rise during the first Covid-19 wave (Mar-Jun 2020) with a larger rise during the second wave (Nov 2020-Feb 2021) There was a different pattern for respiratory complications after surgery, with higher rates observed in both wave 1 and wave 2 The period from March to December 2021 was associated with rates of respiratory complications and in-hospital postoperative mortality returning to levels observed pre-pandemic in 2019 Overall, the report concludes that the vaccination programme had a modest benefit to patients in reducing the risk of respiratory complications, and therefore carries a public health message relevant for both national and international audiences. -
Content ArticleIn this blog, Becki Meakin, Involvement Manager with Shaping Our Lives, a non-profit making user-led organisation that enables individuals to have a stronger voice, writes about why all patients should think about speaking up about their health experiences. She talks about the difference sharing your story can make, and how to get started.
-
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. Paul talks to us about how AvMA helps people who have suffered direct or indirect medical harm and to help them to seek justice, why upcoming changes to the legal system could restrict access to clinical negligence claims and the importance of compassionate engagement in improving harmed patients’ experiences of the healthcare system. -
Content ArticleThe MindEd all-age eating disorders hub is aimed at all professionals, from universal to specialist. It contains key trusted evidence-based learning, curated and approved by an expert panel. The hub contains the following information:NHS policy guidanceProfessional bodies' guidanceProfessional associations' reportsCharitiesNHS learning and good practiceLegislation and reportsKey and influential textsUnder-served populations
-
Content ArticleIn this blog, specialist medical negligence solicitor Maria Panteli discusses the upcoming investigation and possible inquests into deaths relating to jailed breast surgeon Ian Paterson. She looks at what families of those affected by his treatment can expect and covers topics including:What happens at a Pre-Inquest Review?Who takes part in an inquest?How can the medical negligence solicitors help?
-
Event
Busting prostate cancer myths
Patient-Safety-Learning posted an event in Community Calendar
untilJoin Prostate Cancer UK to hear from men with lived experience as we explore the truth behind common prostate cancer myths. Together with our Specialist Nurses, we'll be answering questions and offering advice on tackling difficult subject matters with your loved ones, ensuring they understand the facts. Together, we can help men understand their risk of prostate cancer and save lives. Register for the webinar -
Content ArticleEuropean guidelines advise that patients suffering ST-segment elevation myocardial infarction (STEMI) should be revascularised within 120 minutes of diagnosis. The preferred method of revascularization is primary percutaneous coronary intervention (pPCI). This study in BMJ Heart analysed the Northern Irish STEMI database to establish the proportion of pPCI delivered within the recommended treatment window. It aimed to determine whether there was any difference in long-term survival for patients treated beyond the recommended time window. The authors found that delays that result in primary PCI beyond 120 minutes from diagnostic ECG are associated with a significantly increased risk of mortality following STEMI in Northern Ireland.
-
Content ArticleThis study in PLOS ONE assessed the frequency of adverse event reporting in Ghanaian hospitals, the patient safety culture determinants of the adverse event reporting and the implications for Ghanaian healthcare facilities. The authors found that the majority of health professionals had at least reported adverse events in the past 12 months across all 13 healthcare facilities studied. The patient safety culture dimensions were statistically significant in distinguishing between participants who frequently reported adverse events and otherwise.
-
Content ArticleThis is the recording of a roundtable hosted by the Institute of Health & Social Care Management (IHSCM) about virtual wards. Roy Lilley, IHSCM Chair and health policy analyst, discusses reducing waiting times, being innovative and sustainable and improving patient outcomes and patient journeys with a panel of speakers. The panel includes: Kris Glover, MD & Founder of Neon Health Solutions Paul Rylance, CTO, JKMCare Dr Folarin Majekodunmi, Director at Peopletoo
-
Content Article
The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. -
Content Article
At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We’ve selected 14 useful resources about diabetes. Self-management is perhaps the most important aspect of treating diabetes effectively, so we've included some resources aimed at helping patients manage their diabetes too. Diabetes is a condition that causes the amount of glucose in a person's blood to be too high. When you have type 1 diabetes, your body can’t make any insulin at all, whereas with type 2, you either can’t make enough insulin, or it can’t work properly. There are also other types of diabetes including gestational diabetes, which some women develop during pregnancy, maturity onset diabetes of the young (MODY) and latent autoimmune diabetes in adults (LADA). It is important that people with diabetes are supported to maintain good blood glucose control through diet, insulin and other diabetes medications, to prevent both acute and long-term complications, -
Content ArticleIn this blog Suzanne Rastrick, Chief Allied Health Professions Officer (England) and Rob Moriarty, Personalised Care Strategic Coproduction Group and Peer Leader at NHS England, share the importance of asking the simple question ‘What matters to you?’
-
Content ArticleMedicines can be purchased online from anywhere in the world. In 2021, nearly 53 million items were dispensed from online pharmacies in England, up 300% since 2016. In this blog, Dr Georgia Richards outlines the need for caution when buying medicines online, highlighting that online purchase of medications was cited in 16 Prevention of Future Deaths (PFD) reports between 2013 and 2019. She highlights coroners concerns concerns about: the ease of obtaining drugs via the Internet without any contact with the patient’s medical practitioner or access to the patient’s records. the inability to limit the volume or the frequency of ordering. issues with the regulation of supply, importation and delivery of controlled class A drugs via the international and UK postal system. lack of regulation of the dark web.
-
Content ArticleIn this BMJ opinion piece, Consultant Orthopaedic surgeon Scarlett McNally writes about the need for a new approach to preventing long-term conditions and providing healthcare for patients with multiple conditions. She highlights the importance of Government policy in promoting healthier lifestyle choices and improving patient engagement in shared decision making. She also outlines the importance of retaining healthcare professionals with expertise in managing risk and complexity in patients with multiple morbidity.
-
Content ArticlePharmacovigilance is the observation and monitoring of possible harms from exposure to a variety of pharmaceuticals, biologics and devices. In this blog, Professor of Evidence-based Medicine Carl Heneghan and Clinical Epidemiologist Tom Jefferson talk about a recent attempt to obtain data on the incidence of deaths following Covid-19 vaccination from the Medicines & Healthcare Products Regulatory Agency (MHRA) through a Freedom of Information request. They describe how the MHRA initially said they were unable to provide the information as it would cost too much to extract, and after sending a follow up request to the MHRA's Chief Safety Officer, they have not heard anything further after an initial promise to investigate. They argue that the MHRA is failing the public by failing to investigate the side effects of Covid vaccines using information from Yellow Card reports. This blog is paywalled once you have read a certain number of articles each month.
-
Content ArticleECRI is an independent non-profit that produces an annual list of Top 10 Patient Safety Concerns, and its list for 2023 includes a new emphasis on system safety. In this interview for the Betsy Lehman Center, two leaders at ECRI talk about the list and the current state of patient safety. Shannon Davila, ECRI’s Director of Total Systems Safety and Marcus Schabacker, President and CEO, discuss the need to address gaps in performance with a "total systems approach," the ongoing issue of health inequity and the patient safety risks associated with recent changes in state laws and guidance around obstetrics and maternity.
-
Content ArticleUnpaid carers provide significant levels of support to family or friends–equivalent to four million paid care workers. Carers often need support with their own health and wellbeing, but they are not always able to access this. Researchers from The King's Fund interviewed commissioners and providers of support to unpaid carers, ran focus groups with unpaid carers in four areas of England, spoke to national stakeholders and reviewed existing literature and national data sets, in order to understand the current picture of local support available for unpaid carers in England.
-
Content ArticleThe Women's Health Strategy for England was developed and published in 2022 in response to the growing recognition of the unique health needs and challenges faced by women in England (and the U.K.) and was brought forward to address longstanding gaps in women's healthcare and to promote better health outcomes for women across the country. This Forbes article looks at why women’s health should be included in every government’s agenda. The author speaks to Professor Dame Lesley Regan, Women's Health Ambassador for England about the progress of the strategy and Dr. Ranee Thakar, President of the Royal College of Obstetricians and Gynaecologists about the need to ensure underrepresented groups are included in the strategy.
-
Content ArticleData from NHS Resolution indicates that the number of claims with a primary cause of ‘Fail to warn - Informed consent’ have increased from 128 to 248 claims per year in 2011–2012 and 2021–2022 respectively. This letter in the British Journal of Surgery highlights the impact of failures in both the process and documentation of informed consent. The writers call for further research to investigate unwarranted variation in claims and develop processes to standardise and improve the quality of consent.
-
Content ArticleIn this article for the BMJ, John R Drew, an improvement and culture consultant and Meghana Pandit, chief medical officer at Oxford University NHS Foundation Trust, argue that quality improvement (QI) should be a core tenet of how healthcare organisations are run. They highlight that some of the conditions and assumptions required for QI are at odds with prevailing management practices, with staff feeling more valued and respected while going through the QI process. They discuss the following subjects and questions: QI as the basis of management When do QI and good management coalesce? So is QI just good management? How can we help leaders get on this path?
-
Content ArticleThe tragic and preventable death of Ruth Perry, headteacher at a school downgraded by an Ofsted inspection, has sparked calls for a review of regulatory oversight. While safety and quality must be assured, it’s crucial to consider the impact of regulatory inspections on the well-being of passionate workforces facing complex and challenging environments. In this blog, healthcare entrepreneur Vanessa Webb makes the case that as a potential cause of harm to staff, regulatory inspections in public services including healthcare should be subject to Health and Safety Risk Assessments. There should be a systematic process to identify hazards, evaluate the likelihood and severity of harm, and determine appropriate controls to prevent or mitigate those risks.
-
Content ArticleThis editorial in The Guardian looks at the Government's approach to relieving pressure on GPs, which involves diverting patients to other areas of primary care, including pharmacies. The article highlights potential risks and issues associated with the approach, including the workforce issues currently facing community pharmacy and the comparative lack of standards and regulations for pharmacies. It argues that the Government's approach simply moves the issue to other areas of the healthcare system, rather than dealing with the root cause of the issue facing GP surgeries—retention and recruitment.
-
Content ArticleDesigned by the Inpatient Diabetes Team at University Hospital Southampton (UHS), the DiAppBetes app for healthcare professionals aims to provide easy access to clinical guidance on managing patients with diabetes in hospital. It allows all healthcare professionals—including non-specialists—to quickly check up to date guidance on: the basics of diabetes. screening and diagnosis. type 1 diabetes guidance notes. patient assessment. complications of diabetes. patients with diabetes in a variety of scenarios, including pregnancy, about to have surgery, new to insulin, using an insulin pump and at the end of life. diabetes treatments. The app is freely available and content is generic apart from a few hospital-specific contact details. Hospitals using the Microguide platform for antibiotic guidance can reconfigure the format of the app—if they do this, hospitals should ensure that UHS is acknowledged as the original provider of the app.
-
Content ArticleAchieving an evidence-based practice not only depends on implementation of evidence-based interventions, but also requires de-implementing interventions that are not evidence-based, also known as low-value care (LVC). This is quite a new topic and knowledge is lacking concerning how de-implementation and implementation processes and determinants might differ. This scoping review identified 10 studies describing theoretical approaches that have been used concerning de-implementation of LVC. The findings point to the need for more research to identify the most important processes and determinants for successful de-implementation of LVC, and to explore differences between de-implementation and implementation.
