Patient-Safety-Learning
PSL ModeratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleThis blog by Dr Georgia Richards looks at the system of learning from preventable deaths in the UK. She highlights that following the publication of a Prevention of Future Deaths report (PFD), there is no system in place to ensure responses are received and actions are taken. She then describes how the Preventable Deaths Tracker collects information from PFDs to screen and analyse preventable deaths, so that lessons can be learnt
-
Content ArticleA key priority for all involved in the development, manufacture and prescription of medicines is safety. To keep patients safe, regulators and pharmaceutical manufacturers have a statutory obligation to provide product information covering the most important instructions on how to take medicines correctly. This report by Kent Surrey Sussex Academic Health Science Network (AHSN) outlines the findings of a project around the accessibility of medication information. Patients, carers, healthcare professionals (HCPs) and senior healthcare system stakeholders were asked what they think about current medicines product information, and if it could be improved using digital solutions.
-
Content ArticleThis correspondence published in Anaesthesia reflects on the recent guidance released by the Difficult Airway Society and the Association of Anaesthetists, 'Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals'. The authors highlight that although the guidance is a positive step forward in improving system safety in anaesthesia, there is a need to include a broader range of Human Factors (HF) specialists in the development of guidelines such as these. They call for a higher level of collaboration between clinicians and HF specialists to ensure that healthcare system safety can benefit from years of HF expertise.
-
Content ArticleIn this blog, Jennifer Nelson investigates why doctors have one of the highest suicide rates of any profession. She speaks to experts including health psychologist Jodie Eckleberry-Hunt, who highlights that doctors tend to have a lower level of cognitive flexibility, which may affect their ability to cope when things don't go to plan. Psychotherapist Brad Fern goes on to describe the complex range of reasons that doctors may take their own lives, and describes the importance of tackling silence and isolation among doctors. The blog concludes by addressing the need to separate suicide from other wellbeing issues doctors might face, and by looking at how the system itself contributes to high suicide rates.
-
Content ArticleThis long read by the Nuffield Trust looks at priority areas where further development and action could help improve the effectiveness of virtual wards. It outlines different models for virtual wards and looks at how to ensure effective system oversight. It also highlights the need to ensure the workforce is equipped to run virtual wards effectively and safely.
-
Content ArticleIn this guest post, Michael A. Osborne, Professor of Machine Learning at Oxford's Department of Engineering Science looks at how the medical community is failing to explore the links between Long Covid and ME/Chronic Fatigue Syndrome (ME/CFS). He describes the symptoms common to both conditions and highlights the historic lack of funding and attention ME/CFS research and treatment has received.
-
Content ArticleThis article by Till Bruckner of Transparimed outlines how a new UK law will affect how clinical trial results are reported. The UK Government will introduce a legal requirement to make the results of all clinical trials public within 12 months of trial completion. Any company or university breaking the law will be refused permission to start new trials.
-
Content ArticleThis guidance outlines the Care Quality Commission's (CQC's) approach to assessing integrated care systems (ICSs). It includes information on how these assessments will be carried out. The guidance focuses on: Themes and quality statements Evidence categories How we will assess integrated care systems Reporting and sharing information Intervention and escalation
-
Content ArticleThe Prescription Charges Coalition is a group of 50 organisations calling on the Government to scrap prescription charges for people with long-term conditions in England. This report by the Coalition outlines the results of a survey of over 4,000 people with long-term conditions about prescription charges. It highlights that the prescription charge is a barrier to patients with long-term conditions accessing medicine.
-
Content ArticleIn this blog, Carl Heneghan, Urgent Care GP and Professor of Evidence-based Medicine at the University of Oxford, looks at how the shortage of doctors working in urgent care is affecting patient safety. He tells the story of a patient with a blocked catheter, highlighting that with early intervention, this should cause few complications, but if not treated promptly, it can cause bladder damage and chronic kidney failure. This example highlights the need to ensure patients are seen quickly if they have an urgent need in the community. The blog points out that current Government plans to scale up urgent community response teams are inadequate as they only cover 12 hours a day and there is a shortage of GPs willing to work in urgent care.
-
Content ArticleThe Beryl Institute is seeking feedback on its proposed new global experience measure. The aim is to create a simple, clear experience measure set that ensures global accessibility and applicability, and supports tangible action. This survey aims to help the steering group assess the value and importance of their proposed set of questions. They would like to hear the perspectives of: patient, family members and care partners healthcare/experience leaders The survey should take less than five minutes to complete.
-
Content ArticleThis video offers an introduction to the Systems Engineering Initiative for Patient Safety (SEIPS) framework, an approach that looks at work systems and processes from a systems-based perspective. SEIPS is the main model used within the Patient Safety Incident Response Framework (PSIRF) adopted by the NHS. This video includes an explanation of the model and a dramatisation of the process of making a round of tea in a staff room, illustrating the error traps and design issues present in the environment.
-
Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the work of community mental health teams (CMHTs). Specifically, the investigation looked at the following four areas: assessing a patient’s risk of self-harm or suicide considering menopause as a risk factor for mental health conditions engaging with families caring for people with a first episode of psychosis. Reference event Ms A was 56 years old when she came into contact with mental health services for the first time in September 2019, following a suicide attempt. Ms A spent a month in hospital, and was then discharged home under the care of a community mental health team (CMHT) with a diagnosis of psychotic depression. At the end of May 2020, Ms A was again admitted to hospital following a second suicide attempt. She again stayed in the hospital for about four weeks before being discharged home under the care of a CMHT. Ms A was seen by CMHT workers regularly throughout July, and had a telephone review with a consultant psychiatrist. At the end of July, Ms A’s family became increasingly concerned about her mental state and were unable to make contact with her. On 2 August, Ms A was found deceased at home having died by suicide.
-
Content ArticleThe Operating Room Black Box, a system of sensors and software, is being used in operating rooms in 24 hospitals in the US, Canada and Western Europe. The device captures video, audio, patient vital signs and data from surgical devices in an effort to improve patient safety. This article in the Wall Street Journal looks at how Black Box technology at Duke University Hospital has identified several areas for improvement, including that the hospital needed a better system for sending and tracking specimens. The article also highlights some concerns raised by healthcare professionals about the use of Black Boxes, including fear that data collected might be used to punish staff, or that it may be used as evidence in medicolegal cases outside of hospitals' control.
-
Content ArticleThe first ever HETT North event, which brought together digital health leaders from across the country, took place in March 2023 in Manchester. The event highlighted the latest advancements in digital healthcare, and this blog reports on the final keynote session of the day, which focused on ‘Assessing the landscape of digital health transformation – past, present & future’. Key topics included identifying underlying issues that need to be addressed to allow for digital transformation, and the policy surrounding digital transformation in Integrated Care Systems (ICSs). Alongside Clive Flashman, Patient Safety Learning's Chief Digital Officer, the panel included: Sam Shah, Chair, HETT Steering Committee Henrietta Mbeah-Bankas, Head of Blended Learning & Digital Learning & Development Lead, Health Education England Tremaine Richard-Noel, Head of Emerging Technology, Northampton General Hospital NHS Foundation Trust Liz Ashall-Payne, CEO, ORCHA You can watch a video of the discussion on Youtube.
-
Content ArticleFalsified, fake or counterfeit medicines are medicines disguising themselves as authentic, and they can pose significant health risks. 96% of websites selling medicines operate illegally–but research suggests that over 50% of people are not aware of this. This blog highlights the issue of counterfeit Parkinson's medications being sold illegally online. Mike Isles, Executive Director of the Alliance for Safe Online Pharmacy in the EU describes their high prevalence and gives tips for people with Parkinson's on how to stay safe when buying medicines online.
-
Content ArticleThis editorial in BMJ Quality & Safety argues that patients' perceptions of their safety should not be dismissed when measuring healthcare safety. The authors argue that a differentiation between ‘feeling safe’, as defined through patient experience, and ‘being safe’, as defined through observation and evaluation using clinical outcomes selected by quality experts, creates a power differential and dynamic that degrades the role and value of patient experiences as valid patient safety indicators.
-
Content ArticleThis report summarises the results of the Patients Association's Winter survey 2023, which received 1,933 online responses. The survey aimed to help develop understanding about the experiences of patients during a period of high pressure for the NHS. In addition to the usual winter pressures, the NHS experienced a backlog of care exacerbated by the Covid-19 pandemic, alongside years of underinvestment in the NHS, the absence of a long-term workforce plan and long-standing issues in the social care system.
-
Content ArticleThis report by the Royal College of General Practitioners (RCGP) sets out recommendations for the Government to tackle the workforce and workload crisis in general practice, and support GPs and their teams to meet the healthcare challenges of the 21st century. Based on a survey of more than 2,600 GPs and other practice team members from across the UK, the report provides a snapshot of what frontline staff have faced during one of the most difficult winters experienced in the NHS, and what they think needs to happen to make general practice more sustainable. Respondents describe a profession in crisis, with unmanageable workload and workforce pressures fuelling an exodus of fully qualified GPs.
-
EventuntilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Compassionate engagement and involvement of those affected by patient safety incidents is central to the PSIRF approach. Building on our workshop that explored different models for engaging with families, this workshop will highlight how different organisations are approaching engaging with staff affected by patient safety incidents. PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England, Mrs Christina Rennie, Consultant Ophthalmologist, Clinical Director of Patient Safety and Patient Safety Specialist, University Hospital Southampton NHS Foundation Trust Register for this event Registration closes at 12noon Wednesday 19 April 2023. A link to join the webinar will be sent to registered delegates shortly after registration closes.
-
Content ArticleThis tool from the Parkinson's Association of Ireland allows people with Parkinson's to record their essential medical information in an easy to access format, should they need assistance or medical treatment. It includes: information about the physical symptoms of Parkinson's, including how it affects speech and movement. instructions on how to interact with the person if they are having difficulty communicating. personal details and emergency contacts details of medications and treatments the person is taking.
-
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. Isabela shares how her experience of losing her baby daughter to avoidable harm in 2006 led to her involvement in patient safety advocacy. She talks to us about the vital role of patient campaigners in driving the movement to reduce avoidable harm, and why we need to shift from patient inclusion to belonging in order to improve patient safety. -
Content ArticleIn this podcast, host Thea Joshi is joined by Emma Bailey and Hannah Moore from the Equally Well campaign, which the Centre for Mental Health runs in partnership with Rethink Mental Illness. They share how Equally Well UK is working to improve the physical health of people with severe mental illness, with the critical aim of reducing the unacceptable mortality gap that affects people with severe mental illness. Emma and Hannah discuss how physical health is often neglected in mental health inpatient services, and give examples of good work that is being done to change this.
-
Content ArticleWhistleblowing is synonymous with the exposure of wrongdoing by informed insiders, and is recognised by organisations and governments as an important and positive act in the fight against crime, corruption and cover up. This report was produced by WhistleblowersUK as secretariat to the All Party Parliamentary Group (APPG) on Whistleblowing and sets out the case for an Independent Office of the Whistleblower. It outlines how this can address the failure of the UK to make whistleblowing work for society. Working with groups of experts and specialists including those from academia and law from around the world, the APPG has drawn up the “Whistleblowing Bill”.
-
Content ArticleIn the US, patients receiving cancer treatment via Medicare or Medicaid—two federal health insurance programmes—can face barriers to accessing treatment when insurers use the Prior Authorization Process to deny access. In this letter to the Centers for Medicare & Medicaid Services, the Community Oncology Alliance (COA) outlines its concerns that prior authorizations are acting as "roadblocks to Americans with cancer getting the optimal treatment on a timely basis." Referring to proposed rule changes that aim to reduce the burden that prior authorization processes place on providers, the COA calls for the inclusion of medications to ensure that American's with cancer are not denied the treatment they need.
