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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The Nuffield Trust held its fifteenth Summit in March 2023. In these video interviews captured at the summit, health and care leaders talk about the challenges and issues currently facing the NHS and social care: Prof Kevin Fong on the immense cost of the pandemic to NHS staff Prof Martin Marshall on the range of challenges facing health and care Nigel Edwards on how the NHS gets on the road to recovery Jill Rutter on squeezed budgets and hospitals dominating health finances Dr Arif Rajpura on practical policies for reducing inequality Chris Hopson on promises to decentralise the NHS to better meet patient need
  2. Content Article
    Nuffield Trust’s fifteenth annual Summit took place in March 2023. These videos feature highlights of the speaker sessions: Diagnosing the NHS Priorities in social care Community and rehabilitation services - the key to easing gridlock? Addressing inequalities in general practice - politics, policy and reality Solving the workforce burnout crisis Improving communication between the NHS and the public Changing the centralised culture of the NHS
  3. Content Article
    This report from the National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP) shows what happened after people were admitted to hospital with an asthma attack or COPD exacerbation between 2018 and 2020. The data show that many people are being readmitted to hospital within three months of going home and that some, particularly with COPD, are dying within three months of their exacerbation.
  4. Content Article
    In this Guardian article, Sarah Kendell describes her experience of maternity care in Australia, highlighting the stark difference in care offered before and after a woman has given birth. She says "at the most difficult transition of our lives–after childbirth–the healthcare system leaves us to fend for ourselves," and argues that the impact this can have on the health and wellbeing of women and their babies needs to be considered. She asks whether reallocating some resource from antenatal care to postnatal care would produce health benefits for new mothers and babies.
  5. Content Article
    NHS waiting lists have risen to record numbers since the pandemic and attempts to bring down the numbers of people waiting for treatment have been ramping up. The NHS Elective Recovery Plan (ERP), launched in February 2022, is intended to make a major contribution to reducing waiting lists. This paper by consultancy firm Lane Clark & Peacock sets out: how the national waiting list has changed over the year and the impact of the ERP. inequalities in the waiting list by speciality and geography and how the ERP has so far impacted regions differently. how LCP's previous projections compare to 2022’s waiting list and what their projections are for 2027 in light of over a year's worth of new data being available.
  6. Content Article
    Cauda Equina Syndrome (CES) is a rare but serious spinal condition and if not diagnosed and treated swiftly, it can result in lifechanging injury. Nearly a quarter of compensation claims for spinal surgery in England relate to CES. This CES pathway and accompanying guidance by the Getting It Right First Time (GIRFT) programme, aims to provide healthcare professionals working in all care settings with the ability to effectively diagnose and care for patients presenting with suspected Cauda Equina Syndrome.
  7. Content Article
    This report by the National Paediatric Diabetes Audit (NPDA) looks at diabetes care for children in England and Wales in 2021-22. The effectiveness of diabetes care is measured against NICE guidelines and includes treatment targets, health checks, patient education, psychological wellbeing, and assessment of diabetes-related complications including acute hospital admissions, all of which are vital for monitoring and improving the long-term health and wellbeing of children and young people with diabetes. In 2021/22, 100% of paediatric diabetes teams participated in the NPDA.
  8. Content Article
    This article in BBC Science Focus looks at the factors driving an increase in testosterone prescribing for women in the UK. The author, Dr Michelle Griffin, highlights the need to ensure that there is a strong evidence base for prescribing testosterone to women. While there have been some clinical trials and studies around testosterone as a treatment for low libido, there is concern that patients, doctors and pharma companies are relying on anecdotal accounts of its effectiveness to treat symptoms such as low mood, poor concentration and tiredness. She also highlights that testosterone prescribing is just one example of the lack of research going into women's health issues and treatments, and argues that this is contributing to health inequity.
  9. Content Article
    In this blog, Sonia Barnfield, Clinical Adviser for Maternity Investigations at the Healthcare Safety Investigation Branch (HSIB), looks at risk assessments during the maternity care pathway, following HSIB's recent national learning report on the same subject. Sonia outlines the need for change in the way that risk during pregnancy is assessed and managed, highlighting that there is currently no single national guidance and that HSIB identified repeated examples of insufficiently robust, continuous risk assessment in the maternity pathway. She lays out six key themes highlighted in HSIB's report and looks at how risk assessments should change to improve safety for pregnant women and their babies.
  10. Content Article
    This letter to NHS mental health trusts, Integrated Care Boards and Commissioners outlines NHS England's position on the use of Serenity Integrated Mentoring (SIM) in NHS mental health services. SIM is a model of care that has been used with people with mental health issues who are considered high-intensity users of emergency services. It is a controversial approach as it instructs services providing emergency care not to provide support to these individuals.
  11. Content Article
    The Association of Anaesthetists (AoA) has developed a set of resources to help NHS staff and boards tackle the impact of healthcare worker fatigue. Part of the AoA's #FightFatigue campaign, these resources can be downloaded as a whole package or separate items.
  12. Content Article
    This practical advice and guidance from the Association of Anaesthetists aims to help anaesthetists and other healthcare staff to look after their mental wellbeing. It covers the following topics: Achieving a work/life balance Using mindfulness Managing stress Coping with death Dealing with bullying Guidelines to help anaesthetists at risk of suicide
  13. Content Article
    Sleep deprivation and fatigue lead to a wide range of performance issues that may pose risks to workers and others in the work environment. This review in Frontiers in Neuroscience discusses relevant literature on the topic of fatigue-related performance effects, with a special emphasis physiological and behavioural response variables that have shown to be sensitive to changes in fatigue. It also looks at methods for mitigating these performance effects and discusses their usefulness in regulating them.
  14. Content Article
    This article in the American Journal of Nursing provides basic information about the assessment of dark skin tone and calls for action in academia and professional practice to ensure the performance of effective skin assessments in all patients.
  15. Content Article
    At least 1 in 5 mothers experience a perinatal mental health (PMH) problem, making mental illness the most common serious health problem that a woman might experience in the perinatal period. This resource was produced by the Institute of Health Visiting (iHV) in partnership with the Maternal Mental Health Alliance (MMHA). It draws together principles collated from a comprehensive desktop evidence review of current policy, research, reports and literature on what good PMH care looks like. It aims to support individuals, services, pathways, multiagency groups and networks across health, public health, social care and non statutory services to consider: Where are we now? Is the care we currently provide good enough? What do families want mental health care in the perinatal period to look like?
  16. Content Article
    In this video interview, consultant geriatrician Dr Elena Mucci talks about patient safety in geriatrics and end of life care. She describes the importance of: taking a whole-person approach to caring for older people reviewing medications regularly equipping patients to manage their own health. engaging patients and their families in planning for end of life care at an early stage Elena also explains how she is sharing these messages with both patients and healthcare professionals.
  17. Content Article
    This article in Social Science & Medicine aims to show how patients’ contributions to their safety in hospital are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. The article outlines the conflict between the current focus on encouraging patients to speak up, raise queries and take ownership of their healthcare, and the relational vulnerability created by the 'sick role'—an established societal role that excuses people from their normal duties in society and entitles them to seek help. The authors highlight that supporting staff to elicit concerns from patients, and offer assurance that challenge is welcome, will be crucial in creating an environment where patients can become fully involved in own safety.
  18. Content Article
    This systematic review in the British Journal of Surgery aimed to describe types of cognitive bias in surgery, their impact on surgical performance and patient outcomes, their source, and the mitigation strategies used to reduce their effect. The authors concluded that cognitive biases have a negative impact on surgical performance and patient outcomes across all points of surgical care. This review highlights the scarcity of research investigating the sources that give rise to cognitive biases in surgery and the mitigation strategies that target these factors.
  19. Content Article
    Is the NHS really full of ‘overpaid pen-pushers’? In this podcast, host Jo Vigor talks to guests about the critical role of NHS managers and what it means to bring your humanity to work. Guests: Dr Seema Srivastava, Deputy Medical Director at University Hospitals Bristol and Weston NHS Foundation Trust Emma Challans-Rasool, Founder and Chair of the Proud2bOps operational network and Director of Organisational Development, Culture and Talent at Nottingham and Nottinghamshire Integrated Care System Rachel Burnham, Director of Performance and Information at Guy's and St Thomas's NHS Foundation Trust
  20. Content Article
    Continuous glucose monitors (CGM) are devices that offer an alternative to finger stick blood glucose testing in adults and children with any type of diabetes. This practice guide in the BMJ offers guidance on CGM for primary care providers and aims to reduce uncertainty and improve prescribing rates of CGM.
  21. Content Article
    Medical errors, especially those resulting in patient harm, have a negative psychological impact on patients and healthcare workers. Healing may be promoted if both parties are able to work together and explore the effect and outcome of the event from each of their perspectives. There is little existing research in this area, even though this has the potential to improve patient safety and wellness for both healthcare workers and patients. Using a patient-oriented research approach, this study in BMJ Open Quality examined the potential for patients and healthcare workers to heal together after harm from a medical error. The study's findings suggest that, after a medical error causing harm, both patients and healthcare workers have feelings of empathy and respect towards each other that often goes unrecognised. Barriers to communication for patients were related to their perception that healthcare workers did not care about them, showed no remorse or did not admit to the error. For healthcare workers, communication barriers were related to feelings of blame or shame, and fear of professional and legal consequences. Patients reported needing open and transparent communications to help them heal, and healthcare workers required leadership and peer support, including training and space to talk about the event.
  22. Content Article
    The NHS was struggling before Covid-19 and was further severely disrupted by the pandemic. As a result, it is now dealing with a massive backlog in elective care. This blog by Saoirse Mallorie, Senior Analyst at The King's Fund, looks at the causes and state of the backlog and identifies ways to tackle the issue, including increasing workforce and investment, innovation and focusing on prevention.
  23. Content Article
    This report provides a snapshot of the NHS Confederation's work over the last year. It outlines how the NHS Confederation has challenged the government for a fair funding settlement for the NHS, pressed ministers for a long-term workforce strategy, urged the government and unions to end the industrial dispute and made the case for more autonomy for healthcare leaders.
  24. Content Article
    In this blog, Laura Pickup, Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB) talks about NHS staff fatigue in the run up to World Sleep Day and HSIB's fatigue event on 17 March 2023. She looks at the scientific basis of fatigue and the impact it can have on safety in healthcare settings. She also examines how the rail industry has made changes to deal with staff fatigue and improve safety, highlighting the unique challenges faced by healthcare due to workforce shortages. Laura highlights the conversation that HSIB has initiated about fatigue in healthcare and how to tackle the challenges it poses to safety.
  25. Content Article
    This document outlines the identity and strategy of the European Patient Safety Foundation (EPSF), an independent, public interest foundation based in Belgium.
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