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Content ArticlePeople with mental health difficulties bring a unique and vital perspective to shaping services. While steps have been taken to embed ‘lived experience’ within mental health services, these opportunities can often feel tokenistic, and maintain the unequal power dynamics between clinicians and ‘patients’. In this paper, David Gilbert uses his insights as a mental health service user and his experience in Patient Leadership to consider the limitations of current practice, and the possibilities of a new approach which could transform mental health services.
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Content ArticleThis blog by the Centre for Mental Health looks at data about young people's mental health in 2022 from NHS Digital, highlighting the urgent need for effective mental health services and support for young people. It looks at what needs to change to improve the picture for young people's mental health including addressing child poverty, implementing whole school and college approaches and investing in early intervention support.
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Content ArticleIn this on-demand webinar, professionals across the NHS discuss how their speciality areas interact with urgent care, and how digital health can be used to relieve pressure in relevant areas. Speakers: Dr Tom Micklewright, Medical Director at ORCHA and NHS GP Helen Hughes, Chief Executive at Patient Safety Learning Chris Efford, Clinical Lead Physiotherapist and Digital Fellow, University Hospitals Dorset and DNHS Dorset Digital Services at Home Team Dr Simon Leigh, Health Economist and Director of Research, ORCHA View presentation slides from the webinar
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Content ArticleThis article in the journal Oral and Maxillofacial Surgery for the Clinician looks at the importance of recognising and addressing human factors in surgery. It explores human factors in the context of optimising individual performance, enhancing team working to improve patient safety, and creating better working lives for healthcare professionals across surgery and medicine.
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EventuntilPrimary care services are the front door to the NHS – they are the first port of call when we feel unwell and the main coordinator of care when we are living with ill health. The primary care team have an important role in making people feel welcomed, listened to and taken seriously. At National Voices we often hear stories from groups of people who struggle to have their communication needs met within primary care. As just one example, five years after the launch of the Accessible Information Standard, 67 per cent of Deaf people reported that still no accessible method of contacting their GP has been made available to them (Signhealth, 2022). This issue also affects other groups with specific communication needs - people who don't speak English fluently, people with learning disabilities, autistic people, people with dementia, people with low or no literacy, people who are digitally excluded, people living nomadically, people experiencing homelessness and more. We know that these experiences happen within the context of a primary care team under exceptional pressures. This workshop will bring together people with lived experience from all the groups mentioned above, as well as voluntary sector organisations, members of the primary care workforce, primary care policy leads, as well as commissioners and providers to discuss the challenges and co-produce solutions. At the workshop, we hope to build and improve understanding of: The experiences of people with diverse communication needs within primary care. The barriers primary care teams experience in meeting diverse communication needs, especially under existing pressures. Practical ways that we can embed and improve inclusive communications within the primary care setting. Register for the webinar. If you have any questions, please contact aleyah.babb-benjamin@nationalvoices.org.uk
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Content Article
Psychosocial risk webinar series (FEFO, October 2022)
Patient-Safety-Learning posted an article in Staff safety
This series of webinars by FEFO Consulting looks at how to identify psychosocial hazards at work and manage the associated risks. You can watch the four webinars on FEFO's YouTube channel: ISO 45003 vs Model code of practice – Getting started Change management – Managing psychosocial risks Mental fitness – Opening up conversations HR vs safety – Psychosocial ownership -
EventuntilEvery year, diagnostic errors (missed, delayed, or incorrect diagnoses) affect at least one in twenty adults in the United States and cause substantial harm to patients of all ages. The diagnostic process is complex and so far, only limited effective interventions for diagnostic error reduction have been identified and implemented. A particularly promising way to improve diagnostic safety is to involve patients and their families. Patients’ experiences can contribute to establishing research priorities to reduce diagnostic error, as they provide valuable insights that are complementary to that of researchers and clinicians. Throughout the continuum of health care, patients interact with a variety of health care providers from different medical specialties and in a variety of health care settings. Patients can also have a more prominent role in contributing to the development and implementation of interventions to improve diagnostic safety. As part of IHI’s annual Patient Safety Awareness Week, join us for this free webinar to learn more about partnering with patients and their care partners to improve diagnostic safety. Register for the webinar
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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. Laura and Suzy talk to us about the importance of embedding human factors in the design of healthcare systems and tools, the importance of equipping staff to think about system safety, and their work to establish a nationwide conversation about the impact of fatigue. -
Content ArticleThis online course by NHS England helps participants learn how to engage with different people and communities to reduce inequalities and ensure inclusive access to healthcare. It involves three hours of study time per week over two weeks and aims to equip healthcare professionals to: help the people they work with access healthcare services understand how people have different experiences in their access to healthcare explore inclusive engagement activities develop an awareness of implicit bias and underrepresentation
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Content Article
Useful tips to aid sleep (Association of Anaesthetists)
Patient-Safety-Learning posted an article in Staff safety
This article by the Association of Anaesthetists offers guidance for healthcare workers on how to get a good sleep. It includes advice on the following techniques and ideas: Unchallenge your brain Have a hot bath Sleep in a way that works for you Be prepared Power napping tips -
Content ArticleIn this episode of the Coffee and a Gas podcast, consultant anaesthetists Dr Roopa McCrossan and Dr Emma Plunkett talk about fatigue and how they pioneered the Association of Anaesthetists' Fight Fatigue campaign.
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Content Article
Poster - Working well at night (RCOA, 8 November 2018)
Patient-Safety-Learning posted an article in Staff safety
This poster by the Royal College of Anaesthetists, The Association of Anaesthetists and the Faculty of Intensive Care Medicine outlines practical principles for minimising the impact of fatigue for staff working night shifts. It includes tips for what to do before nights, during nights and between nights and advice on recovery after nights. -
Content Article
Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society (1 November 2021)
Patient-Safety-Learning posted an article in Workforce and resources
Regulators, organisations, communities and workers often struggle with how to manage shift duration and address associated risks from fatigue and sleepiness, while continuing to meet the societal demands for work. This article in the Journal of Clinical Sleep Medicine proposes a series of guiding principles help design a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks. -
Content ArticleIn this video Kenny Gibson, Head of Safeguarding for NHS England and NHS Improvement, explains what trauma informed care is and describes the role of healthcare professionals in recognising trauma in colleagues and patients. He talks about the importance of overcoming unconscious bias around whether individuals have experienced trauma and outlines the importance of avoiding retraumatising victims. He also highlights that healthcare professionals can play a key role in bringing hope to people who have been traumatised.
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Content ArticleThis article looks at how Sheba Medical Center in Tel Aviv, one of the largest health systems in the region, has used artificial intelligence to turn around statistics on patient safety. In 2016, the Accelerate Redesign Collaborate Innovation Center at Sheba launched a an AI solution called Aidoc to read CT scans. It is being used to more accurately predict stroke and pulmonary embolism, allowing healthcare professionals to offer preventative treatment more quickly that when CT scans are read purely manually.
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Content ArticlePeter Seaby had Down's Syndrome and autism and was cared for at home by members of his family for 62 years. However, in 2017, Peter was removed from the home he shared with his sister Karen, who was his full time carer, and placed in a care home. Karen and Peter's brother Mick were not told by social services why Peter was moved. Within six months of being in the home, Peter choked on a carrot and died. Karen and Mick found the subsequent inquest into Peter's death in July 2021 to be inadequate and launched a Judicial Review challenge which was successful in quashing the findings of the initial inquest. A new inquest was held in February 2023 Journalist George Julian has been following and reporting on Peter's second inquest and has written several blog posts about the case, highlighting serious failings in his care that led to his death: Peter Seaby’s 2nd inquest – how he came to be in the care of the Priory Group Peter Seaby’s 2nd inquest “I have stood on my own in this” Peter Seaby’s 2nd inquest – the SALT plan Peter Seaby’s 2nd inquest – record keeping and decision making Peter Seaby’s 2nd inquest – April 2018 Peter Seaby’s 2nd inquest – May 2018 Peter Seaby’s 2nd Inquest – Conclusion
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Content ArticleRisk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway. This thematic review draws on findings from the Healthcare Safety Investigation Branch's (HSIB's) maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’). It examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included. The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.
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Content ArticleEmergency care services in the UK face an unparalleled crisis, with more patients than ever before experiencing extremely long waiting times in Emergency Departments (EDs), associated with patient harm and excess deaths. This explainer from the Royal College of Emergency Medicine (RCEM) outlines the latest data on ED waiting times and the impact this is having on patient safety.
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Content ArticlePatients with Long Covid—defined by the National Institute for Health and Care Excellence (NICE) as signs and symptoms that persist for more than four weeks following acute Covid-19—may present in primary care with symptoms of palpitations (tachycardia) triggered by standing or minimal exertion. These may be accompanied by dizziness, breathlessness, chest pain, sweating, bloating, fatigue and other symptoms which may be caused by a dysfunction of the autonomic nervous system (dysautonomia). This practice pointer in the BMJ outlines: how tachycardia present in patients with Long Covid. what clinical assessment should involve. how to test for postural orthostatic tachycardia syndrome in primary care. drug and non-drug treatments that are available. what patients can do for themselves. when patients should be referred to a specialist.
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Content ArticleThis article by Katherine Virkstis, Managing Director of the US health thinktank Advisory Board, looks at the growing problem of a nursing 'skills gap' in the US. She argues that this area is often overlooked, but needs to be tackled to ensure patients are safe. A recent boom in new nurses graduating means that the balance of the nursing workforce is now less experienced than it has previously been. The growing complexity of patients and care approaches in healthcare systems also means that the demand for highly-trained nurses with specific skills has increased. The author explains this as a widening 'experience-complexity gap' and suggests four strategies to close the gap: Bolster emotional support and show staff your own vulnerability as a leader Dramatically scope the first year of practise Differentiate practice for experienced nurses Reinforce experienced nurses' identity as system citizens
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EventuntilHealth and care, and academic environments can have specific expectations that influence the evaluation of public involvement. These expectations may shape why the evaluation takes place and the approaches deemed ‘valid’. The hosts of this ‘Necessary Conversation’ argue that these environments and the approaches that they tend to favour, can lead to public contributors being absent from the conversation about what matters. Lynn Laidlaw leads this session with Niccola Hutchinson-Pascal and others to be confirmed. Lynn will be asking who is pushing the impact and evaluation agenda, where does the power lie, and what are the different forms of impact that exist? Sign up for this event
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Content ArticleIn this video, William Pileggi, a registered nurse anaesthetist, discusses the implementation of the Golden Eagle Project at the VA Pittsburgh Healthcare System to improve outcomes for veterans who may be prone to experiencing post-operative emergent delirium. Through assessments to prescreen for PTSD, staff training and using alternative drug therapies, his hospital has had zero injury events related to emergent delirium since 2018. With minor modifications, the program is replicable at civilian hospitals.
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Content ArticleThe UK Covid-19 Inquiry is the independent public inquiry set up to examine the UK’s response to the Covid-19 pandemic, assess the impact of the pandemic and learn lessons for the future. The Inquiry is Chaired by Baroness Heather Hallett, a former Court of Appeal judge. This is a recording of the UK Covid-19 Inquiry's preliminary hearing for its third investigation looking at the impact of the pandemic on healthcare. The agenda includes: introductory remarks from the Chair update from Counsel to the Inquiry including designation submissions from core participants. Read the transcript of the hearing.
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EventuntilTe Ngāpara Centre for Restorative Practice invites you to attend the virtual symposium Restorative Health Systems: Healing, learning, and improving after harm. This free event is being held in association with the Health Quality & Safety Commission in Aotearoa New Zealand. The symposium will provide a virtual space for knowledge sharing and exchange among the growing international community of clinicians, researchers, consumers, investigators policymakers, and practitioners working in health settings. We aim to share what is happening globally in this emerging field and to reflect on the future of restorative initiatives in the health system context. The symposium will incorporate a series of different sessions, including interactive dialogues with international critical thinkers and advocates, presentations on key issues relevant for the field and research relating to restorative initiatives. View the programme (PDF) This is the first of a symposium series as part of the Te Ngāpara Centre for Restorative Practice’s commitment to supporting the development of restorative knowledge. The symposium will take place on Zoom on Wednesday 29 March, 8am - 12pm (NZDT) 0600 Australia (AEDT) 2000 London UK (BST) 1200 Vancouver (PDT) 1500 Montréal (EDT) Register for the symposium
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Content ArticleThis report is aimed at people who are working with those who have a learning disability, in the role of commissioners or providers of services. It was produced on behalf of the Hampshire Safeguarding Adults Board by a multi-agency group and seeks to understand why people with a learning disability are at greater risk of choking, looking at what can be done locally in Hampshire to improve outcomes for people who are at risk of choking, in any care setting. The report makes a number of recommendations based on common sense and good practice.
