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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    For people who have sensory impairments or learning disabilities, understanding complex medical information presents a barrier to access. The Accessible (AIS) Information Standard, introduced in 2016, gives disabled people and people with sensory loss the legal right to receive health and social care information and communications in a format that works for them. In 2018, two years after the AIS became law, Karl, who is blind and relies on braille and assistive technologies to access information and communication about his healthcare and appointments, contacted his local Healthwatch to tell them he was having ongoing issues accessing his healthcare information and communications. This case study tells Karl's story and highlights why considering patients' individuals accessibility needs is so important.
  2. Content Article
    This presentation by the European Patient Safety Foundation (EPSF) outlines the issues associated with healthcare worker fatigue and highlights case studies of interventions to help fight fatigue in healthcare. It introduces the Fight Fatigue in Europe campaign and outlines its five-year action plan to #FightFatigue.
  3. Content Article
    This guide by the National Patient Safety Agency offers guidance for junior doctors on what to do if they are involved in a patient safety incident. It includes case studies on: medication error competence communication patient identification reporting It also includes guidance on how to deal with a complaint.
  4. Content Article
    Second victims are healthcare workers who experience emotional distress following patient adverse events. This mixed method study in BMJ Open looks at how the RISE (Resilience In Stressful Events) programme was developed at the Johns Hopkins Hospital to provide this support. It examined: developing the RISE programme recruiting and training peer responders pilot launch in the Department of Paediatrics hospital-wide implementation.
  5. Content Article
    People with poor mental health tend to experience poorer physical health and are more likely to die younger. This perspective article by consultant psychiatrist Peter Byrne aims to apply public health principles to improving the physical health of selected groups with mental health issues. It presents evidence of the lifetime effects of adverse childhood experiences and inequalities: the ‘causes of the causes’, outlines seven drivers of physical disorders that cause preventable deaths, and describes how psychiatrists must work with mental health teams to reverse rising mortality.
  6. Content Article
    This study in Brain, Behaviour & Immunity - Health aimed to examine associations between symptomatic Covid-19 history, neurocognitive function and psychiatric symptoms. The authors used cognitive task performance, functional brain imaging and a prospective population survey to conduct the study. Converging findings from laboratory and population survey data support the conclusion that symptomatic Covid-19 infection is associated with task-related, functional imaging and self-reported indices of cognitive dysfunction as well as psychiatric symptoms. In some cases, these findings appear to be more amplified among women than men, and among older women than younger.
  7. Content Article
    In this blog, TranspariMED Founder Till Bruckner reviews The Truth Pill: The Myth of Drug Regulation in India, a new book that looks at problems with the medications regulatory system in India. The book's authors, Dinesh S. Thakur and Prashant Reddy T, draw on in-depth legal and regulatory analyses, numerous case studies and responses to hundreds of Freedom of Information requests to document glaring gaps in India’s legal framework and severe shortcomings in regulatory oversight and enforcement.
  8. Content Article
    This presentation on fatigue and shift work is used as an induction session for doctors in training. It covers: Why are we talking about fatigue? What do you need to know? What can we do about fatigue? Improving sleep habits Working well at night How long to nap for Recovery after night shifts Driving tired Rest facilities Individual and organisational responsibilities and standards
  9. Content Article
    This ethnographic qualitative study in the BMJ aimed to describe how patients are engaged with cancer decisions in the context of multidisciplinary teams (MDT) and how MDT recommendations are carried out in the context of a shared decision. The study was carried out at four head and neck cancer centres in the north of England. The authors found that the current model of MDT decision-making does not support shared decision-making, and may actively undermine it. They recommend the development of a model that allows the individual patient more input into MDT discussions, and where decisions are made on potential treatment options rather than providing a single recommendation for discussion with the patient. Deeper consideration should be given to how the MDT incorporates the patient perspective and/or delivers its discussion of options to the patient.
  10. Content Article
    This article by the Association of Anaesthetists (AoA) defines fatigue, looks at its causes and highlights how healthcare worker fatigue can impact on patient safety. It includes a 'High-risk checklist' outlining factors that could contribute to healthcare worker fatigue including recent illness, use of alcohol and medications and stress.
  11. Content Article
    In this article, the Association of Anaesthetists (AoA) outlines its three-point plan to address the culture surrounding healthcare professional fatigue in hospitals and tackle the problem of excessive fatigue. Part of the AoA's #FightFatigue campaign, the plan involves the following aspects: Detection Education Prevention
  12. Content Article
    Dysphagia is the medical term for swallowing problems. There are different causes and types of dysphagia, and difficulties in any of the main stages of the eating, drinking and swallowing process can be called dysphagia. This guidance from Public Health England provides information on different aspects of making reasonable adjustments for people at risk of dysphagia including: Assessment of dysphagia Management of dysphagia Consent and capacity The attached PDF includes an easy-read summary of the guidance.
  13. Content Article
    Difficulty in swallowing—known as dysphagia—is a serious problem for some adults with learning disabilities and, in serious instances, can lead to death. Improving the safety of people with dysphagia is essential, and introducing individual patient management guidelines can reduce the risks associated with this potentially life-threatening condition. This document from the NHS National Patient Safety Agency outlines the issues facing adults with learning disabilities who have dysphagia and introduces support materials that can provide practical help for these people. The tools can be adapted for local use and for any adult who has dysphagia.
  14. Content Article
    This paper identifies the critical reasons healthcare leaders today must invest in experience leadership and structure. Contributions to this paper were captured from 42 participating organisations through a 50-item survey designed by the Institute’s Experience Leaders Circle. The reveals six reasons why a dedicated experience effort, and a structure to support it, are essential to becoming a provider of choice. The study concludes with seven positive outcomes important for healthcare executives to consider.
  15. Content Article
    This document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
  16. Content Article
    This animation explains systems thinking and the principles of human factors in simple terms. Aimed at healthcare managers and clinicians involved in local level incident investigation, the film uses an example scenario–the incorrect prescription of medications–to introduce the concept of systems thinking and how to use it in healthcare safety investigations.
  17. Content Article
    In this blog, Dr Ciaran Crowe, an ST6 doctor in obstetrics and gynaecology, talks about bullying in the healthcare system and what we can do to tackle unacceptable behaviour. He highlights the results of the 2014 National Training Survey, in which 8% respondents reported being bullied and 13.8% reported witnessing bullying, and points out that certain specialities have a higher than average number of bullying incidents reported. He also examines the triggers for bullying in healthcare settings and looks at ways to tackle the issue.
  18. Event
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    More than 1,400 English GP practices, around one in five, offer patients access to their prospective medical records: that means patients can see new entries to their medical records such as tests results, appointment notes and hospital letters online and through the NHS App and certain other apps. This webinar aimed at patients explains more about NHS England's programme to enable patients to access their medical records via the NHS App. Hear from: Patients Association members Claude and Greta about what the benefits are to them of being able to access their health information digitally GP Dr Brian McMillan, a Senior Clinical Lecturer at the Centre for Primary Care and Health Services Research, University of Manchester, and a Registered Health Psychologist, whose research interests include how digital technology can improve patients' experiences of primary care Registered nurse Tristan Stanton who is Assistant Director of Programmes – Primary Care, at NHS England and leads the programme to give people access to their online health records. The Patients Association's Chief Executive, Rachel Power, will chair the webinar. Sign up for the webinar
  19. Content Article
    The OptiBreech project is a research study exploring the feasibility of evaluating a new care pathway for women with a breech pregnancy. About 1 in 25 babies are born bottom-down (breech) after 37 weeks of pregnancy. Women who wish to plan a vaginal breech birth have asked for more reliable support from an experienced professional. This aligns with national policy to enable maternal choice. In this video, Dr Shawn Walker explains why the combination of meconium and tachycardia, particularly in the first stage of labour, indicates increased risk in breech births.
  20. Content Article
    This episode of the Health Service Journal's Health Check podcast features NHS Providers’ new chief executive Sir Julian Hartley, who cautions against creating provider trusts which are extremely large. Sir Julian talks about his fears that leaders could lose touch with the front line. He also answers questions about the role of collaboratives, as well as the shift from competition to system working, the risks of reintroducing a payment by results-style tariff, the importance of the promised long-term NHS workforce plan and the growing voices questioning the future of the NHS model.
  21. Content Article
    In healthcare, leadership has a big influence on quality of care and the performance of hospitals. How staff are treated significantly influences care provision and organisational performance, so understanding how leaders can help ensure staff are cared for, valued, supported and respected is important. Research suggests ‘inclusion’ is a critical part of the answer. In this article, Roger Kline looks at how creating a compassionate, inclusive culture improves patient safety—and by contrast, how a culture of fear and bullying has a negative effect. He examines why toxic leadership cultures develop and what can be done to transform leadership in NHS organisations.
  22. Content Article
    Co-produced by young people and researchers from the University of Bristol and London School of Hygiene and Tropical Medicine, ‘EDUCATE’ will help teach students about the human papillomavirus (HPV) vaccine and provide reassurance about receiving the vaccine, which is usually offered to teenagers at school as part of the national vaccination programme.
  23. Content Article
    Hospitals and other medical organisations are being hit by a rising number of cyberattacks; ransomware strikes on healthcare doubled annually between 2016 and 2021, according to a study published in December in the Journal of the American Medical Association. After a cyberattack, hospitals are forced to cancel procedures, reroute patients to other facilities and resort to pen-and-paper record-keeping. In this article, Wall Street Journal reporter James Rundle looks at how cyberattacks and a regulatory push are increasing the pressure on medical device manufacturers to improve the security of their products.
  24. Content Article
    This document offers advice and guidance for people with Long Covid who are having difficulties communicating with others as a result of their symptoms. It explains how Long Covid can impair communication by affecting speech, language and voice. It also outlines how many people are affected by Long Covid-related communication issues, explains how speech and language therapists can help and offers simple tips on how to improve communication with Long Covid.
  25. Content Article
    This practice recommendation offers practical recommendations to assist acute-care hospitals in prioritising and implementing strategies to prevent healthcare-associated infections (HAIs) through hand hygiene. It updates Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals through Hand Hygiene, published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association and The Joint Commission.
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