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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The Patients Included charters were created by Lucien Engelen in 2010. Fed up of hearing people talk about 'what the patient wants' at medical conferences where no patients were present, he decided he would no longer speak at or attend conferences where patients were not speaking, offered bursaries to attend or part of the organising committee. The charters provide organisations with a way to demonstrate their commitment to incorporating the experience and insight of patients into their organisations by ensuring that they are neither excluded nor exploited. The charters that have been published so far include: Conferences (v.1.0 May 2015) Journals (v.1.0 April 2016) Patient information resources (v.1.0 December 2016) Ethics (v.1.0 April 2018) The Patients Included logo can also be used by conferences who adopt the conference charter.
  2. Content Article
    This NHS England podcast examines how the application of system-based approaches to learning from patient safety incidents will be vital to the success of the Patient Safety Incident Response Framework (PSIRF). Guests Darren Thorne from the consultancy Facere Melius, Jane Carthey, a Human Factors and Patient Safety Consultant and Laura Pickup from the Healthcare Safety Investigation Branch (HSIB) discuss NHS England's learning response toolkit.
  3. News Article
    The cost of living crisis could force dying patients to move into hospice beds as they can no longer afford to heat their homes, it is claimed. The stark warning comes as the care sector faces soaring energy bills of its own, with the industry predicting a huge hike in costs next year. Speaking about the impact the cost of living crisis is having on patients, Paul Marriot, Chief Executive of North East hospice St Cuthbert’s, said: “Here in the North East, for example, many of our patients are already on low incomes and the fact that they are ill increases their costs. The key thing is that they are in a time in life when they’ve got less choice around what they do about [costs]. So it’s not an opportunity for them to switch off the heating, it’s not an option for them, just to wear more clothes, it’s not an option for them to see it out until the spring, because they may not be here in the spring." Read full story Source: The Independent, 17 October 2022
  4. Content Article
    Patient (or lived experience) leadership involves people affected by life-changing illness, injury or disability becoming equal partners in NHS decision-making. This expert briefing by patient leadership champion David Gilbert highlights the most significant developments in the field of patient leadership.
  5. Content Article
    Safety communication refers to the sharing of safety information within organisations in order to mitigate hazards and improve risk management. External stakeholders, such as patients and carers, also communicate safety information to healthcare organisations. This article in the Journal of Risk Research examines the nature of safety communication behaviours seen in patients and their families by identifying and examining 410 narrative accounts. The author found that the success of patient and family safety communication in reducing risk was variable. Problems in hospital safety culture such as high workloads and downplaying safety problems, meant that information provided was often not acted upon.
  6. Content Article
    This three-hour online course introduces the concept and approach to thematic analysis in safety investigations. It builds on the concepts discussed in HSIB's Level 2 course A systems approach to learning from patient safety incidents, so attendees must have completed the Level 2 course prior to enrolling on this course.  The course will run on the following dates: 11 June 2024 24 June 2024 10 July 2024 15 July 2024 HSIB courses are aimed at NHS staff in health and social care settings in England, who are involved in safety investigations for learning. Courses run online and are free of charge to attend for NHS staff.
  7. Content Article
    This joint position statement from The Royal College of Physicians (RCP) and National Institute for Health and Care Research (NIHR) sets out a series of recommendations for making research part of everyday practice for all clinicians. Its recommendations are aimed at stakeholders across the health and care system, with the overall aim of embedding research in clinical practice: Trusts, health boards and integrated care systems (ICSs) Health Education England and NHS England and statutory education bodies and the departments of health in the other UK nations Regulators Funders
  8. News Article
    An “institutionalised” and “counterproductive” system of hiring and firing trust leaders was a contributory factor to care failings which caused the death of at least 45 babies an inquiry has concluded. The inquiry into maternity care at East Kent Hospitals University Foundation Trust, chaired by Bill Kirkup, discovered what it described as the latest ”major service failure” in NHS maternity care. It concluded that successive chairs and chief executives were “wrong” to believe the trust had provided adequate care for more than a decade and urged they be held accountable. But he added the churn of senior management had been “wholly counterproductive” for the trust. His report said: “We have found at chief executive, chair and other levels a pattern of hiring and firing, initiated by NHS England. The practice may never have been an explicit policy, but it has become institutionalised. In response to difficult problems, pressure is placed on a trust’s chair to replace the chief executive, and/or to stand down themself." Read full story Source: HSJ, 20 October 2022 (paywalled)
  9. News Article
    The deadline for the NHS to move to a new system for safety incident reporting has been delayed after widespread concerns the rollout could be a ‘disaster’. A memo from NHS England to local teams yesterday, seen by HSJ, says the deadline to transition to the new “learning from patient safety events” database has been pushed back by six months to September 2023. The creation of LFPSE is a key strand of NHSE’s safety strategy, along with the overhaul of how serious incidents are investigated. It aims to make it easier for staff across all healthcare settings to record safety events, as the service will be expanded to include primary care. It will replace the current national reporting and learning system, a central database created in 2003 to help identify trends and maximise learning from mistakes. The new system is part of a national strategy that pledges to save 1,000 extra lives and £100m in care costs each year from 2023-24. Multiple patient safety managers at local trusts had raised concerns to HSJ about the previous March deadline, with one patient safety lead saying it would have been a “disaster” if enforced. Helen Hughes, chief executive of charity Patient Safety Learning, said NHSE also needs to change its way of working, as well as the deadline extension. She said: “We believe that NHS England needs to seriously reconsider their approach to engaging with trust leaders and staff on this issue, so that improvements can be made to the new LFPSE service to ensure it has the best possible chance of success, and to enable patient safety improvement.” Read full story (paywalled) Source: HSJ, 20 October 2022
  10. News Article
    Patients in England are being put at risk because of the unacceptably poor service they receive from GPs, MPs say. The House of Commons' Health Committee blamed the failure to tackle doctor shortages, which had led to a decline in the GP-patient relationship. Seeing a GP should not be like booking an Uber with a driver you are unlikely to see again, the MPs said. The warning comes just weeks after ministers launched a drive to improve access to GP services. But the cross-party group of MPs said more needed to be done. Louise Ansari, from the patient group Healthwatch England, said, "The impacts of poor access can be huge, with people feeling abandoned and suffering in silence and not getting referred to hospitals for more specialised treatment." Read full story Source: BBC News, 20 October 2022
  11. Event
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    The concerns about the state and stability of the NHS were deeply entrenched before 2020 and then of course the pandemic hit. The additional pressures and longer waiting times for appointments and treatment have only grown following a time when the NHS staff have experienced stresses like they never have before. The situation has led to increased fears of privatisation and increasing staff shortages as so many seek work elsewhere. But where does this leave our national health service and what does the future hold for a life saving institution which is struggling to survive itself? Join the Independent’s latest panel discussion as part of our virtual event series where our health correspondent Rebecca Thomas will ask a panel of experts including Dr Alexis Paton, director at the Centre for Health and Society, Hannah Barham-Brown, a GP and also deputy leader of the Women’s Equality Party and Dr Suzanne Tyler, RCM's Executive Director, Trade Union, about how they think the NHS can be healed and how it’s future can be secured. Register for the event
  12. News Article
    An expert panel convened by the US Food and Drug Administration voted 14-1 on Wednesday to recommend withdrawing a preterm pregnancy treatment from the market, saying it does not work. During the sometimes contentious three days of hearings, the drugmaker Covis Pharma, backed by some clinicians and patient groups, had argued there is evidence to suggest the drug, called Makena, might work in a narrower population that includes Black women at high risk of giving birth too soon. But FDA experts and others said the data does not support such a view. In closing arguments, Peter Stein, director of the Office of New Drugs at the FDA’s Center for Drug Evaluation and Research, agreed on the urgent need for a drug to reduce the incidence of preterm birth — a leading cause of infant mortality in the United States. But he said the data indicates that Makena is not that drug. Stein said, “Hope is a reason to keep looking for options that are effective,” he said. “Hope is not a reason to take a drug that is not shown to be effective, or keep it on the market.” Read full story Source: The Washington Post, 19 October 2022
  13. Content Article
    This Health and Social Care Select Committee report examines the pressure currently facing general practice, which is leading to low morale, GPs leaving the profession and problems recruiting new GPs. In turn, patients are increasingly dissatisfied with the level of access they receive. The root cause of the situation is that there are not enough GPs to meet the ever-increasing demands on the service, coupled with patients presenting with increasing complexity due to an ageing population. The report outlines the Committee's assessment of the key issues, including the problems with reliance on locum doctors and lack of continuity of care, and outlines what the Government should do to equip general practice for the future.
  14. News Article
    The main corridor of an acute hospital has been closed to patients and staff and turned into a ‘makeshift ward’, in what sources describe as an ‘absolutely unprecedented’ situation. The move by Aintree Hospital comes after staff clashed with paramedics last week about whether ambulance patients could be brought into the crowded emergency department. One staff member, who wished to remain anonymous, said: “It’s exceptional for this to happen, but I can see it happening more over winter. It’s a rock and a hard place… either you wait in the ambulance if the queue is too long, or you wait in the main hospital corridor. Neither option is ideal.” Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said: “Across the country, the urgent and emergency care system is in unprecedented crisis. Emergency medicine teams and our paramedic colleagues are doing their very best to deliver effective care in exceptionally difficult circumstances. Circumstances like these require ICB leaders to engage, take control of the situation and accept their responsibility. This will both help to de-escalate the situation and ensure the right decision is made for the patients, the ED teams and ambulance crews." Read full story Source: HSJ, 19 October 2022 (paywalled)
  15. Content Article
    This opinion piece by GP educator and writer John Launer looks at the current delays and cancellations to routine appointments facing patients with long term conditions. He describes his personal experience of waiting three years with no face-to-face of phone appointment to review his condition, when this should happen every six months. John outlines the fact that routine outpatient care in some hospitals is unravelling, but with no monitoring of the situation and without publicity. He highlights the risks for patients who are not receiving the regular contact with healthcare professionals that they need, including medical complications, emergency admissions and even preventable deaths. There is particularly risk to patients who do not feel able to contact their consultant or specialist. When speaking to the hospital department about how the risks were being mitigated, John was concerned to discover that there were no screening procedures in place for clinicians to determine which patients were at highest risk; no prioritisation as going on and there was no system in place to monitor the consequences of this.
  16. Event
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    This webinar from The Yorkshire Quality and Safety Research Group explores a recent research study into how vulnerable patients are able to contribute to their safety. Over the last decade a wealth of studies have explored the way that patients are involved in patient safety internationally. Most begin from the premise that patients can and should take on the role of identifying and reporting safety concerns. Most give little attention, however, to the impact of the patient’s health status and vulnerability on their ability to participate in their safety. Drawing on qualitative interviews with 28 acute medical patients, this article aims to demonstrate how patients’ contributions to their safety in the acute medical context are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. Our analysis is underpinned by theories of vulnerability and risk. This enables us to provide a deeper understanding of the ways vulnerability shapes patients’ involvement in their safety. Acute medical patients engage in reassurance-seeking, relational and vigilance work to manage their vulnerability. Patients undertake reassurance seeking to obtain evidence that they can trust the organisation and the professionals who work in it and relational and vigilance work to manage the vulnerability associated with dependence on others and the unpredictability of their status as acute medical patients. We argue that patients are involved in the process of creating patient safety at the point of care. Foregrounding the theory of vulnerability and its relationship to risk offers new insights into the potentials and limits of patient involvement in patient safety in the acute care context. Liz Sutton is a Research Associate in the Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester. She has considerable expertise in qualitative research including: qualitative interviewing, focus group facilitation and ethnography. Her ethnographic projects have been conducted in different settings including hospital acute care and in care homes, where she has explored such issues as the quality and safety of care and how context affects antibiotic prescribing. Her PhD research explored how vulnerability affects patient involvement in patient safety. Her other interests include dementia care, healthcare quality improvement and health inequalities. Register for the webinar
  17. Content Article
    In this blog, Dr Amy Proffitt, Royal College of Physicians (RCP) patient involvement officer, explores how the patient voice is represented in patient safety. She highlights the importance of engaging patients from a diverse range of backgrounds and responding to research that highlights particular populations who are experiencing worse outcomes. Eddie Kinsella, chair of the RCP’s Patient and Carer Network, then goes on to share his thoughts on patient safety, highlighting the role of patient partners in bringing about culture change in the NHS, and as advocates for the wider community, especially those who are most disadvantaged.
  18. Content Article
    In this blog, Jen Flatman, medicines safety and governance pharmacist, discusses a resource to support people to continue to use their medicines safely once they leave hospital. The medicines safety checklist was designed by patients and carers, for patients and carers, helping bridge the transition between hospital and the next destination. The points on the checklist are designed to act as a prompt, ensuring individuals are aware of key information to continue to use their medicines safely. They also act as a reminder to the reader to ask questions if they are unsure about anything.
  19. Content Article
    Patients are increasingly feeding back about their healthcare experiences online and NHS Trusts are adopting different approaches to responding. This study in the journal Digital health aimed to explore the sociocultural contexts underpinning three organisations who adopted different approaches to responding to online patient feedback. The authors identified a range of barriers facing organisations who ignore or provide generic responses to patient feedback online and demonstrated the sociocultural context in which online interactions between staff and patients can be used to inform improvement. However, they highlight that this represented a slow and difficult organisational journey.
  20. Content Article
    In this blog, peer researchers Saffron, Bianca and Alysha describe their involvement in a study about violence and mental health funded by the UKRI Violence, Abuse and Mental Health Network. The study looked at how adolescents’ experiences of violence and neighbourhood disorder—such as vandalism and muggings—affects their mental health as they move into adulthood. As peer researchers, they helped analyse data and used their lived experience to interpret the findings and co-author an academic research paper. They highlight the value of involving people with relevant lived experience in research studies.
  21. Content Article
    This article by Carrie Murphy looks at the practice of inserting a 'husband stich' or 'daddy stitch', where midwives or obstetricians make an unnecessary extra stitch when repairing episiotomies or tearing from birth. The belief is that it will make the vaginal opening tighter and therefore increase pleasure for the woman's sexual partner. The author highlights that this is a real practice that has been carried out on women for many years, and describes the ongoing impact it can have on women affected, many of whom don't realise they have been given too many stitches. This misogynistic and unethical practice can cause additional pain for women during sex. The women featured in this article state that they did not consent to the practice, being vulnerable after childbirth and in many cases unaware of what a 'husband stitch' was. Angela Sanford reports only finding out that she had a 'husband stitch' five years after birth at a cervical screening appointment where the nurse expressed concern. Murphy expresses her concern that the practice may still be carried out without women's consent, leaving them feeling violated and in pain.
  22. Event
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    2022 marks the 10th anniversary of “Journalen” in Sweden. It was in 2012 that Region Uppsala first give citizens online access to their electronic health records (EHR) for the first time. Since then, a lot has happened in Sweden, and today people all over Sweden have direct online access to their EHR through the e-health service “Journalen” on 1177.se. Online access to EHRs is also highly relevant internationally, and we have also invited international researchers to Uppsala to share experiences of the implementation and effects of patients online access to records throughout the world. It will be a 2-day event with invited speakers from both the US and Europe. The conference will have a scientific focus and will also be open to the public. Conference programme Register for the conference
  23. Content Article
    This video by Joyce Harper, Professor of Reproductive Science at the Institute for Women's Health at University College London, highlights short-term and long-term menopause symptoms, outlines their causes and suggests ways that women can deal with them. Her key message is that everyone should understand these symptoms and anyone suffering should go to see their health professional—no one should have to put up with symptoms that affect their life.
  24. Content Article
    This simple poster highlights the main symptoms of the menopause including hot flushes. headaches, mood swings, palpitations and tiredness. It encourages women to recognise the symptoms and seek help from their GP.
  25. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Judy talks to us about the power of After Action Reviews (AARs) to promote learning and bring about lasting improvements in healthcare. She also discusses the opportunity that the new Patient Safety Incident Response Framework (PSIRF) offers to take a more people-focused approach to learning from patient safety incidents.
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