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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    With 1.4 million people providing 50 or more carer hours a week for a partner, friend or family member, carers make a significant contribution to society and the NHS. NHS England has developed 37 commitments to carers spread across eight key priorities, that have been developed in partnership with carers, patients, partner organisations and care professionals. Some of the areas covered include: raising the profile of carers education and training person-centred coordinated care primary care This webpage contains information on: Supporting carers in general practice: a framework of quality markers How to identify and support unpaid carers Supporting commissioners End of year progress summary
  2. Content Article
    Policymakers are increasingly emphasising the role of health services in addressing social and economic factors that shape health, but guidance on how this should be done in practice is limited. This long read from The Health Foundation outlines a framework to understand potential approaches for NHS organisations to address social factors that shape health, focusing on local and regional action. It describes four categories of potential approaches, from more narrow interventions focused on improving care for individual patients, to broader partnerships to improve health of populations.
  3. Content Article
    This article tells the story of two-year-old Chloe, who died after hospital staff failed to recognise that she had meningitis, sending her home after her parents first took her to A&E. The NHS Trust carried out an internal investigation which identified many areas where care should have been better and set out a range of recommendations for improving care of children in A&E in the future. The Trust only apologised to the family after an out-of-court settlement was made.
  4. Content Article
    Realistic Medicine is Scotland's approach to a sustainable health and social care system. The Realistic Medicine Podcast shares the stories, experiences and projects of teams and communities across Scotland. In this episode, Dr Graham Kramer, National Clinical Lead for Self Management and Health Literacy, talks about health literacy and the importance of people being able to understand and engage in their own health and healthcare.
  5. Content Article
    A broken hip or ‘hip fracture’ is a serious injury, which each year in the UK leads to around 75,000 people needing hospital admission, surgery and anaesthesia, followed by weeks of rehabilitation in hospital and the community. The National Hip Fracture Database (NHFD) is an online platform that uses real-time data to drive Quality Improvement (QI) across all 163 hospitals that look after patients with hip fractures in England and Wales. This report highlights key research carried out using data from the NHFD in 2021, and makes a number of recommendations to improve treatment and outcomes for patients with hip fractures.
  6. Content Article
    In this blog, Saffron Cordery, Interim Chief Executive at NHS Providers, examines progress on the Government's manifesto pledge to build 40 new hospitals in England by 2030. Known as the New Hospital Programme (NHP), many of these projects are facing serious delays, with seven of the 40 not yet having a completion date. In a recent survey by NHS Providers, nearly two in three leaders said delays to the programme affected their ability to deliver safe and effective patient care, with all those facing delays reporting cost implications. Saffron highlights the opportunity the NHP presents to boost healthcare and renew services, and argues that the impact on communities will be huge if the new hospital plans are scrapped.
  7. Content Article
    During the Covid-19 pandemic there was a large-scale shift to remote consulting in UK general practice. In 2021, we saw a partial return to in-person consultations, which occurred in the context of extreme workload pressures due to backlogs, staff shortages and task shifting. This study in the British Journal of General Practice looked at media depictions of remote consultations in UK general practice at a time when general practice was under stress. The authors did a thematic analysis of national newspaper articles about remote GP consultations during two time periods: 13–26 May 2021, following an NHS England letter, and 14–27 October 2021, following a government-backed directive, both stipulating a return to in-person consulting. They found that newspaper coverage of remote consulting was strikingly negative and conclude that remote consultations have become associated in the media with poor practice. They recommend proactive dialogue between practitioners and the media to help minimise polarisation and improve perceptions around general practice.
  8. Content Article
    In this blog, Ted Baker, Former Chief Inspector of Hospitals at the Care Quality Commission, suggests that a false view that health services are intrinsically safe leads to defensive responses to safety concerns and perpetuates a culture of blame. He argues that the mismatch between safety as described and the reality of safety in practice prevents healthcare professionals being able to speak up about safety concerns. By taking an alternative approach that accepts the risk inherent in healthcare and the fallibility of individuals, he believes we can build organisations and systems that really learn from safety events. In order to do this, we need staff to feel able and supported to speak up, something that can be achieved through widespread understanding of safety society and building a supportive culture. Ted argues that this open culture is still lacking within many services.
  9. Content Article
    The last 10 years have seen substantial growth in medical devices that can help people with diabetes to manage their condition, including the development of automated insulin delivery (AID) systems. Regulatory approval has been granted for the first AID systems, and a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach. This consensus report from the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association offers a review of the current landscape of AID systems and recommends targeted actions.
  10. Event
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    It is essential that NHS teams are encouraged to educate the workforce about the digital services and products available across the vital area of wound care. Digital Health enables a speedier application, results in improved patient safety, and alleviates staff pressures. The foundational core of these emerging innovations is the essential need for the NHS workforce to understand how “Digital Transformation” works. Especially regarding wound care, as it is such an easily adopted and accessible route. This webinar featuring senior stakeholders across NHS England/Academic Health Science Network and industry will suggest a straightforward solution for the NHS to apply in combatting the wound care crisis, and how incredibly assistive and helpful it is. Register for this webinar
  11. Content Article
    In this position statement, the National Quality Board (NQB) outlines: Key requirements for quality oversight in Integrated Care Systems (ICSs) The role of System Quality Groups (formally Quality Surveillance Groups) NQB work to support quality oversight in ICSs
  12. Event
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    On 12 October, 11:00-12:00 CET, the ETUI is hosting a webinar on cancer risks in healthcare workers: identification of Hazardous Medicinal Products (HMPs). In the healthcare sector, 12.7 million workers across the EU are potentially exposed to Hazardous Medicinal Products (HMPs). While these drugs are vital in the treatment of different diseases (for example, cancers and psoriasis), they can also pose health risks to those exposed to them at work such as nurses, pharmacists and cleaners. The ETUI has identified 121 HMPs commonly used in the healthcare sector which can cause cancer or reproductive disorders in professionals exposed to them on a daily basis. Download the report here As the Carcinogens, Mutagens & Reprotoxic Substances Directive (CMRD – Dir (EU) 2004/37/EC) has been recently revised to specifically cover HMPs, the ETUI list of HMPs is timely to raise awareness about these risks in the healthcare sector and help employers use the European guidelines on the safe management of HMPs to be published soon by the European Commission. Programme Welcome and introduction Claes-Mikael Ståhl, Deputy general secretary, ETUC (tbc) The ETUI list of Hazardous Medicinal Products (HMPs) Ian Lindsley, Secretary of the European Biosafety Network Q&A with the audience moderated by Marian Schaapman, Head of the Working conditions, health and safety unit at the ETUI Conclusions - Tony Musu, senior researcher in the health and safety and working conditions of the ETUI Register for the webinar
  13. Content Article
    The Office for National Statistics reports that 98,000 children are now living with the symptoms of Long Covid in the UK. To support these children and young people at school and college, Long Covid Kids has collaborated with education resource website Twinkl to produce a series of resources for teachers and teaching staff about Long Covid. Although the resources are free to download, you will need to sign up for a Twinkl account to access them.
  14. Content Article
    Reliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
  15. Content Article
    This document outlines how Health Education England (HEE) hopes to expand the role of simulation and immersive learning technologies in the education and training of the NHS workforce. Simulation is defined as ‘a technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully safe, instructive and interactive fashion’. This document considers how existing techniques and technologies can benefit wider policy and strategy goals in health and care, outlining HEE's intention to: promote and strengthen the dialogue between different system and stakeholder organisations, networks, and communities to enable and evaluate opportunities for sharing intelligence and innovation provide a platform for collaboration on common themes of work generate evidence of impact that will help support the transformation in health and care that is required for the future needs of patients and society.
  16. Content Article
    In this blog for The House, Jeremy Hunt MP outlines how tackling long-term challenges in the health system will improve staff morale. While celebrating some short-term measures announced by the new Health Secretary Thérèse Coffey, he argues that longer term reforms are needed to "break the cycle of long waits, burned-out staff and declining standards." The key priority he outlines is workforce reform, including workforce projections and investment in training new healthcare workers for the future. He suggests that this will also encourage NHS staff to remain in their roles by restoring trust and confidence.
  17. Content Article
    In England, around 10 million adults and 12,000 children have a musculoskeletal (MSK) condition. Ethnic minority groups, people from lower income households and those living in areas of high deprivation are most affected. In this guest blog for the Arthritis and Musculoskeletal Alliance (ARMA), Bola Owolabi, Director of the National Healthcare Inequalities Improvement Programme at NHS England, highlights the role that MSK health inequalities play in people's lives. She looks at the link between socio-economic disadvantage and poor health outcomes, and discusses the wider implications of disability due to MSK conditions. She describes work being done by the NHS, and highlights ARMA's work to narrow MSK health inequalities through listening to the experiences of underserved communities and working in partnership to improve care.
  18. Content Article
    Mr B was 71 years' old and was undergoing treatment for cancer of the oesophagus. During surgery, a nasogastric tube that had been inserted became dislodged and was put back into place by medical staff, despite guidelines against this. The family realised that something had gone wrong in the operation and Mr B became very seriously ill, dying five months later. When the family asked the hospital for an investigation, they revealed that a hole had been made in Mr B’s stomach when the nasogastric tube was replaced. There was no assurance given that steps would be taken to prevent similar errors in the future, and no apology from the hospital. The family sought legal advice and came to an out of court settlement with the hospital.
  19. Event
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    To address health disparities, we need to focus on improving health literacy, digital literacy and digital access. In this 30-minute live webinar and Q&A from Health Education England, you will find out about our newly available maps and online tool using, place-based geodata to identify levels of health literacy and digital access in your area. The session will also introduce easy read resources for shared decision making, co-produced with experts by experience, and how to use these are part of a series of steps to address local health disparities. Register for the webinar
  20. Content Article
    This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control.
  21. Content Article
    This article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive.
  22. Content Article
    This longitudinal study in BMJ Quality & Safety aimed to examine the impact of nursing team size and composition on inpatient hospital mortality. The authors found that registered nurse staffing and seniority levels were associated with patient mortality. The lack of association for healthcare support workers and agency nurses indicates they are not effective substitutes for registered nurses who regularly work on the ward.
  23. Content Article
    Community Diagnostic Centres (CDCs) can relieve pressure on NHS acute services and bring diagnostic services closer to patients. This resource by the Chartered Institute of Ergonomics & Human Factors (CIEHF) explores ten principles for including systems thinking in the design of the diagnostic workforce and CDC services.
  24. Content Article
    Many nurses also act as family caregivers, and this study in the journal Nursing Outlook aimed to examine the impact of family caregiving on nurses, their colleagues and the organisations they work for. Nurse caregivers and healthcare organisation leaders completed two surveys about views on family caregiving. The authors found that healthcare leaders perceived family caregiving to have a larger impact on the nurses’ health and work performance than nurses themselves. Family caregiving was also identified as a potential contributor to burnout, and the authors highlight that lack of workplace support for family caregiving may influence nurses decisions about leaving or reducing their role.
  25. Content Article
    This article tells the story of Baby E, who died two hours after delivery following issues with the management of her labour. The maternity unit was short-staffed on the night of Baby E's birth and there were delays in getting her mother to theatre for a caesarean section. Baby E's parents felt that the hospital withheld information from them, failing to inform them of internal investigations that had taken place following Baby E's death. At the inquest, the coroner concluded that errors had been made, including the fact that Baby E's low heart rate had been missed. She also criticised the decision-making process in the management of labour, but concluded that she was unable to say whether this had made a difference to whether or not Baby E lived.
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