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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The Covid-19 pandemic triggered a very sudden and widespread shift to remote consulting in general practice. Many patients and healthcare professionals have welcomed the convenience, quality and safety of remote consulting, but there are inherent tensions in choosing between remote and face-to-face care when capacity is limited. This report by the Nuffield Trust explores the opportunities, challenges and risks associated with the shift towards remote consultations, and the practical and policy implications of recent learning.
  2. Content Article
    In this article for The Cut magazine, author Rae Nudson looks at the sometimes severe pain that women face when having gynaecology examinations and procedures, and how this has been accepted and normalised by healthcare professionals. She highlights a lack of understanding about the complex nature of pain, which leads to an expectation that women just need to 'put up' with pain during cervical screening, IUD fitting, hysteroscopy and other procedures. Speaking to women who have had painful and traumatising experiences, she discusses the long-term impact that these negative experiences can have, including putting women off attending potentially life-saving screening appointments. She also outlines the particular problems faced by Black women during gynaecological procedures, caused by incorrect assumptions that they feel pain less and are more able to tolerate it. These assumptions are rooted in historical oppression and racism, but research demonstrates that they still have a bearing on how healthcare professionals treat women from Black and other minority backgrounds.
  3. Event
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    “Getting the human factors right minimises error, and maximises performance. It makes it easier to do the right thing, and harder to do the wrong thing.” - Health Education England. Human Factors Training (HFT) has been endorsed by the NHS and embedded in Mandatory training in many hospitals throughout the UK. It aims to reduce errors and harm to patients by educating NHS staff on the factors that create unsafe environments . During the recent NOA webinar discussing Never Events and Serious Incidents, a poll of participants showed that 40% had none or little knowledge of Human Factors. For this webinar we welcome Fran Ives, Human Factors Specialist and the Human Factors team at the Robert Jones and Agnes Hunt Hospital (RJAH) where HFT has been established for all staff to discuss the principles and experience of the Trust. The RJAH team will give a brief overview of human factors and ergonomics, its relevance and role in improving patient safety, how it has been embedded at RJAH and the impact it has had. Fran will highlight her experience of the application of Human Factors both within a large NHS Trust and an Academic Health Science Network, including the successes and challenges of setting up and developing a service and what difference such a service can make. Speakers include: Fran Ives, Chartered Human Factors Specialist, West Midlands Academic Health Science Network Dr Sophie Shapter, Consultant Anaesthetist & Lead for Human Factors and a Patient Safety Specialist, The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Mr Simon Lewthwaite, Consultant Orthopaedic Surgeon, The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Register for the webinar
  4. Content Article
    In this blog, Melanie Ottewill, National Investigator and Senior Investigation Science Educator at HSIB, shares some key messages from a recent seminar delivered by Tracey Herlihey, Head of Patient Safety Incident Response Policy and Lauren Mosley, Head of Patient Safety Implementation at NHS England. The seminar looked at the new Patient Safety Incident Response Framework (PSIRF) published in August 2022. PSIRF fundamentally shifts how the NHS responds to patient safety incidents for learning and improvement, promoting a proportionate approach to responding to patient safety incidents. It focuses on ensuring resources allocated to investigating and learning are balanced with those needed to deliver improvement. Melanie describes the cultural shift needed to implement PSIRF so it really makes a difference, and talks about the important of compassionate engagement.
  5. 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. Sarah and Jaydee are working on an innovative project at NHS Dorset Integrated Care Board (ICB) to ensure general practice is a central part of improving patient safety across services. They talk about the value and challenges of collaborative working, how they are tailoring their offer to fit the needs of local GP practices, and making patient safety a core part of training for all healthcare professionals.
  6. Content Article
    This poster outlines a simple point of care risk assessment that can be carried out by healthcare professionals before each interaction with a patient.
  7. Content Article
    This German study in the Journal of Patient Safety aimed to analyse the strength of safety measures described in incident reports in outpatient care. 184 medical practices were invited to submit anonymous incident reports to the project team three times in 17 months. The authors coded the incident reports and safety measures, classifying them as as “strong” (likely to be effective and sustainable), “intermediate” (possibly effective and sustainable) or “weak” (less likely to be effective and sustainable). The study found that the proportion of weak measures was high, which indicates that practices need more support in identifying strong patient safety measures.
  8. Content Article
    The National Quality Board (NQB) has refreshed its Shared Commitment to Quality to support those working in health and care systems. The publication provides a nationally-agreed definition of quality and a vision for how quality can be effectively delivered through ICSs. The refresh has been developed in collaboration with systems and people with lived experience and has a stronger focus on population health and health inequalities. The NQB was set up in 2009 to promote the importance of quality across health and care on behalf of NHS England and Improvement, NHS Digital, the Care Quality Commission, the Office of Health Promotion and Disparities, the National Institute for Health and Care Excellence, Health Education England, the Department of Health and Social Care and Healthwatch England.
  9. Content Article
    The Voluntary Organisations Disability Group (VODG) has launched a commission on Covid-19, Disablism and Systemic Racism to explore how the worst impacts of Covid have fallen on Disabled people, particularly those from Black, Asian and minoritised ethnic groups. The Commission is examining the extent to systemic neglect of social care over many years has caused negative outcomes that have been worsened by confused approaches by the Government during the pandemic. This includes poor implementation of policy and conflicting guidance. The work will gather evidence, scrutinise the Department of Health and Social Care’s policies and responses to the pandemic, including ways in which systemic racism may have further worsened outcomes for disabled people of colour, and build solutions and support for transformative and sustainable change in social care, based on justice and human rights. The Commission is calling on Disabled people and people with long-term health conditions from Black, Asian and minoritised ethnic groups to share their views and experiences of the Covid-19 pandemic as part of its 'Call for Views and Experiences'. They are also keen to hear from families, carers and people who work in social care.
  10. Content Article
    The burden of multiple conditions is unevenly distributed across the population, and evidence shows that people living in the most deprived areas are developing conditions on average 10-15 years earlier than those living in the least. This report from The Taskforce on Multiple Conditions established by The Richmond Group of Charities, outlines a series of key questions and opportunities for change, designed to support and shape the plans and actions of everyone responsible for the delivery of health and care services. The research for the report focused on four areas of England containing communities on low incomes, people from minority ethnic groups and people living in both urban and rural environments. A rapid evidence review into the literature on health inequalities and multiple long-term conditions was also carried out to inform the report.
  11. Content Article
    This article tells the story of Mr K, who died following a misdiagnosis of tension pneumothorax. Mr K was 81 and had a history of chronic obstructive pulmonary disease (COPD) and bullous emphysema. He had been diagnosed with a bulla, a large air pocket, in his right lung. The medical team treating Mr K after his admission to hospital with shortness of breath failed to review his previous x-ray and medical notes, and did not involve the respiratory team in his treatment. This led to his misdiagnosis, after which he was fitted with an unnecessary chest drain. The drain collapsed the bulla and ruptured a blood vessel leading to progressive bleeding. The medical team did not recognise their error or Mr K's bleeding and he died two days following the insertion of the drain. At his inquest, the Coroner found that the unnecessary chest drain led to Mr K's death, and that there was a missed opportunity to reassess the situation at a review the next day. They ordered that a prevention of future death report be made as the evidence heard at the inquest revealed a number of matters that gave rise to concern.
  12. Content Article
    This article tells the story of Rod, who underwent a dorsal column stimulator implant for chronic pain in 2007. However, following surgery Rod realised something was wrong, and X-rays confirmed that the surgeon had applied the electrodes to the wrong side of his body, resulting in the need for several follow-up surgeries. This left Rod's chronic pain untreated, as well as giving Rod scarring, additional pain and mental stress. He has been unable to gain any financial compensation or admission of liability from the NHS Trust that made the error.
  13. Content Article
    Acute prescribing forms a large part of the daily workload for GP practices. Quality improvement (QI) methodology can be used to help improve prescribing processes and ensure that prescribing work is managed by the right member of your team, safely and effectively. This toolkit is designed to help primary care multidisciplinary teams, including pharmacotherapy services, safely improve their acute prescribing processes in line with the Essentials of Safe Care. An acute prescription is defined as any prescription without a serial or repeat mandate.
  14. Content Article
    This cross-sectional survey in the BMJ Open aimed to examine the sociodemographic characteristics, activities, motivations, experiences, skills and challenges of patient partners working across multiple health system settings in Canada. This survey was the first of its kind to examine the characteristics, experiences and dynamics of a large sample of self-identified patient partners at a population level. Although patient partners who took part were from similar sociodemographic background, the scope, intensity and longevity of their roles varied. Respondents predominantly identified as female (76.6%), white (84%) and university educated (70.2%). Primary motivations for becoming a patient partner were the desire to improve the health system based on either a negative (36.2%) or positive (23.3%) experience. Respondents reported feeling enthusiastic (83.6%), valued (76.9%) and needed (63.3%) always or most of the time. Just under half felt they had always or often been adequately compensated in their role.
  15. Content Article
    This information sheet produced by South Australia Health's Safety and Quality Unit describes how patients and staff can work together to make sure that if clinical deterioration occurs, it will be acted upon in a timely and effective manner. The information also applies to carers, family members, friends or the patient’s appointed responsible person. It includes information relating to deterioration during an emergency department visit or hospital stay, and at and after discharge.
  16. Content Article
    Nursing education has long utilised simulation in different forms to teach the principles and skills of nursing care, from anatomical models to computer-based learning. This chapter from Patient Safety and Quality: An Evidence-Based Handbook for Nurses looks at simulation training as a strategy to prevent healthcare errors. It explores the value of human patient simulation in nursing education programs.
  17. Content Article
    The Department of health funded an initiative in 2013 to pioneer new approaches that would create a more integrated form of care. In order to receive funding, local Clinical Commissioning Groups were required to engage a range of stakeholders in a practical approach that generated the development of an integrated model of care. To fulfil this requirement, two sequential simulation (SqS) workshops were designed using real patient scenarios from the locality, covering the areas of general practice, community health and adult social care. They were attended by a diverse group of patients and frontline staff. In pre- and post-workshop questionnaires, attendees strongly agreed that they had had an opportunity to contribute to all discussions and raise questions, concerns and ideas (100%). Knowledge of current and new models of care was vastly improved and the opportunity to share information and to network was valued. The SqS approach seen as breaking professional barriers by 100% of attendees.
  18. Content Article
    M was a young boy who had severe asthma, resulting in regular trips to A&E. His condition was eventually well controlled with a Seretide inhaler. When M's family moved house and changed their GP, they requested a new prescription of Seretide, but when they got to the pharmacy were given the wrong type of inhaler used to treat a different form of asthma. The GP had unwittingly chosen the wrong medication from a drop-down menu. M and his family were unaware that he was taking the wrong medication, and after a few days, M became breathless and his family decided to take him to hospital. Sadly, he died on the journey to A&E. At the inquest, the Coroner found that there two main issues that contributed to M’s death: the unintentional prescription of Serevent the failure to arrange and organise follow up contributed to M’s death.
  19. Content Article
    These standards for the clinical care of adults with sickle cell disease were produced by the Sickle Cell Society in collaboration with a broad multi-disciplinary group of healthcare providers, patients and support groups.
  20. Content Article
    Compassionate leaders place quality of care at the heart of what they do, and respect and empower people drawing on and delivering care to achieve this together. This article sets out NHS England's vision for developing compassionate, inclusive leadership, highlighting that it results in better outcomes for everyone. It sets out the following four priorities: The NHS Leadership Academy will soon be publishing new NHS Leadership Competency Frameworks for system leaders. We support these frameworks and ask each of our professional bodies, colleges and employers to review their own systems to ensure that our leaders have the skills to lead compassionately today, with curiosity to transform our services for tomorrow. We commit to supporting compassionate, inclusive leadership and doing what we can to create the conditions for it, including addressing issues that stand in the way such as bureaucracy and misaligned policy. This leadership is crucial to developing and maintaining an open and transparent culture committed to learning and continuous improvement, that is responsive and accountable to the public. We will go further to open up the recruitment pool for future leaders and will support the recruitment and development of a diverse talent pipeline with the right skills, behaviours and values to be our leaders of today and tomorrow. We will support those leading ICSs to develop a new kind of system leadership, which inspires collaboration, diversity of thought and experience, and always puts the well-being of people drawing on and delivering services first. ICS implementation guidance on effective clinical and care professional leadership can now be found here. We will lead by example and ensure that our people have the tools to support compassionate behaviours. This will require a continuous approach to lifetime learning and a growth mindset, based on an agile and evolving way of seeing the world.
  21. Content Article
    This video summarises the story of Heather, who has cauda equina syndrome and suffered permanent damage as a result of negligent hospital treatment.
  22. Content Article
    When leaving hospital with medicines, there can be a lot of information to take in. This checklist designed by the Royal College of Physicians (RCP) Quality Improvement and Patient Safety (QIPS) is designed to help patients and their carers use medications safely when they leave hospital. It includes: Questions to consider before you leave hospital Questions to consider when you’ve left hospital Further useful resources Medicines safety and governance pharmacist Jen Flatman has written a blog about how the checklist was developed.
  23. Content Article
    This practice pointer in The BMJ provides an update on treating Long Covid in primary care and outlines how healthcare professionals might respond to questions that patients ask about the condition. The article provides information on: Definition of Long Covid Epidemiology Symptoms and case definition Questions patients ask Further resources for patients and healthcare professionals
  24. Content Article
    At the start of the Covid-19 pandemic, demand on the NHS 111 system exceeded capacity and only around half of calls were answered during that time. This investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the delivery of NHS 111 and other telephone triage services during a national healthcare emergency. HSIB first identified a potential safety risk associated with NHS 111’s response to callers with Covid-19-related symptoms when concerns were raised through HSIB’s Citizens’ Partnership. The national investigation aimed to understand: the set-up, design and delivery of the Covid-19 telephone triage service accessed by the public by dialling 111 in response to the pandemic. the context and contributory factors influencing the pathway for patients calling NHS 111 with Covid-19-related symptoms. The investigation used four real patient safety incidents involving patients and their families who dialled NHS 111 for advice during the Covid-19 pandemic. All four patients in these reference events—Vincenzo, Ali, Patrick and Dr C—died of Covid-19 having been advised by NHS 111 to stay at home.
  25. Content Article
    Sonia Sparkles is a senior manager in healthcare who is using her artistic skills to improve the way healthcare services communicate with patients. Her goal is to empower patients to feel at ease in healthcare settings and able to fully engage in their care. In this blog, Sonia describes how her own experience of being in hospital helped her see healthcare from a patient's perspective. While an inpatient, she felt disempowered, frightened and unable to ask the questions she wanted to. Having reviewed some NHS patient literature, Sonia realised that there was a need to find a way to communicate clearly with patients and invite them to share their concerns with healthcare staff. She produced a series of 23 posters as a starting point to get people thinking about how to communicate with patients in a simple, visual and empowering way.
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