Jump to content
 View Profile  See their activity

  • Posts

    4,120

  • Joined

  • Last visited

Patient-Safety-Learning

PSL Moderators

 Content Type 

Everything posted by Patient-Safety-Learning

  1. Content Article
    This letter to the editor published in The Journal of Biomedical Research outlines the ways in which simulation will be used in medical education in the future. The author highlights that: simulation is likely to become much more closely linked to assessment in the future. our vision of what constitutes simulation will change radically in the future, with access to simulation becoming easier and wider. the future of simulation in medical education will follow the same path as the future of healthcare—more primary care, management of long term conditions and patient self-management.
  2. Content Article
    This article looks at the enormous growth in the use of clinical simulation that has happened over the last 20 years, examining why simulation is an effective tool in training healthcare professionals and how it can be applied to different healthcare topics and settings. The authors look at the history of simulation in medical training, theories related to simulation, the typology of simulation, the importance of simulation education during the Covid-19 pandemic and current trends and innovation in simulation education.
  3. Content Article
    Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity and its associated diseases. This pathway written by East Kent Hospitals University Foundation NHS Trust (EKHUFT) provides guidance for multidisciplinary teams to allow them to provide appropriate care for each bariatric patient according to their unique shape, size and body dynamics.
  4. Content Article
    In this blog, Jeremy Hunt MP, Founder of Patient Safety Watch, argues against introducing more targets for GPs. The new Health Secretary, Therese Coffey MP, plans to introduce a target to ensure that all patients see their GP within two weeks. The blog highlights two issues with this approach: Setting a new target won’t make it a reality Having too many targets result is a system that depersonalises patients, deprofessionalises frontline staff and means it is difficult for health services to prioritise It then proposes that the health system should learn from the UK education system's approach to regulatory oversight, which is aimed at driving up standards, rather than achieving grades.
  5. Content Article
    This qualitative study in BMC Medicine aimed to improve understanding of the reality of making and sustaining improvements in complex healthcare systems. It focused on understanding the implications of complexity theory, introducing a framework known as Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence). This approach is accompanied by a series of ‘simple rules’ that aim to make complexity navigable (whilst recognising that it will never be simple), providing actionable guidance to both practice and research. The authors concluded that the SHIFT-Evidence framework provides a tool to guide practice and research. The ‘simple rules’ have potential to provide a common platform for academics, practitioners, patients and policymakers to collaborate when intervening to achieve improvements in healthcare.
  6. Content Article
    This guidance from NHS England aims to support Integrated Care System (ICS) leaders as they develop their approach to quality management, providing clarity on how quality concerns and risks should be managed through systems. It provides an overarching approach to quality risk response and escalation, including guidance on routine, enhanced and intensive quality assurance and improvement activity.
  7. Content Article
    This mixed method case study in The BMJ aimed to evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. The authors found that creating individual summary care records (SCRs) was a complex, technically challenging and labour intensive process that occurred more slowly than planned. They concluded that complex interdependencies, tensions and high implementation workload should be expected when rolling out SCRs.
  8. Content Article
    This article tells the story of Stuart, who died as a result of medication errors while recovering from surgery at a private hospital in January 2013. Stuart had dystonia, an incurable condition that he managed by taking a careful balance of three medications. Following surgery to remove his larynx, the private neurological centre where he was staying ran out of clonazepam, a medication Stuart needed to control his dystonia. Stuart became very unwell, but instead of seeking advice from a doctor, the nurses treated his symptoms as a UTI. on 26 December he was found unresponsive in bed and rushed to ICU at a local hospital. but died a few weeks later from sever kidney and muscle damage. An inquest into Stuart's death found that the lack of clonazepam had caused an increase in Stuart’s muscle spasms, eventually leading to severe muscle and kidney damage. He then developed bronchopneumonia, which was the final factor in his death.
  9. Content Article
    This article in The BMJ by Tessa Richards, Senior Editor for patient partnership and Henry Scowcroft, Patient Editor, looks at the way in which people with expertise rooted in lived experience were excluded from policy decisions during the early stages of the Covid-19 pandemic. They argue that engaging patients, families, and frontline health and social care professionals would have prevented some of the excess morbidity and mortality that came from policy responses to the pandemic, particularly among elderly people, those with long term conditions and those in lower socioeconomic groups.
  10. Content Article
    This blog by Victoria Vallance, Director of Secondary and Specialist Care at the Care Quality Commission (CQC) discusses how engagement with frontline NHS maternity staff has informed the CQC's inspection approach, and is being used to support improvements in care. She highlights that recent reviews and reports highlight recurring concerns that affect maternity safety: the quality of staff training, poor working relationships between obstetric and midwifery teams, and a lack of robust risk assessment. She then goes on to talk about an event held by the CQC that brought together staff from NHS maternity services across England to discuss the challenges that they face and seek their views on what needs to change to overcome them.
  11. Content Article
    Healthcare Inspectorate Wales (HIW) is the independent inspectorate of the NHS and regulator of independent healthcare in Wales. This annual report highlights key findings from HIW's regulation, inspection and review of healthcare services in Wales. It demonstrates how HIW carried out its functions and outlines the number of inspections and quality checks it undertook during 2021-22.
  12. Content Article
    In this blog, Soojin Jun, Cofounder of Patients for Patient Safety US, argues that it makes sense for healthcare organisations to be at the forefront of conservation efforts, as they exist to promote people's wellbeing. She points to a 2020 study that demonstrated how the global healthcare supply chain contributes to environmental damage, counteracting what healthcare exists to promote. Going forward, people will want to know how much waste healthcare systems generate, and how efficiently they use resources, and the article looks at how organisations and patients can be proactive in promoting sustainability.
  13. Content Article
    The Resilient Surgeon is a podcast by The Society of Thoracic Surgeons in the US. In this episode, Dr Michael Maddaus interviews Dr Amy Edmondson, a scholar of leadership, teamwork and organisational learning. Dr Edmondson defines psychological safety as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. It makes a team a safe place for interpersonal risk-taking. In this podcast, she explains how psychological safety is the key to unlocking high quality conversations that result in improved team outcomes.
  14. Content Article
    This is the story of the avoidable death of Glyn Davies, as told by his sister Anne. Glyn had an obstruction of the small bowel caused by adhesions from previous surgery and died from aspiration pneumonia after two weeks in intensive care at The Royal Lancaster Infirmary. Glyn's family felt that the investigation following his death had not been dealt with well, with evidence being withheld from the Coroner. This included information in Glyn's medical notes that indicated he had caught the hard-to-treat bacterial infection Stenotrophomonas Maltophilia, from either the ventilator or tubes whilst in intensive care. The family then took legal action against The University Hospitals of Morecambe Bay NHS Foundation Trust and the case was settled out of court in March 2020.
  15. Content Article
    This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation.
  16. Event
    until
    Health First Europe and the members of the European Patient Group on Antimicrobial Resistance are glad to invite you to our Parliament Roundtable Debate entitled “Engaging with patients and closing knowledge gaps to fight antimicrobial resistance: the role in infection prevention and antimicrobial stewardship.” The event will take place in a hybrid format on Thursday 27 October, 10:00-11:30 CEST (9:00-10:30 BST), kindly hosted by MEP Ondřej Knotek (Renew Europe, Czech Republic), and under the patronage of the Czech Presidency of the Council. Join us to learn more about how AMR affects patients across Europe and how everyone can take action to prevent the development of resistant bacteria. Please register as soon as possible to secure a spot in the European Parliament or to join the conference remotely! We hope you’re able to join us. Register for the event
  17. Content Article
    This guidance from the Irish Health Services Executive (HSE) aims to help healthcare staff improve venous thromboembolism (VTE) prevention in hospitals. Hospital-acquired blood clots, or VTE, are the most common preventable cause of in-hospital death. Assessing patients’ risk of VTE and bleeding and choosing the appropriate thromboprophylaxis such as medicines or compression stockings early in their hospital admission reduces their risk of developing a blood clot. 
  18. Content Article
    The Francis Inquiries in 2010 and 2013 highlighted nurse staffing as a patient safety factor contributing to the care failings identified at Mid Staffordshire NHS Trust. The reports and government response led to the development of national ‘safe staffing’ policy. This two-year study by the University of Southampton and Bangor University examined the impact of safe staffing policies nationally and explored variation in local responses. The authors concluded that: Policies provided leverage and raised the profile of nursing workforce issues at board level, contributing to a willingness to invest in increasing nursing numbers. However, a lack of assessment of the likely scale of investment (and human resources) required nationally to achieve ‘safe staffing’ led to financial considerations becoming a barrier to achieving the policy vision. External pressures, such as lack of workforce supply and reduced access to temporary staffing, have constrained Trusts’ abilities to fully implement policies aimed at ensuring safe staffing on acute wards.
  19. Content Article
    Richard von Abendorff's elderly mother died an avoidable, painful death in hospital due to being inappropriately prescribed Nalaxone. In this article, Richard outlines the steps he has taken to try and ensure lessons are learned from his mother's experience. Eventually, in 2014 NHS England published a patient safety alert relating to inappropriate doses of naloxone in patients on long-term opioid treatment. A coroner’s palliative expert report identified issues contributing to Richard's mother's poor end of life care, noting that purely advisory palliative services in an acute hospital setting are ‘not fit for purpose’ to meet the needs of more complex dying patients. Richard expresses his frustration at an ongoing lack of interest and action related to substandard end of life care.
  20. Content Article
    This study in the SA Journal of Human Resource Management aimed to develop a conceptual framework that identifies the critical success factors that affect the implementation of team coaching in organisations. The results indicate that to integrate successful team coaching into any organisation, effective analysis of an organisational context is required. This includes leadership stakeholders, team effectiveness, competency of a coach and employee engagement. The study also identified constraints that may prevent successful implementation of team coaching.
  21. Content Article
    This article tells to story of the events that led to the death of a patient named George from an avoidable medication error in December 2012. George slipped and fell in his garden in October 2012, badly hitting his head. He was taken to hospital where he was diagnosed with a subdural haematoma–when blood collects between the skull and the surface of the brain. After successful life-saving surgery at King’s College Hospital, George was moved to a ward to recover. George suffered from osteoarthritis and had been taking the anti-inflammatory medication naproxen to manage this for some time, accompanied by omeprazole to protect the stomach lining. As he recovered in hospital, he was prescribed his normal naproxen, but was not given the omeprazole to go with it. By the time the hospital stopped the medication, approximately one month later, George had developed severe bleeding and ulcers in his stomach. George’s condition worsened and he died on 4th December 2012.
  22. Content Article
    This dashboard presents the results of a patient safety survey conducted by the European Alliance for Access to Safe Medicines (EAASM) and European Collaborative Action on Medication Errors and Traceability (ECAMET). The dashboard shows variations in different hospital-reported measures of patient safety across thirteen European countries. The questions in the survey focus on accreditation, training, electronic health records and recording, tracking and publishing of medication error data.
  23. Content Article
    The US President’s Council of Advisors on Science and Technology (PCAST) consists of individuals from sectors outside of the US Federal Government who advise the President on policy matters where the understanding of science, technology and innovation is key. This is the recording of a live-streamed meeting of PCAST, where invited speakers presented opportunities to advance scientific innovation, including improving patient safety.
  24. Content Article
    Sepsis is the leading killer of infants and children worldwide and kills more than 250,000 Americans each year. On 1 April 2012, 12-year-old Rory Staunton died from sepsis after grazing his arm while playing basketball at school. This account by Rory's parents Orlaith and Ciaran Staunton describes the multiple errors by the school and different healthcare professionals that led to their son's death - from the wound not being cleaned by the school, to Rory's paediatrician missing key sepsis warning signs and the ER's failure to read Rory's blood test results that showed he was seriously ill. The article also includes a link to a short video where Orlaith and Ciaran describe what happened to Rory.
  25. Content Article
    Simulation is a training technique that replaces real experiences with guided experiences. These experiences replicate substantial aspects of the real world in a fully interactive manner. This article looks at the future of simulation in healthcare, categorising applications of simulation into 11 dimensions: The purpose and aims of the simulation activity The unit of participation in the simulation The experience level of simulation participants The healthcare domain in which the simulation is applied The healthcare disciplines of personnel participation in the simulation The type of knowledge, skill, attitudes of behaviour addressed in simulation The age of the patient being simulated The technology applicable or required for simulations The site of simulation participation The extent of direct participation in simulation The feedback method accompanying simulation
×
×
  • Create New...