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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    The National Institute for Health and Care Excellence (NICE) is developing an update to the guideline on assessment and prevention of falls in older people and people 50 and over at higher risk. It has published the final scope for the update alongside consultation comments and responses, an equality impact assessment and the stakeholder list. The final guidance is expected to be published on 13 June 2024.
  2. Content Article
    Polypharmacy refers to the prescription of many medicines to one patient. As more people live longer with multiple long-term conditions, the number of medicines they take often increases. This can have a significant burden on the person managing and trying to adhere to multiple medicines regimes, and can also be harmful. The Academic Health Science Networks (AHSN) Network's Polypharmacy Programme aims to support healthcare professionals to identify patients at potential risk from polypharmacy, and to support better conversations about medicines. Based on the recommendations of the National Overprescribing Review (NOR) published in September 2021, the programme aims to achieve the following outcomes: A national network of Polypharmacy Communities of Practice, all working to address the system-wide challenges of problematic polypharmacy in their geographies. Routine use of the NHSBSA Polypharmacy Prescribing Comparators to identify and prioritise patients for a shared decision-making Structured Medication Review. Increased confidence amongst the primary care prescribing workforce to safely stop medicines identified to be inappropriate or unnecessary. A change in patient expectations – to anticipate having a shared decision-making conversation about their medicines regularly, especially as they get older. A contribution to the evidence base around how to help patients to feel more empowered to open up about their medicines issues. A contribution to the evidence base around how to tackle problematic polypharmacy.
  3. Content Article
    In this article for The Guardian, journalist Sirin Kale speaks to Janet Williams about the impact the epilepsy drug sodium valproate has had on her family. Janet took the medication to treat her epilepsy throughout her two pregnancies in 1989 and 1991, but had never been warned about the potential risks to her babies. Foetal valproate syndrome can cause spina bifida, congenital heart defects and developmental delays and is believed to have affected around 20,000 children in the UK. Both of Janet's sons were affected by the medication and require full time care as a result. Janet describes how being told about the risks would have enabled her to make an informed decision about whether to have children, and how her experience led her to help set up In-FACT (the Independent Fetal Anti Convulsant Trust) in 2012.
  4. Content Article
    There is evidence that certain subgroups of the population have a higher risk of developing dementia than others. Aside from the most important risk factor—age,—other risk factors include ethnicity, sex, learning disability and socio-economic status. This report by the UK Dementia Research Institute (UK DRI) details the impact of scientific research on health inequalities for people affected by dementia. In order to make sure dementia diagnosis and treatments are effective for everyone, we need to understand how and why different groups are affected differently, so that we can target interventions where they are most needed and maximise their benefit. The report was produced by leading dementia scientists from the UK DRI who are taking action to reduce health inequalities through their own research. This includes: Researching “blood biomarkers” to pave the way for a blood test to diagnose Alzheimer’s disease. Ensuring both male and female mice are used equally in animal research so that findings can be applied to the whole population. This is policy across the UK DRI. Broadening understanding of the implications of ethnicity on risk of Alzheimer’s disease through genetic studies. Working to make clinical trials more accessible to all. Pioneering accessible, scalable, and affordable new therapies. Investigating rarer forms of dementia to plug the knowledge gap and support people living with these diseases. Addressing the environmental and lifestyle factors that impact brain health to better understand the link between socio-economic status and dementia risk.
  5. Content Article
    The opioid epidemic is a major public health concern in the US—according to the Center for Disease Control and Prevention (CDC), 70,630 people died from drug overdoses and 10.1 million people misused opioid prescriptions in 2019 alone. There are also an estimated 180,000 serious opioid-related adverse events in inpatient settings recorded annually. This blog by Dr Diane Perez, advisory board member at the Patient Safety Movement Foundation, looks at how patients and their families can get involved in solving the opioid epidemic. Opioids are potent pain relievers so it is critical that anyone that has a prescription be properly informed about the potential risks–both in and out of the hospital setting.
  6. Content Article
    Safety II moves away from simply looking at what went wrong, and aims to understand the realities of everyday work in a constructive and positive way. It focuses on the system as a whole, rather than the end result of the work done. In this blog, Professor Suzette Woodward, Professional and Clinical Advisor in Patient Safety, looks at the role of the Safety II approach in making maternity services safer. She outlines the importance of asking and listening to staff about how to reduce complexity and reform areas of the system that are prone to error.
  7. Event
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    This webinar offers a chance to explore the challenges and opportunities of the Safety-II approach with Mark Sujan, co-author of the BMJ Quality and Safety article ‘The problem with making Safety-II work in healthcare.’ In 2020 Q’s ‘Organisational Resilience & Safety-II’ Special Interest Group (SIG) ran workshops to share adaptations being made to address the emerging COVID-19 crisis. Many solutions were shared but significant challenges were identified. In this webinar we will build on the insights found and explore the arguments in the recent BMJ Quality and Safety article, ‘The problem with making Safety-II work in healthcare.’ We will be joined by the paper’s co-author Mark Sujan, as we lean into the promises and potential of Safety-II, and what gaps we need to bridge to revolutionise our understanding of what safety truly is in health care. The one hour webinar will: Outline the challenges and opportunities of a Safety-II approach Allow you to hear from peers implementing Safety-II Provide you with an opportunity to discuss your experiences of Safety-II in small groups Register for the webinar
  8. Content Article
    This letter from NHS Confederation to Thérèse Coffey MP, the new Secretary of State for Health and Social Care, sets out what needs to be done to support the delivery of an emergency winter plan for health and social care services. It outlines the views of NHS Confederation members on what will be needed to deliver the ‘ABCD’ highlighted as priorities by the Secretary of State: ambulances, backlogs, care and doctors and dentists.
  9. Content Article
    In this blog, Jeremy Hunt MP, Founder of Patient Safety Watch, outlines six priorities for the new Health Secretary, Therese Coffey MP. He argues that these patient safety priorities will help reduce elective and emergency pressures and save money.
  10. Event
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    This webinar from the Irish Health Services Executive National Quality and Patient Safety Directorate will enable you to: understand what restorative just culture means in practice appreciate how you can apply restorative just culture to your local context learn the benefits of restorative just culture for patients, staff and business hear top tips for applying restorative just culture Register for the webinar
  11. Content Article
    This article in the Daily Mail looks at the link between mild Covid infection, heart disease and other circulatory issues. The article describes the experience of TV doctor Xand van Tulleken, who suffered from recurrent atrial fibrillation after catching Covid-19 in March 2020. It then looks at the cardiovascular symptoms being reported by people with Long Covid, and highlights different research studies around the world which are establishing a link between Covid infection and cardiovascular problems.
  12. Content Article
    For people who have been diagnosed with dementia, accessing post-diagnosis support can be challenging, particularly when the systems meant to provide support are confusing, limited or in some areas, non-existent. The World Alzheimer Report 2022 looks at the issues surrounding post-diagnosis support, a term that refers to the variety of official and informal services and information aimed at promoting the wellbeing of people with dementia and their carers. This report explores the aspects of living with dementia following diagnosis, through 119 essays written by researchers, healthcare professionals, informal carers and people living with dementia from around the world. These expert essays are accompanied by the results of a survey carried out in May 2022, with responses from 1,669 informal carers in 68 countries, 893 professional carers in 69 countries and 365 people with dementia from 41 countries.
  13. 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. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care.
  14. Content Article
    This review by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) looks at current NCEPOD data to identify themes relating to healthcare inequalities. It was was commissioned by Healthcare Quality Improvement Partnership (HQIP) on behalf of the Healthcare Inequalities team at NHS England and NHS Improvement, as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The review identifies four area of healthcare inequalities: Protected characteristics - age and disability Socioeconomic deprivation Inclusion health groups Organisation of healthcare services
  15. Content Article
    Happy Patient is a three-year project co-funded by the European Union, that seeks to reduce the impact of antimicrobial resistance (AMR) by decreasing the inappropriate use of antibiotics for the management of common community-acquired infection. Up to 25,000 people die every year in Europe as a direct consequence of the misuse of antibiotics, a figure that rises up to 30,000 in the United States (European Centre for Disease Prevention and Control). The Happy Patient Website offers a variety of communication tools for healthcare professionals and patients, including: Leaflet - Viruses or bacteria: What caused your infection? Urinary tract infections: A leaflet for older adults and their families Antibiotics prescription pad 5 myths about urinary tract infections (UTIs) in nursing home residents What you need to know if you have been prescribed an antibiotic
  16. Content Article
    This Expert Panel evaluation was commissioned by the House of Commons Health and Social Care Committee. It reviews evidence to determine whether the Government’s policy commitments relating to the health and social care workforce in England are appropriate and have been effectively implemented. The Expert Panel consists of members with recognised expertise in research and policy evaluation, complemented by experts with research expertise and practical experience in the health and social care workforce.
  17. Content Article
    Patients are becoming increasingly involved in their health through technology such as health apps, and regulators are already struggling to control the market without constraining innovation. Clinical Safety must therefore adapt to the ever-changing world of health apps, if it is to fulfil its purpose and ensure that only the safest technologies are used by patients. In this blog, GP Tom Micklewright looks at some of the safety issues relating to health apps. He highlights that unlike with other new systems, health apps are rarely deployed in a controlled environment, which can cause problems when trying to apply clinical safety standards to them. He looks at five of the issues health apps can cause for safety teams: Intended scope and use Updated health apps Clinical safety, health apps and AI Different places, different features Monitoring clinical safety He then offers some potential solutions to these problems: Continuous assessment of health apps Centralise clinical safety, don’t localise Differentiated approach to clinical safety Aggregated incident reporting
  18. Content Article
    To be effective, clinical governance should reach every level of a healthcare organisation—it requires structures and processes that integrate financial control, service performance and clinical quality in ways that will engage clinicians and generate service improvements. In this article for the BMJ, the authors argue that because clinicians are at the core of clinical work, they must be at the heart of clinical governance. They look at problems with the prevailing model of clinical governance and describe an alternative approach.
  19. Content Article
    Midwives, public health nurses and practice nurses are in an ideal position to address mental health and emotional well-being with women in the perinatal period. However, research involving midwives, public health nurses and practice nurses in Ireland indicates that there is considerable variation in perinatal mental health assessment and care. All three groups identify the following issues as barriers to addressing perinatal mental health issues: Lack of knowledge on the range of perinatal mental health problems Lack of skill in opening a discussion and developing a plan of care with women Organisational issues, such as lack of policies, guidelines and care pathways This document produced by the Irish Health Service Executive, aims to provide an evidence-based guidance document for midwives, public health nurses and practice nurses in the area of perinatal mental health care.
  20. Content Article
    This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list six top Learn articles about medication safety in social care.
  21. Content Article
    This worksheet produced by NHS Education for Scotland is designed to be used by healthcare teams as a prompt to highlight the various system-wide factors that contribute to an issue. It aims to help teams understand how these factors relate and interact to produce different outcomes.
  22. Content Article
    This article explores the question of why change management was an issue in the NHS in the 1980s. It reports the results of a study which explored reasons for variability in the observed rate and pace of strategic service change in the NHS. The article introduces the metaphor of 'receptive' and 'non-receptive' contexts for change, as well as outlining eight 'signs and symptoms' of receptivity. It provides a logic and language which may enable a better understanding of the processes of change in the NHS.
  23. Content Article
    Each year, up to 100 million people in the US experience acute or chronic pain, mainly because of short-term illnesses, injury and medical procedures. It is therefore important that patients are offered effective treatment options to reduce symptoms and improve function. Nonopioid management is the preferred option, but there are circumstances for which short-term opioid therapy is appropriate and beneficial. Finding the balance between these approaches is an ongoing problem in the management of acute noncancer pain. This cluster randomised clinical trial featured in JAMA Health Forum, aimed to assess whether clinician-targeted interventions prevent unsafe opioid prescribing in ambulatory patients with acute noncancer pain. The authors found that the use of comparison emails decreased the proportion of patients with acute pain who had never taken opioids receiving an opioid prescription. The emails also reduced the number of patients who progressed to treatment with long-term opioid therapy or were exposed to concurrent opioid and benzodiazepine therapy. They concluded that healthcare systems could add clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing.
  24. Content Article
    This guideline developed by the World Health Organization (WHO) is intended for healthcare professionals involved in the care of patients with suspected or confirmed Covid-19. It is not meant to replace clinical judgment or specialist consultation, but rather to strengthen frontline clinical management and the public health response. Considerations for special and vulnerable populations, such as paediatric patients, older people and pregnant women, are highlighted throughout the text. This guideline is a product of the contributions of several WHO team members and independent experts from all over the world.
  25. Content Article
    According to the World Health Organization (WHO), medication harm accounts for 50% of the overall preventable harm in medical care.  As well as telling the story of Melissa Sheldrick, who has been campaigning to improve medication safety since her son Andrew died as a result of a medication error, this blog looks at how making it 'safe-to-say' can reduce the risk of medication errors. Healthcare systems need a culture shift that makes it safe-to-say when something has gone wrong, is going wrong, or could go wrong. The authors argue that it is only when errors are appropriately managed, reported, responded to and learned from that we can improve the system as a whole, support people impacted to heal and take informed action to prevent similar incidents from happening in the future.
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