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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this interview for Pharmacy Update Online, Patient Safety Learning's Chief Executive Helen Hughes talks about how the hub was established to provide free, easily-accessible information about patient safety for everyone. "By everyone we mean literally everyone–the hub was designed by and for clinicians, patient safety experts, patients, family members, policy makers, academics–everyone. We wanted a knowledge repository, all in one place, that people could find easily and use to inform their campaigning, their work, their education.” Helen describes how the hub's audience and reach has grown over the three years since it was launched—the hub has had a million page views from people in more than 200 countries, and 450,000 unique users. Although it was started as a UK-based resource, over time more people around the world have found out about it. Helen also discusses Patient Safety Learning's work to make patient safety a core purpose of healthcare, and the vital nature of patient involvement in patient safety.
  2. Event
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    This webinar is jointly sponsored by the International Society for Quality in Healthcare (ISQua) and American Academy of Pediatrics' Council on Quality Improvement and Patient Safety (AAP COQIPS) Join us for our first ISQua - AAP COQIPS webinar! In this interactive webinar you will learn about implementation tools and resources to decrease medication errors in the ambulatory paediatrics setting. These tools can also be applied to children with medical complexity, who are frequently at higher risk for medication errors due to challenges with care fragmentation, miscommunication, and polypharmacy. Register for the webinar
  3. Event
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    Pharmacy Forum NI and the DoH Strategic Planning & Performance Group (SPPG) have created a three-part webinar series entitled, ‘A systematic Approach to Insulin Safety in Community Pharmacy’. The first webinar in the series will take place on Wednesday 21 September 2022 at 7-9pm via Zoom and will focus on an introduction to human factors, concepts & tools, and their relevance to patient/medication safety and the wellbeing of the pharmacy team. Event programme and registration Who should attend? These events are targeted at all members of the community pharmacy team who play a part in the safe supply of medicines to patients, namely: pharmacists and foundation trainee pharmacists pharmacy technicians and assistants owners and superintendents medicines safety leads Guest speakers We are delighted to partner with Professor Paul Bowie and Dr Helen Vosper for the three-part event series. Professor Paul Bowie is a Safety Scientist, Medical Educator and Chartered Ergonomist and Human Factors specialist. He has over 25 years’ experience in a range of quality and safety leadership and advisory roles in healthcare, medical defence, military medicine and academia. He gained his doctorate in significant event analysis from the University of Glasgow in 2004 and has published over 150 papers on healthcare quality and safety in international peer-reviewed journals and co-edited a book on safety and improvement. Paul is also Honorary Professor and a PhD supervisor/examiner in the Institute of Health and Wellbeing at the University of Glasgow and a Visiting Professor at Queen’s University, Kingston, Canada. He is Honorary Fellow of the Royal College of Physicians of Edinburgh and the Royal College of General Practitioners, and a Chartered Member of the UK Institute of Ergonomics and Human Factors where he is the patient safety lead of the healthcare specialist interest group Dr Helen Vosper is a chartered ergonomist and graduate of the Loughborough Human Factors Masters Programme and an academic with 15 years’ experience of teaching Human Factors to healthcare students and professionals, including pharmacy students and pharmacists. She is currently the lead for Patient Safety in the School of Medicine, Medical Sciences and Nutrition at the University of Aberdeen. Helen also has a part-time role as a Senior Investigation Science Educator at the Healthcare Safety Investigation Branch and is a scientific adviser in Human Factors and Patient Safety to NHS Education for Scotland.
  4. Content Article
    This document outlines the terms of reference for the independent review into maternity services at Nottingham University Hospitals NHS Trust (NUH), commissioned by NHS England and led by Donna Ockenden. The review has been established in light of significant concerns raised about the quality and safety of maternity services at NUH, and concerns voiced by local families. It replaces a previous regionally-led review after some families expressed concerns and made representations to the Secretary of State for Health and Social Care. The review began on 1 September 2022 following early engagement with families and NUH from June 2022. It is expected to last 18 months, although this timeframe is subject to review. Learning and recommendations will be shared with NUH as they become apparent, to allow rapid action to improve the safety of maternity care. The only and final report is expected to be published and presented to NUH and NHS England around March 2024.
  5. Content Article
    With patients increasingly being able to view their healthcare records online or via an app, it is very important that they understand what their records say. This webpage by the NHS explains what some of the most common medical abbreviations mean, to help patients understand what has been written about their care and treatment.
  6. Content Article
    In this blog, Ian Lavery, Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB) summarises a presentation given to HSIB staff by healthcare improvement expert Professor Mary Dixon-Woods. The presentation highlighted that a recommendation alone could fall short of the intended impact on the healthcare system. It looked at creating recommendations to respond to real world working, the importance of involving people most affected by patient safety incidents and why it's vital to look at when things go right.
  7. Content Article
    This video series by the Australian Commission on Safety and Quality in Healthcare aims to promote sepsis awareness among healthcare professionals and the wider community. The three videos were created as part of the Australian National Sepsis Awareness Campaign. The videos provide key information about: sepsis signs and symptoms. potential health problems after sepsis. simple ways to reduce the risk of sepsis. timely recognition and management of sepsis across healthcare settings.
  8. Content Article
    These resource lists compiled by US insurance company MedPro Group, highlight a number of expert and evidence-based sources that can be used to increase awareness of safety issues, identify areas of risk and determine mitigation strategies. They cover a wide range of healthcare safety topics: Advanced practice providers Anaesthesia and surgery Artificial Intelligence Bed safety and entrapment in senior care Behavioural health Behavioural health in senior care Burnout in healthcare Culture of safety Cybersecurity Disclosure of unanticipated outcomes Disruptive behaviour Elder abuse Electronic Health Records Emergency medical Treatment and Labour Act Emergency preparedness and response Emergency preparedness and response in senior care organisations Ergonomics and safe patient handling Falls and fall risk in older adults Handoffs and care transitions Health equity and social determinants of health Health literacy and cultural competence Healthcare-associated infections Healthcare compliance HIPAA Human trafficking and trauma-informed care Infection prevention and control in ambulatory care settings Infection prevention and control in dentistry Infection prevention and control in senior care organisations Informed consent LGBT+-inclusive care Maternal morbidity and mortality Medical marijuana Medication safety during care transitions Obstetrics and gynaecology Opioid prescribing and pain management Patient engagement Pressure injuries in older adults Sepsis Social media in healthcare Staff shortages and workforce issues Suicide screening in primary care Telehealth/telemedicine Violence prevention in home healthcare Violence prevention in the Emergency Department Wrong-site procedures
  9. Content Article
    The Patient Experience Library aims to gather research and evidence about patient experience in one place, so that it can be accessed and used to improve patients' experiences of healthcare. In this annual report, The Patient Experience Library presents its top picks of evidence gathering about patient experience in England from the last twelve months. The research featured in the report includes studies by patient voice organisations, health charities, academic institutions and policy think tanks. The research takes variety of formats, from peer-reviewed formal research to less formal approaches built on community relationships, that lead to trusted dialogue and deep insight.
  10. Content Article
    Confusion between drug names that look and sound alike continues to occur and causes harm in all care settings, despite persistent prevention and mitigation efforts by industry, regulators, health systems, clinicians, patients and families. This editorial in BMJ Quality & Safety examines the results of a study that assessed the effect of mixed case (often referred to as ‘tall man’) text enhancement on critical care nurses’ ability to correctly identify a specific syringe from an array of similarly labelled syringes. The authors suggest further developments in this field of research and argue that a variety of different interventions will be needed to reduce medication errors caused by drug name confusion.
  11. Event
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    What we’re getting wrong about the “Five rights of medication use” and other safety myths Despite decades of focus, medication errors, which result from weak medication systems and human factors, constitute the greatest proportion of total preventable harm. Yet across decades of efforts to improve medication safety, a disproportionate burden continues to be placed on human performance, while examination and focus on improving systems and the cultures in which humans work is often limited and reactive. In recognition of World Patient Safety Day, this free Institute for Healthcare Improvement (IHI) webinar examines how traditional approaches to medication safety continue to impede progress. Interprofessional faculty with expertise in systems thinking and human factors engineering will share insights on reorienting our thinking and approaches to medication safety. This webinar will provide fresh ideas for engaging a cross-disciplinary, systems perspective and harnessing team members in the improvement of systems to support medication safety. What you'll learn Review commonly held myths about humans that limit progress in medication safety, including the “Five Rights of Medication Use.” Discuss how human factors design and interventions support human performance and improvements in medication safety. Identify at least one idea for change that you can consider for improving medication safety in your organization. Register This webinar will take place at 12:00-13:00 ET (17:00-18:00 BST)
  12. Content Article
    In the UK, over 26% of adults take prescription medications and in the US the figure is around 66%. But up to 50% of patients fail to take their medications as prescribed. As healthcare steadily pivots towards digital health, Dr. Bertalan Meskó and Dr. Pranavsingh Dhunno ask how new technologies can improve medication management. In this article for The Medical Futurist, they look at the importance of empowering patients to reduce the risk of medication errors. They highlight five medication management technologies that could help patients improve their own medication safety: Smart pill dispensers which deliver audible and visual cues to remind patients to take medications at the right time Medication reminder apps which help manage medication regimens and can sync the data with a caregiver or doctor Digital therapeutics which support patients to make treatment decisions Digital pills which integrate tracking technology into pills themselves Telemedical platforms that allow patients to request advice or raise concerns with their doctors.
  13. 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 seven tools and articles related to patient engagement and medication safety, including an interview with a patient advocate campaigning for transparency in medicines regulation, a blog outlining family concerns around prescribing and consent, and a number of projects that aim to enhance patient involvement in using medications safely.
  14. Content Article
    Issues with medication management and errors in medication administration are major threats to patient safety. This article for the US Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network takes a look at the AHRQ's current areas of focus for medication safety. The authors look at evidence-based solutions to improve medication safety in three areas: High-risk medication use and polypharmacy in older adults Reducing opioid overprescribing, increasing naloxone access and use and other interventions for opioid medication safety Nursing-sensitive medication safety The article also explores future research directions in medication safety and highlights that these will advance patient safety overall.
  15. Content Article
    On 24 June 2022, the US Supreme Court overruled both Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey and returned the question of abortion’s legality to the US. The ruling opens the door to additional State efforts to limit access to medication abortions, prevent third parties from assisting anyone seeking an abortion or punish women who end their pregnancy. This opinion piece in The New England Journal of Medicine looks at the implications of the end of Roe v. Wade beyond abortion, examining how it could affect other aspects of healthcare rights in the USA. The author, Zita Lazzarini from the Division of Public Health Law and Bioethics at the University of Connecticut School of Medicine, argues that the Supreme Court's ruling opens the door for state regulation of other healthcare decisions, including those regarding contraception, end-of-life care, care for LGBTQ patients and fertility treatments. She highlights that common forms of birth control including IUDs and emergency contraception are already being targeted by some states as “abortifacients,” and raises concerns that State laws declaring that life begins at fertilization will potentially endow thousands of frozen embryos with rights, imposing impossible burdens on fertility centres and their clients.
  16. Content Article
    This poster highlights some key issues associated with by antimicrobial resistance (AMR), which is caused by inappropriate use of antibiotics. It outlines the objectives and results of the AMR Patient Group, a coalition of patient groups across Europe working to address the serious public health threat posed by AMR. It also outlines the AMR Patient Group's policy recommendations to European and national health authorities.
  17. Content Article
    Despite global consensus that access to pharmaceuticals as a lifesaving commodity is a fundamental human right, 2 billion people globally still lack access to medicines. In this blog, Karrar Karrar, Access to Medicines Adviser at Save the Children, looks at why weak regulatory systems are a major patient safety issue in low- and middle-income countries. He highlights that lack of regulatory capacity results in falsified, substandard and fake medicines making their way into local pharmacies and hospitals. It also delays patient access to new medicines due to lengthy processing times. Karrar argues that governments must prioritise investments in strengthening national regulatory systems and increase cross-country collaboration to strengthen regional and global regulatory networks and systems.
  18. Content Article
    Patient safety culture is a vital component in ensuring high-quality and safe patient care. This cross-sectional study aimed to assess doctors’ and nurses’ perceptions of patient safety culture in five public general hospitals in Hanoi, Vietnam. The study found that the mean scores among nurses were significantly higher than that among physicians for several categories: supervisor/manager expectations staffing management support for patient safety teamwork across units handoffs and transitions Nurses reported significantly higher patient grades than physicians (75% vs 67.1%) and around two-thirds of physicians and nurses reported no event in the past 12 months (62.8 and 71.7% respectively). The authors recommend that hospitals develop and implement intervention programs to improve patient safety, including around teamwork and communication, encouraging staff to notify incidents and avoiding punitive responses.
  19. Content Article
    This Good Practice Series published by The Royal College of Pathologists is a topical collection of focused summary documents, designed to be easily read and digested by busy front-line staff. The documents contain links to further reading, guidance and support, and cover the following topics: Supporting people of Black, Asian and minority ethnic heritage Urgent release of a body Learning disability and autism Organ and tissue donation Post-mortem examinations Child deaths Mental health and eating disorders Out-of-hours arrangements
  20. Content Article
    The Institute of Health Equity (IHE) is working with local authorities up and down the country to help them implement the right approaches to reduce health inequalities. The public health department of Luton Borough Council commissioned IHE to support the local authority and other partners to act on health inequalities and become the first ‘Marmot Town’. This report is based on an assessment of data and local evidence and makes recommendations to reduce health inequalities and make Luton a fairer place to live, work, grow up and grow old in.
  21. Content Article
    In this blog for Psychology Today, Gary Klein looks at the psychological causes of diagnostic errors, arguing that being clear about the exact causes of these errors is the only way to reduce them. Drawing on physical causes of diagnostic error identified in an Institute of Medicine report in 2015, he highlights the need to go further in understanding the explanations the report offers for diagnostic errors.
  22. Content Article
    This blog describes the experience of Colonel Steven Coffee, Cofounder of Patients for Patient Safety US, who experienced a series of medical errors following the birth of his son. After a missed diagnosis of galactosemia, his son suffered liver failure and underwent a liver transplant at eight weeks old. Following his operation, the hospital where he was being treated did not have access to the powdered soy milk which was essential for his son's recovery. This experience spurred Colonel Coffee on to become an advocate for patient quality and safety in health care. For the last nine years, he has worked toward improved patient safety as the first community chair of MedStar Health’s Patient and Family Advisory Council for Quality and Safety (PFACQ).
  23. Content Article
    Healthcare service innovations are considered to play a pivotal role in improving organisational efficiency and responding effectively to healthcare needs. However, healthcare organisations often encounter difficulties in sustaining and sharing innovations. This qualitative study aimed to explore how healthcare innovators of process-based initiatives see and understand factors that either facilitated or obstructed the implementation of innovation. The authors found that even though the innovations studied were very varied, innovators often highlighted the significant role of the evidential base of success, the inter-personal and inter-organisational networks, and the inner and outer context.
  24. Content Article
    In healthcare, there is a well-recognised gap between what we know should be done, and what is actually done. This article considers new models that look at the implementation of evidence-based practice in healthcare systems, particularly looking at the application of a conceptual model called 'sticky knowledge'.
  25. Content Article
    Hypothermia is a common problem in the operating theatre, and it contributes to many poor outcomes including rising costs, increased complications and higher morbidity rates. This literature review in the Journal of PeriAnesthesia Nursing aimed to determine the best method and time to prewarm a patient in order to prevent hypothermia during or after surgery. The authors suggest that forced-air warming is most effective in preventing perioperative hypothermia. Eighty-one percent of the experimental studies reviewed found that there was a significantly higher temperature throughout surgery and in the post-operative care unit for patients who received forced-air prewarming.
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