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Content ArticleRestorative justice brings those harmed by crime or conflict and those responsible for causing their harm into contact with each other. In healthcare, this can involve bringing together patients and families of patients who have suffered avoidable harm, and the healthcare professionals who may be responsible for this harm. The aim is to enable everyone affected by an incident to play a part in helping to set right the hurt or injury caused, and hopefully find a positive way forward. This blog outlines the content of a lecture given to staff at the Healthcare Safety Investigation Branch (HSIB) by Jo Wailling, Senior Research Fellow at Te Herenga Waka - Victoria University of Wellington, New Zealand, who is a globally-renowned expert in restorative practice and justice in healthcare. It covers Jo's experience of co-designing and evaluating New Zealand's innovative restorative response to surgical mesh harm, practical examples for patient safety investigations and how HSIB is going to integrate restorative justice principles in its future investigations.
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Content ArticleThe Commission on Young Lives (COYL) was set up in September 2021, to propose a new settlement to prevent marginalised children and young people from falling into violence, exploitation and the criminal justice system, and to support them to thrive. Its national action plan will include ambitious practical, affordable proposals that government, councils, police, social services and communities can put into place. This detailed report by COYL examines the state of children and young people's mental health, describing the current situation as "a profound crisis." It examines the impact of the pandemic on young people's mental health, as well highlighting the lack of capacity and inequalities present in children and young people's mental health services. It then looks in detail at factors that contribute to mental health issues in children and young people and prevent marginalised groups from accessing mental health support.
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EventThe Restraint Reduction Network is a movement of people who want to eliminate the use of unnecessary restrictive practices, protect human rights and make a positive difference in people's lives. This webinar is an opportunity to find out more about participating in this project, which goes live in September 2022. The session will help you understand your practice in relation to use of psychotropic medication with children and young people and will give you the opportunity to compare your practice to other inpatient units through a benchmarking dashboard. Register for the webinar
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Content ArticleThis opinion piece in The BMJ looks at the impact of the government's decision to make the wearing of masks in healthcare settings the decision of local providers, dependent on local risk assessment and prevalence. It highlights reports of patients wearing high-filtration FFP2 or FFP3 respirator—many of who are immunocompromised—being asked to remove and replace them with less effective single-use masks in order to gain entry to NHS facilities for treatment. The authors highlight that Covid-19 is an airborne pathogen and that the likelihood of contracting the virus increases with length of time spent in contaminated air. They argue that downgrading mask use in healthcare settings puts everyone at risk, but that it is a particular issue for patients who are clinically extremely vulnerable due to underlying health conditions or because they are undergoing treatment for cancer. They call on the government to upgrade masks to FFP2 or FFP3 respirators in order to protect staff and patients and reverse the worrying trend of clinically extremely vulnerable patients avoiding attending healthcare services.
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EventuntilBringing together a community of human factors in patient safety advocates across Ireland and abroad, the annual Human Factors in Patient Safety Conference will offer the opportunity to gain valuable knowledge and insights from human factors experts. The conference will include contributions from: Martin Bromiley OBE, Founder of Clinical Human Factors Group UK – Listening Down to Develop your Safety Behaviours Mr Peter Duffy, Consultant Urologist – Whistle in the Wind: a Personal Exploration of the Consequences of Whistleblowing in Healthcare Professor Eva Doherty (Chair), Director of Human Factors in Patient Safety – The Irish Context, panel discussion Healthcare professionals can register for the event here. For more information, please email mschumanfactors@rcsi.ie.
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Content ArticleThis National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report highlights the results of a study into quality of care received by people aged 0-24 receiving long-term ventilation (LTV). It aimed to identify remediable factors in the care provided to children and young people who were receiving, or had received, LTV.
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Content ArticleYoung people from different backgrounds with different lived experiences can have different physical and mental health outcomes. This briefing document by the Association for Young People’s Health (AYPH) offers a definition for health inequalities that is specific to young people, and a conceptual framework to help identify key causes and factors that influence health outcomes. As well as highlighting the impact of Covid-19 on young people's health and wellbeing, the paper focuses on different factors that will affect young people's health outcomes now and in the future, including education, employment, housing, geographical area, development of behaviours and relationships.
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Content ArticleProven patient safety solutions such as the World Health Organization’s Surgical Safety Checklist can be difficult to implement at scale. This article looks at a voluntary initiative launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that implemented the checklist by 2017 had higher levels of CEO and physician participation than comparison hospitals, and engaged more in activities such as in-person meetings and teamwork skills trainings. The authors suggest three considerations for hospital, state and national policy makers: Successful programs must be designed to engage all stakeholders (CEOs, physicians, nurses, surgical technologists, and others) Offering a variety of program activities—both lower-touch and higher-touch—over the duration of the program allows more hospital and individual participation Change takes time and resources
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Content ArticleVaginal tapes, slings and meshes are medical devices that are surgically implanted to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women. This report written on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) by York Health Economics Consortium, provides summaries of safety and adverse events related to vaginal tapes for SUI and POP. The summaries were developed using the data reported in systematic reviews of the effects and safety of vaginal tapes published in the 10 years up to 2012.
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Content ArticleLack of capacity in social care is having a severe effect on NHS services as hospitals are unable to discharge patients without appropriate care arrangements in place. This is causing delays right across the healthcare system. In this report, NHS Confederation highlights the risks to patient safety caused by the workforce crisis affecting social care in England. In the Confederation's latest survey, 99% of healthcare leaders agreed that there is a social care workforce crisis in their local area, and almost all agreed that it is worse than a year ago and expect it to deteriorate into this winter. The report recommends the government focus on the following key priorities to deal with the crisis: Increase pay in the social care sector, starting by immediately implementing a national care worker minimum wage Publish a long-term, properly funded plan to develop the care workforce and offer career progression opportunities Commit to increasing overall investment to increase access to care to those who need it, meet future demand and pay more for care
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Content ArticlePatient choice has been a feature of the NHS in England for the last two decades, but patients' knowledge about what choices they have in accessing their NHS healthcare is variable. This report by the Patients Association and the Independent Healthcare Providers Network (IHPN) looks at the role patient choice can play in tackling the elective care backlog. The report found that: there are significant variations in waiting times across the country. patients do not need to travel long distances to access care more quickly. On average, a patient would need to travel just 13.2 miles to go from one of the worst performing providers to one of the top performers. the potential for reducing waiting times by accessing care through an alternative provider was backed up by both polling and focus group work, which found the public is enthusiastic about patient choice. people's awareness of their rights around where they receive their NHS treatment is low, suggesting the Government and NHS England need to do more to promote choice and make it easier for patients to understand the options available to them.
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Content ArticleIn this letter to the Secretary of State for Health and Social Care, Rachel Power, Chief Executive of the Patients Association, calls on Steve Barclay to ask the Government to develop a long-term workforce strategy for the NHS. She also requests that the government urgently fund social care and calls on Steve Barclay to take action to remedy the threat to patient safety caused by staff shortages.
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Content ArticleDepression is one of the most common mental health issues and GPs often diagnose and treat patients with the condition. In this blog, Dr Ed Beveridge offers his top tips for the assessment, management and treatment of adults with depression in primary care. It provides information on: assessing and screening people with depression for underlying conditions. pharmacological and nonpharmacological treatment options. when to refer to secondary care or seek specialist advice.
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Content ArticleThis video examines the crisis facing NHS ambulance services in the UK and looks at the impact of delays and lack of capacity on patient safety. Paul Brand, UK Editor at ITV News, speaks to ambulance crews, patients and a recently bereaved family about their experiences, and highlights the increased stress levels ambulance staff are reporting. Note: The video contains footage of a 999 call that some viewers might find distressing.
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Content ArticleThis practical guide was commissioned by The Health Foundation and NHS England to support NHS systems to tackle health inequalities. Co-written by the Yorkshire and Humber Academic Health Science Network and a reference group of national experts, stakeholders, service providers and people with lived experience of inequalities, the guide suggests practical action that systems can take to ensure equitable access, excellent experience and optimal outcomes for all. The guide covers four key areas for action and features good practice examples which systems and providers can adapt and apply to their local context. There are also checklists to assist system leaders, managers, clinicians, and operational staff, to design new models of care and embed sustainable action to drive down healthcare inequalities. The guide supports the national Core20plus5 approach to reduce healthcare inequalities which focuses on a population group of the core 20% most deprived nationally and those from inclusion health groups; outlining five clinical areas of focus.
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Content Article
The Patient Revolution: How we revolt guide (June 2022)
Patient-Safety-Learning posted an article in Culture
This guide from The Patient Revolution aims to help healthcare activists contribute to an international movement for care. It summarises the foundations of The Patient Revolution's collective work towards the goal of careful and kind care for all. Underpinning these foundations is the idea that industrialised healthcare undermines compassionate, individualised care and costs more, both in terms of patient safety and financial cost. The guide provides tools and principles to help activists transform the way care is offered and promote genuine patient-healthcare collaboration. -
Content ArticleThe Accessible Information Standard gives disabled people and people with sensory loss the right to get healthcare information they can understand and communications support if needed. A survey conducted by HealthWatch between February and May 2022 aimed to investigate whether the standard is being delivered by health services, and whether it offers enough support to patients. While the survey participants were self-selected, their views are likely to reflect those of a significant group of people who need communications support. HealthWatch hopes that the survey's findings will help NHS and social care decision-makers hear what is working and what could be better from the public's perspective.
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Content ArticleThis document outlines the UK Government's response to the Health and Social Care Select Committee report on the treatment of autistic people and people with learning disabilities, published in July 2021. It contains responses to three main areas of interest raised by the Committee's report: Community support: reducing the number of autistic people and people with learning disabilities in inpatient facilities, and the benefits of the Trieste model The use of restrictive practices in inpatient facilities and wider concerns relating to the appropriateness and continued use of such facilities The wellbeing of and accountability for autistic people and people with learning disabilities including the creation of a new role: the Intellectual Disability Physician, and the need for independent reviews into the deaths of autistic people and people with learning disabilities
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Content ArticleEach year, 7,000 to 9,000 people die as a result of a medication errors in the US, and the total cost of looking after patients with medication-associated errors exceeds $40 billion. Alongside this financial cost, adverse events caused by medication errors also cause patients significant psychological and physical pain and suffering. The article aims to: identify the most common medication errors. review some of the critical points at which medication errors are most likely to occur. outline strategies to prevent medication errors occurring. summarise multidisciplinary team strategies for decreasing medication errors.
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Content Article
UK Infected Blood Inquiry website
Patient-Safety-Learning posted an article in Other reports and inquiries
This is the website of the independent public statutory Inquiry established to examine the circumstances in which patients in the UK were given infected blood and blood products, in particular since 1970. The Inquiry is Chaired by barrister Keith Langstaff, who has experience of health-related public inquiries. The website contains information on: public hearings and meetings evidence latest news on the Inquiry how to get support if you have been affected by infected blood products. The Inquiry team is also inviting patients and family members of patients who received infected blood or infected blood products to give evidence to the Inquiry, either as a written statement or by speaking to an intermediary. Evidence given to the Inquiry will contribute to its findings and recommendations. -
Content ArticleOver the few years, the Royal Air Force (RAF) has been going through a cultural evolution. In this episode of the Human Factors podcast, Ian James and Avril Webb give an insight into how the implementation of Human Factors and attitudes to safety have evolved in the RAF, and the positive impact this has had on the organisation.
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Content ArticleIn this opinion piece for The Guardian, Professor Devi Sridhar, chair of global public health at the University of Edinburgh discusses the global threat of monkeypox—a virus that causes fever, swollen lymph nodes and distinctive rashes on the face, palms, the soles of the feet and genitalia. The World Health Organization (WHO) has designated the recent outbreak of monkeypox a public health emergency of international concern. Professor Sridhar highlights the need to take a collaborative approach across borders to ensure the outbreak is brought under control. She outlines that the most effective strategy in preventing the virus spreading further is to protect the group most at risk from the virus—men who have sex with men (MSM)—through vaccination.
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Content ArticleThe Birth Injury Help Center is a US-based online resource centre that provides information on birth injuries, as well pregnancy and childbirth. This article provides information for pregnant women about foods, drinks, medications and activities to avoid during pregnancy.
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Content ArticleThis briefing paper by thinktank The Centre for Mental Health explores evidence about the links between factors that worsen mental health, showing that living in poverty increases people’s risk of mental health difficulties, and that more unequal societies have higher overall levels of mental ill health. It also demonstrates that poverty and economic inequality intersect with structural racism to undermine the mental health of racialised and marginalised groups in society. Among other things, it highlights inequalities in access to primary care and mental health services across the UK.
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Content ArticleThis article in DIA Global Forum examines a new collaboration between the European Commission, the European Medicines Agency (EMA) EU Member States Belgium, France, and Germany, the Bill & Melinda Gates Foundation and the recently established African Medicines Agency (AMA). The group will mobilise more than €100 million over the next five years to support the AMA and other African medicines regulatory initiatives at regional and national levels. The initiative will foster collaboration and sharing of technical expertise by European regulators with AMA. It also aims to assist African national regulatory authorities (NRAs) in achieving the minimum World Health Organization (WHO) requirements for effective regulatory oversight of quality-assured, safe, local production of medicines and vaccines.
