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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient. This report analyses the 467 claims relating to extravasation injuries received by NHS Resolution between 1 April 2010 and 1 December 2021. It includes information about specific injuries caused by extravasation, factors that led to injuries and specialities in which most injuries occurred.
  2. Content Article
    This US study in The Journal of Nursing Care Quality examined the relationship between nurse-reported patient safety grades and both burnout and the nursing work environment. It found that healthcare organisations may reduce negative patient safety ratings by reducing nurse burnout and improving the work environment at an organisation-wide level.
  3. Content Article
    This report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a pilot launched to evaluate HSIB’s ability to carry out effective local investigations at specific hospitals and trusts, while still identifying and sharing relevant national learning. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB. The investigation reviewed the case of a patient who had a stroke and was due to be taken to his local hospital emergency department (ED), but the ED advised paramedics this was not possible as their stroke service was closed. The alternative was to take him to a neighbouring hospital, but they also advised that they could also not take the patient. This was then referred back to the original ED, who restated their position, eventually leading to the neighbouring hospital agreeing to accept the patient. Once the patient arrived he then had to wait 40 minutes in an ambulance as the ED was very busy.
  4. Content Article
    The Covid-19 pandemic has exacerbated existing health inequalities for refugees and migrants. These populations have shown lower rates of Covid-19 vaccination uptake, and may face a range of individual, social, practical and logistical barriers to accessing vaccines. The World Health Organization (WHO) has developed this guide to provide practical recommendations, strategies and good practice for understanding and addressing barriers to Covid-19 vaccination among refugee and migrant populations. It is intended to support all stakeholders responsible for the rollout of Covid-19 vaccines to refugee and migrant populations.
  5. Content Article
    Medication errors can occur at any point in the system for prescribing, dispensing and administering drugs in the NHS – and can often be the result of human errors creeping in as burned out staff misread or miscalculate the amount needed. This article in the Health Services Journal examines how closed loop medication management systems can improve patient safety by ensuring patients are prescribed the right dosage of the right medications. The author speaks to Islam Elkonaissi, former lead pharmacist for cancer services in Cambridge, about the importance of well-planned implementation and bridging the gap between IT specialists and healthcare workers to make sure that potential for communication errors is minimised. They also discuss the value of the huge amounts of data AI systems can collect, which in turn make the systems more precise and accurate.
  6. Content Article
    This webpage contains information from the Royal College of Anaesthetists (RCOA) on coroners' reports that have been sent to the RCOA so that action can be taken to prevent future deaths. The webpage contains: information about the latest reports received. links to articles relating to the patient safety issues identified. information on multidisciplinary team training. training videos.
  7. Content Article
    In this blog Patient Safety Learning highlights the key issues included in its recent response to the Royal College of Obstetricians and Gynaecologists new draft guidance for healthcare professionals who are involved in providing outpatient hysteroscopy.
  8. Content Article
    This is the first Women's Health Action Plan published but the Government of Ireland, and it sets out women's priorities for their health. Women, their representatives and women's health professionals have influenced the development of the Action Plan by sharing their insights and experiences through listening projects and participation opportunities carried out by the Women's Health Task Force 2020-2021. The Action Plan responds to key issues that women raised, including faster access to specialist services, reputable sources of health information and enhanced healthcare experiences. Supporting documents and related reading are provided alongside the Action Plan, including information about the Women's Health Taskforce.
  9. Content Article
    This document sets out the Northern Ireland Department of Health's ambitions to improve medication safety in Northern Ireland, in line with the World Health Organization's Third Global Patient Safety Challenge 'Medication without Harm'. It outlines the need for safer use of medicines in Northern Ireland and highlights four ways in which the Department for Health will address these challenges: Engagement with patients and the public Introducing new systems and practice Engagement and training of health and social care staff Reducing the burden of avoidable harm from high-risk medicines by building good practice in to the supply of all medications
  10. Content Article
    While inequalities in health have always been a problem, the Covid-19 pandemic has shone a spotlight on inequalities, and created an opportunity for change. In this long read by The King's Fund, the authors look at the importance of developing a long-term approach to tackling health inequalities. They examine at historical attempts to tackle health inequalities and argue that we need an enduring national mission to tackle inequality. They highlight that action is needed at national and local levels if this mission is to succeed.
  11. Content Article
    This is the report and formal minutes of a House of Commons Public Accounts Committee session that examined the issues surrounding NHS backlogs and waiting times in England. The session particularly focused on accountability in how NHS England and the Department for Health and Social Care manage workforce and resources. At the end of December 2021, 6.07 million patients were waiting for elective care, the biggest waiting list since records began. Only 64% (3.87 million) of these patients had been waiting for less than 18 weeks, compared with the performance standard which requires 92% to have been waiting for less than 18 weeks. Similarly, in December 2021, only 67% of patients with an urgent referral for suspected cancer were treated within 62 days compared with a requirement for 85% to be treated within that time. The report highlights that although the Covid-19 pandemic had a significant effect on the backlog, NHS waiting time performance had declined steadily in the years before the pandemic.
  12. Content Article
    Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world.  The World Health Organization (WHO) has launched the Third WHO Global Patient Safety Challenge: Medication Without Harm to improve medication safety. Considering the huge burden of medication-related harm, Medication Safety has also been selected as theme for World Patient Safety Day 2022. WHO has launched a series of webinars to introduce the strategic framework for implementation of the Challenge, technical strategies, tools and provide technical support to countries for reducing medication-related harm. The webinars share country and patient experiences in implementing the Challenge. This webinar focuses on the role of patients and their families in improving medication safety, recognising that they are the only constants in increasingly complex healthcare systems, and that they can provide essential information and feedback.
  13. Event
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    East Midlands and West Midlands Patient Safety Collaboratives will be hosting a webinar on appreciative inquiry (AI). Hosted by Appreciating People, it will focus on ‘what works’ and the existing strengths and assets of people, team and organisations. The pandemic and current working challenges has shown how resilient and creative the maternity and neonatal workforce has been, so this workshop aims to support you to build upon your current knowledge and experiences. The webinar will share tools to focus on levering and amplifying strengths, and there will be time for reflective conversation with colleagues. AI helps build psychological safety and is extensively used by many NHS trusts who are part of Learning From Excellence. Register for the webinar
  14. Event
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    Join cross-sector leaders and their learning partners to explore the role the voluntary sector can play in helping to tackle health inequalities in neighbourhoods, places and Integrated Care Systems (ICSs). As ICS structures are set to become formalised in July, The King’s Fund, Innovation Unit and Institute for Voluntary Action Research are providing support to understand effective cross-sector collaboration. Together, they will share learning from work in partnership with, or funded by, The National Lottery Community Fund, and profile people doing it on the ground. This webinar will spotlight three place-based partnerships that have been working to address health inequalities in their areas: Supported by the Innovation Unit Andrew Billingham and Lisa Cowley from Beacon Vision, representing the Dudley & Wolverhampton Health Equality Development Grantee partnership in conversation with Steve Terry, Head of Engagement, Black Country & West Birmingham ICS. Steve has recently moved into this role having previously been funded through the ICS to explore Engagement & Partnership with VCSE. The Dudley & Wolverhampton Healthy Communities Together Project has partnered with Steve and others to create a culture of change across the system. The work focuses on empowering and enabling positive impacts both in terms of service delivery and integration to make long lasting improvements for people and communities. Supported by the King’s Fund Neil Goulbourne, Director of Strategy, Planning and Performance, One Croydon, will reflect on experience in building a shared agenda, trust and partnership working to support a move to better understanding health and wellbeing needs at neighbourhood level. One Croydon plan to use that insight to commission new health services from a more diverse range of providers. Supported by the Institute for Voluntary Action Research Sonal Mehta, Partnership Lead (VCSE) for Bedfordshire, Luton and Milton Keynes Integrated Care System, will share an approach to setting up a Health and Wellbeing Alliance in Milton Keynes. Their aim was to involve the voluntary sector in strategic discussions about the design and commissioning of health and care services. As well as hearing from experienced system leaders in the NHS, Local Authority and voluntary sector about how cross-sector collaboration can drive health improvements for local people, there will be space for networking and discussion. Who is this event for? Colleagues working at place or system level within emerging Integrated Care Systems, policy professionals in NHS England and Improvement, and local VCSE organisations. Networking opportunity Following our webinar, we will be running a 45 minute informal networking session. Meet other cross-sector leaders and reflect on what you’ve heard, and what it means for your own work. Register for this webinar
  15. Event
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    Virtual wards were a key part of the response to the early phases of the pandemic and again to Omicron. Indeed, in late December 2021 NHS England issued urgent guidance saying a minimum of 15 per cent of covid positive hospital patients should be treated in virtual wards. And the national body’s 2022/23 priorities and operational planning guidance – issued around the same time – goes further, stating that “the scope for virtual wards is far greater”. By the end of 2023, systems are expected “to have completed the comprehensive development of virtual wards towards a national ambition of 40–50 virtual beds per 100,000 population”. Funding has been promised to support this transformation. So can virtual wards work at scale in the NHS? Is it possible to make such setups part of business at usual? What do we know about how to most effectively implement virtual wards? What are potential challenges and how can they be overcome? Is the 2023 target realistic – and desirable? This HSJ webinar, run in association with Doccla, will bring together a small panel of experts to discuss the answers to these questions. Panellists Tara Donnelly, director of digital care models, NHS England and NHS Improvement Fiona McCann, respiratory consultant and clinical lead for respiratory medicine, Northampton General Hospital Trust Martin Ratz, founder, Doccla Matthew Winn, chief executive, Cambridgeshire Community Services Trust and national director of community health, NHS England and NHS Improvement Claire Read, contributor, HSJ (chair) Register for the webinar
  16. Content Article
    This article in the journal JAMA Network Open aimed to determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish antibiotic stewardship programs focusing on patient safety, is associated with reductions in antibiotic use in long term care settings. The authors looked at 439 long term care settings and found that participation in training on antibiotic stewardship from AHRQ was associated with a reduction in antibiotic use and urine culture collection. Fluoroquinolones, an antibiotic class targeted by the AHRQ safety program, had the greatest decrease.
  17. Content Article
    In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the difficulties people experience in disposing of needles and injection devices safely at home. Variation in services across the UK can lead individuals to dispose of sharps incorrectly, posing a risk to refuse workers and the wider public.
  18. Content Article
    This blog by GP Dr Abbie Brooks examines rising patient demand for GP services and the need to manage patient expectations around appointment waiting times. It looks at the impact of the pandemic, and how patients can help primary care cope with increased demand by ensuring they are using the appropriate NHS service for their needs and being patient while waiting for initial and follow up appointments.
  19. Event
    This webinar from The European Hospital and Healthcare Federation (HOPE) on 29 March at 14:00 BST (15.00 CEST) will look at the Flemish Institute for Quality of Care (VIKZ). VIKZ is a network organisation financed by the Flemish government that has as primary goal to measure, follow up and publicly report quality and safety of care in the Flemish healthcare sector for the purpose of quality improvement. The objectives of the webinar are to: present the methodology used. give an overview of preliminary results. discuss challenges and future objectives of the VIKZ. Speaker Svin Deneckere, director Flemish Institute for Quality of Care (VIKZ) Register
  20. Content Article
    The Green Book is published by the UK Health Security Agency and contains the latest information on vaccines and vaccination procedures for vaccine-preventable infectious diseases in the UK.
  21. Content Article
    The spread of the Covid-19 pandemic presented significant challenges in the management of patients with chronic diseases like multiple sclerosis (MS). This article in Frontiers in Neurology looks at how telemedicine was used as an alternative to face-to-face consultations with MS patients during the pandemic. Recognising the variation in care that occurred as different centres adopted telemedicine, they make a series of recommendations for the use of telemedicine in managing MS patients.
  22. Content Article
    In this article for The BMJ, Partha Kar, consultant in diabetes and endocrinology, looks at the importance of education and peer support in self-management for people with long-term conditions. He looks at how diabetes peer support and education programmes have adapted to the need for remote access during the pandemic, and suggests that increased access to these elements of diabetes care may have helped reduce diabetic ketoacidosis hospital admissions during the first wave of Covid-19.
  23. Event
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    The King's Fund and Healthwatch England join forces on 28–31 March 2022 to explore how meaningful engagement and listening to people’s experiences can result in better-quality care. We will all need to use health and social care services at some point in our lives. Many complex factors can influence the quality of care we receive. However, policy-makers and researchers are increasingly highlighting the importance of putting people's voices at the centre of organising and planning health care services. Although seen as important, listening to people properly, harnessing the lessons from feedback and implementing them to make changes is not always straightforward. How can the NHS and social care services ensure that they really listen to and learn from people and communities? Event topics How to listen well – we'll show you examples of good-quality engagement and the methods you can use to implement these How you can improve commissioning and service delivery by listening to people How public engagement is a critical asset in the battle against health inequalities How people’s voices are already making a difference to strategy and policy-making The opportunities to ensure people’s voices are used meaningfully within integrated care systems. Buy tickets
  24. Content Article
    Sharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this blog, Sharon reflects on events that have unfolded since the publication of the Independent Medicines and Medical Devices Safety Review 'First Do No Harm' report and the Government's response to it. She examines ongoing failures in the government's response and fulfilment of their policy recommendations. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Primodos: The next steps towards justice (November 2020) Mesh: Denial, half-truths and the harms (March 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy
  25. Content Article
    Focused practice is an approach to primary care where a family doctor or GP chooses one or more specific clinical areas as a major part-time or full-time component of their practice. In recent years, there has been a global increase in focused practice and a decline in offering a comprehensive scope of practice in primary care. This Canadian study in the British Journal of General Practice looked at factors influencing family doctors' decisions to work in focused practice. The authors of the study concluded that: both early-career and resident family doctors unanimously saw focused practice as a way to avoid the burnout or exhaustion they associated with comprehensive practice in the current structure of the healthcare system. more research is needed to understand the implications of family physician choices of focused practice within the physician workforce.
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