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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this blog, Clare Rayner, an occupational physician, describes how an international collaboration to help understand Long Covid was established by harnessing the power of technology and social media. This collective, between a group of UK doctors experiencing prolonged health problems after Covid-19 infection and a globally renowned rehabilitation clinic at Mount Sinai Hospital in New York, aims to help both patients and healthcare professionals by disseminating learning about Long Covid from both sides of the Atlantic.
  2. Content Article
    In this blog, Aimee Robson, Deputy Director of Personalised Care at NHS England, talks about how healthcare workers can introduce one simple question into their communication with patients: “What matters to you?” She highlights that facilitating dialogue with patients about their own priorities is the first step in achieving personalised care, a key commitment outlined in the NHS Long Term Plan.
  3. Content Article
    'Deep End’ general practices serve communities in the most socioeconomically disadvantaged areas. The analogy of the deep end of the swimming pool to describe how a one size fits all funding model for NHS GP practices regardless of area-based differences in patient needs leaves health professionals in high-deprivation places treading water to stay afloat. Lincolnshire’s East Coast is now amongst the most deprived communities in the UK. This in-depth article in BJGP Life reports on an event for local healthcare professionals and academic researchers hosted by First Coastal Primary Care Network (FCPCN) in November 2021, in Skegness, Lincolnshire. The aim of the event was to discuss the challenges that health professionals working within the FCPCN face with a focus on inequities and the experiences of the healthcare workforce.
  4. Event
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    The Safety for All campaign has organised this webinar in partnership with NHS Supply Chain and Patient Safety Learning. It will look at the challenges in healthcare supply chain and patient and staff safety. As we emerge from Covid restrictions, it is timely to look back and forward at the challenges facing the supply chain in healthcare, but also to ensure that safety for both patients and staff are prioritised amongst the other challenges facing the NHS and social care in the future. The webinar will be chaired by Jonathan Hazan, Chair of Patient Safety Learning, and will feature a keynote speech from the Chair of NHS Supply Chain, Heather Tierney-Moore. Heather will discuss Supply Chain’s role in supporting the NHS to deliver safe and excellent patient care, safety, sustainability, resilience and efficiency. This will be followed by a panel discussion with representatives from supply chain, patient safety, industry and the MHRA and a further session on how human factors need to be integrated into the process of delivering safety in healthcare. Finally, there will be a case study on a patient and staff safety issue in perioperative care and how better procurement can help deliver better care and safety in infection prevention. The webinar will be hosted on Microsoft Teams, join the webinar using this link. Full Webinar Programme
  5. Content Article
    This webpage from the British Medical Association (BMA) contains analysis of NHS data and is updated monthly. It highlights the growing backlogs across the NHS and includes operations data and information on the cancer waiting list, GP referrals and A&E waiting times.
  6. Content Article
    Promoting a ‘just culture’ is a key theme in patient safety research and policy, reflecting a growing understanding that patients, their families and healthcare staff involved in safety events can experience feelings of sadness, guilt and anger, and need to be treated fairly and sensitively. There is also growing recognition that a ‘blame culture’ discourages openness and learning. However, there are still significant difficulties in listening to and involving patients and families in organisations' responses to safety incidents, and for healthcare staff, a blame culture often persists. This can lead to a sense of sustained unfairness, unresponsiveness and secondary harm. The authors of this article in BMJ Quality & Safety argue that confusion about safety cultures comes in part from a lack of focused attention on the nature and implications of justice in the field of patient safety. They make suggestions about how to open up a conversation about justice in research and practice.
  7. Content Article
    General practice has always been the foundation and gateway to the NHS, but this part of the healthcare system is now under strain due to greater demand from an increasingly complex patient profile, and a stretched workforce. Lack of staff and coherent planning means that the current model is not fit for purpose, and this has resulted in a recent decrease in patient satisfaction. This proposal by the think tank Policy Exchange outlines the reforms that could help the NHS develop a model of general practice to better meet the needs and interests of patients and healthcare workers.
  8. Content Article
    Medical research is progressing to clarify the full range of sub-acute and long-term effects of post-COVID-19 syndrome (Long Covid), but most manuscripts published to date only analyse the effects in patients discharged from hospital, which may induce significant bias. This Spanish study in the journal Scientific Reports aimed to analyse the single and multiple associations between post-COVID-19 characteristics with up to six months of follow-up in hospitalised and non-hospitalised Covid-19 patients. Key findings include: At six months follow-up, fatigue, arthralgia, fever, breathlessness, emotional disturbance, depression, cognitive deficit, haemoglobin, total bilirubin, and ferritin are correlated with the gender of the patient Patients with previous respiratory diseases and abnormal body mass index, ex-smoker, and dyspnoea had a robust statistically significant association. Non-hospitalised patients may suffer more severe thromboembolic events and fatigue than hospitalised patients. Functional lung tests are good predictors of chest CT imaging abnormalities in elderly patients with Long Covid.
  9. Content Article
    The Perfect Patient Information Journey is Patient Information Forum's long-running project investigating how high-quality information can be provided throughout a person’s journey with a long-term condition.
  10. Event
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    This webinar is part of the HSJ Elective Care Recovery Virtual Series. To clear the waiting list backlog, hospitals will need to drive more elective activity within capacity and resource constraints. It demands the need to think differently and to work differently, questioning assumptions about the ‘normal’ ways of doing things. In this session we’ll explore innovative ideas, digital interventions and transformation programmes designed to free up time in elective pathways. Key topics include: Patient-initiated follow-ups Reducing outpatient appointments Pre-operative transformation / digitisation Investing in digital tools to improve efficiency in elective care pathways Register
  11. Event
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    In the first of the Health Services Journal (HSJ) Elective Care Recovery Virtual Series, we’ll be exploring the requirements of the Elective Recovery Plan – which was published in February - and the role that digital innovations can play in tackling long waiting lists and ensuring patients are prioritised by clinical need. We will start by hearing from Sir Jim Mackey, chief executive, Northumbria Healthcare Trust and national director for elective care recovery about the broad direction of the plan and its key asks of NHS organisations. Then we will look at the role that digital innovations can play in supporting patients and clinicians and hear from some examples where this has been put into practice. Viewers will be able to pose questions to the panellists during the discussion. Speakers include: Sir James Mackey, national director of elective recovery and chief executive, Northumbria Healthcare Foundation Trust Viki Jenkins, heart failure advanced nurse practitioner and echocardiographer, Betsi Cadwaladr University Health Board James Illman (Chair) Register
  12. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old.
  13. Content Article
    This article details the case and findings of an investigation by the Parliamentary and Health Service Ombudsman (PHSO) into the death of Stephen Durkin. Stephen died after suffering organ failure from sepsis, while under the care of Wye Valley NHS Trust. His wife, Michelle Durkin, subsequently made a complaint that delays in the diagnosis and treatment of sepsis led to her husband’s death.
  14. Content Article
    Since the start of the pandemic, the number of people waiting for NHS treatment in England has grown to 6.1 million - the highest level since comparable records began – and is expected to rise further as those who have missed out on care come forward. In February 2022, the government published the NHS elective recovery plan which aims to increase NHS treatment capacity to 30% above pre-pandemic levels by 2024−25. However, there are many uncertainties around the future demand for care and the number of ‘missing’ patients who will eventually return to seek NHS care. This tool developed by the Institute for Fiscal Studies (IFS) allows you to simulate how waiting lists may change over the next four years under different assumptions.
  15. Content Article
    This systematic review in the BJGP aimed to review literature published up to December 2020 on the prevalence of burnout among GPs in general practice, and to determine GP burnout estimates worldwide. The review found: there is moderate to high GP burnout around the world. substantial variations in how burnout is defined, which has resulted in considerable variation in GP burnout prevalence estimates. that this variation presents a challenge in developing a uniform approach that considering GPs' work contexts will allow better understanding and definition of burnout.
  16. Content Article
    This study in the Journal of Patient Safety examined how hospitals outside mandatory 'never event' regulations identify, register, and manage 'never events', and whether practices are associated with hospital size. In Switzerland, there is no mandatory reporting of 'never events' and little is known about how hospitals in countries without 'never event' policies deal with these incidents in terms of registration and analyses. The study found that many Swiss hospitals do not have valid data on the occurrence of “never events” available, and do not have reliable processes installed for the registration and examination of these events. Surprisingly, larger hospitals do not seem to be better prepared for “never events” management.
  17. Content Article
    Samantha Gould was 16 years old when she died by suicide due to an overdose of prescribed medication on 2 September 2018. She had borderline personality disorder that meant she was at risk of deliberate self-harm and suicide. In this report, the Coroner highlights concerns about a systemic weakness in the way in which Child and Adolescent Mental Health Services and primary care communicate with local pharmacies concerning 16-18 year old patients who are at risk of deliberate overdose. In spite of a safety plan agreed with Sam’s consultant psychiatrist whereby Sam’s parents would be responsible for her medication, Sam was able to pick up older prescriptions on 1 September 2018 without challenge, and it was those medications that were fatal in the combined amounts ingested by Sam.
  18. Content Article
    This blog summarises investigations about Covid-19 and its impact on the healthcare system carried out by the Healthcare Safety Investigation Branch (HSIB). It highlights learning from five HSIB reports: COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation Early warning scores to detect deterioration in COVID-19 inpatients Oxygen issues during the COVID-19 pandemic Treating COVID-19 patients using continuous positive airway pressure (CPAP) Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response
  19. Content Article
    In this blog for BJGP Life, GP and Public Health Specialty Registrar Richard Armitage looks at the patient safety implications of changes made to gender markers on patient records. Patients in the UK are able to change the gender marker on their NHS patient record on request at any time. This action triggers the creation of a new NHS number and imports the patient’s medical information into a new patient record, without any reference to the patient's previous gender identity or original NHS number. The author highlights that failure to transfer this information could inhibit high quality care for trans patients, especially with regard to population screening programmes which invite patients according to age and gender markers on their patient record. He argues that public health officials, in collaboration with their primary care colleagues, should: respectfully communicate sex-specific health risks with their trans patients encourage them to consider requesting and accessing the appropriate population screening programmes support them in accessing screening in a dignified manner.
  20. Content Article
    Debriefing after a patient death or serious incident is important for staff wellbeing, especially in the emergency medicine environment. While on placement in an emergency department, medical student Max Sugarman realised there was no debrief for staff or students involved in critical incidents. This led him to develop the TAKE STOCK hot debrief tool, which is an adaption of the STOP5 model created by Edinburgh EM and the Scottish Centre for Simulation and Clinical Human Factors. In this blog, Max talks about how critical incidents affect staff, how to make time for debriefs and how the TAKE STOCK tool works in practice.
  21. Content Article
    Skin cancer is one of the most common cancers worldwide, with one in five people in the US expected to receive a skin cancer diagnosis during their lifetime. Detecting and treating skin cancers early is key to improving survival rates. This blog for The Medical Futurist looks at the emergence of skin-checking algorithms and how they will assist dermatologists in swift diagnosis. It reviews research into the effectiveness of algorithms in detecting cancer, and examines the issues of regulation, accessibility and the accuracy of smartphone apps.
  22. Content Article
    This article in the Journal of Diabetes Science and Technology reviews the literature from various geopolitical regions and describes how a substantial number of patients with diabetes improperly discard their sharps. Data support the need to develop multifaceted and innovative approaches to reduce the risks associated with improper disposal of medical sharps into local communities.
  23. Content Article
    Employers have a duty of care to support doctors when they are faced with an abusive patient or their guardians/relatives. This guidance from the British Medical Association (BMA) gives background information and steps that all employers and healthcare workers should take when discrimination against a healthcare worker occurs.
  24. Content Article
    The Covid-19 pandemic has presented new challenges for patients with non-communicable diseases (NCDs) as healthcare systems experience increased resource constraints, conflicting priorities, challenges related to emerging or re-emerging diseases, and difficulties in prioritising NCD services. This report summarises a World Health Organization (WHO) meeting held in December 2020 that aimed to harness the power of community knowledge to tailor priorities, programmes and practices for NCDs and mental health, so that they are realistic, appropriate and attractive to the target populations. Patient experts and representatives with NCDs addressed the following questions: What does meaningful engagement mean? How do we engage meaningfully? Where do we go from here?
  25. Content Article
    This article in the journal Health Affairs describes the three essential elements of shared decision making: Recognising and acknowledging that a decision is required Knowing and understanding the best available evidence Incorporating the patient's values and preferences into the decision. The authors argue that more physicians need training in the approach, systems need to be reorganised around the principles of patient engagement, and more research is needed to identify which interventions are most effective.
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