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Claire Cox

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Everything posted by Claire Cox

  1. Content Article
    This anonymous blog high lights the vulnerability of patients, especially when it come to consent. This is a shocking account of events by a well informed patient when they were wrongly consented for a gynaecological procedure.
  2. Content Article
    AvMA was originally established in 1982 as Action for the Victims of Medical Accidents following public reaction to the television play Minor Complications by AvMA’s founder Peter Ransley. The name was changed in 2003 to Action against Medical Accidents. Since its inception, AvMA has provided advice and support to over 100,000 people affected by medical accidents, and succeeded in bringing about massive changes to the way that the legal system deals with clinical negligence and in moving patient safety higher up the agenda in the UK.
  3. Content Article
    Promoting patient and occupational safety are two key challenges for hospitals.  Recent studies have shown there are key topics that are interrelated and form a critical foundation for promoting patient and occupational safety in hospitals. So far, these topics have mainly been studied independently from each other. This study did a combined assessment of hospital staffs’ perceptions of four different topics: psychosocial working conditions leadership patient safety climate occupational safety climate.
  4. Content Article
    The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process supported by the Resuscitation Council (UK) and UK Royal Colleges to create personalised anticipatory care plans for patients. Hampshire Hospitals NHS Foundation Trust has been an early adopter of this process with variability in engagement with this process across our trust. Published in Progress in Palliative Care, this paper describes a quality improvement project was performed to improvement engagement with ReSPECT as well as consistency and quality of documentation.
  5. Content Article
    Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture). Safety-I and Safety-II is written for all professionals responsible for their organisation's safety, from strategic planning on the executive level to day-to-day operations in the field. It presents the detailed and tested arguments for a transformation from protective to productive safety management.
  6. Content Article
    Given an unacceptably high incidence of diagnostic errors, the authors sought to identify the key competencies that should be considered for inclusion in health professions education programmes to improve the quality and safety of diagnosis in clinical practice. Olsen et al. believe that one of the most promising and sustainable ways to improve diagnosis is to improve education and training in the health professions. The first step in this process is to define the outcomes that trainees in each profession must achieve in order to be effective members of a diagnostic team in the modern healthcare setting. This paper, published in Diagnosis journal, defines these competencies.
  7. Content Article
    Speaking up, raising concerns, whistleblowing. However you describe it, we know it can be daunting. Supporting 'National Speak Up Month' , the General Medical Council (GMC) has provided advice and tools to help you.
  8. Content Article
    Through speaking with Royal College of Paediatrics and Child Health (RCPCH) Members, child health workers and reviewing existing resources, it was identified that there was a lack of practical 'how to' materials to support professionals in delivering face to face sessions with children, young people and families. The impact was two-fold. Some professionals felt they didn’t have the confidence or skills to involve children, young people or families and ensure they had a voice. In addition,  young patients and their families were not consistently involved in providing feedback on services, in identifying gaps, reviewing service deliverables and being involved collaboratively with professionals to develop and test solutions. Ultimately it provides a missed opportunity to provide a service-user centred service that meets their needs as well as the potential for reducing long term disengagement with treatment plans.  This would inevitably impact on patient safety.  By having a service that actively listens and involves the service users strategically, is fit for purpose, meets the needs of the patient, family and professional and has shared ownership in developing the best service possible, services can become more effective and efficient. 
  9. Content Article
    Inpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
  10. Content Article
    Rob Behrens talks to Dr Henrietta Hughes, the National Guardian for the NHS. Dr Hughes explains how her career as a GP has helped her in her national role and how NHS organisations can better support their Freedom To Speak Up Guardians.
  11. Community Post
    Lets talks NEWS... Nurse and carer worry, I like to think that Critical Care outreach teams take this very seriously and that the 'worry' has a heavy influence in our management. Many of our patients may score 0, but warrant a trip to the ITU (AKI patients for instance). However, as part of our escalation policy it states that staff should alert the doctor and or the Outreach team when NEWS is 5 or 3 in one parameter. This causes the 'radar referral effect'. We often have a group of these patients on our list. Personally, I find them difficult to prioritise as they are often receiving frequent observations and have a plan. By concentrating on this group and make sure they have everything in place can take time, but... what about those not scoring in this threshold? Do they get pushed to the bottom of the list? Should nurses follow this protocol to safeguard themselves as well as the patient or are we not looking for sick patients in the right place? Don't get me wrong, the NEWS has been revolutionary in the way we deal with deterioration, but as a tool to prioritise this may not be the case. There are softer signs at play here....has anyone got any solutions to deal with the 'radar referals' Lots to discuss @Ron Daniels @Emma Richardson @LIz Staveacre @Danielle Haupt @Kirsty Wood
  12. Content Article
    A great  initiative by East Sussex Healthcare NHS Trust to reinforce the importance of basic checks to keep patients from harm when administering medicines.
  13. Content Article
    The National Institute for Healthcare Research (NIHR) are the nation's largest funder of health and care research and provide the people, facilities and technology that enables research to thrive. Working in partnership with the NHS, universities, local government, other research funders, patients and the public, they deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.
  14. Content Article
    As improvement practice and research begin to come of age, Mary Dixon-Woods in this BMJ feature considers the key areas that need attention if we are to reap their benefits. Mary Dixon-Woods is the Health Foundation Professor of Healthcare Improvement Studies and Director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety, she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians.
  15. Content Article
    Following the inquest into the death of former patient Amy Allan and the subsequent Preventing Future Deaths report given to Great Ormond Street Hospital for Children, Chief Executive Matthew Shaw would like to outline how the hospital is learning from this and what action has been taken to address the concerns that have been raised.
  16. Content Article
    The All Party Parliamentary Group (APPG) for Whistleblowing was launched in July 2018 to look at the case for an Independent Office for the Whistleblower. The APPG have set an ambitious workplan aiming to take back the UK’s lead on this legislation, proposing to deliver world class, gold standard draft legislation – a global solution to a global problem. The objectives of the APPG for Whistleblowing are: Influencing policies and decisions that affect whistleblowers globally. Drafting legislation to ensure effective protection for whistleblowers. Commissioning and publishing research, based on our work with whistleblowers and relevant groups and stakeholders across all sectors. Engaging our supporters in campaigns to influence decisions affecting whistleblowers. Giving whistleblowers safe platforms to speak out on issues affecting them. Promoting positive social attitudes towards whistleblowing. Encouraging MPs to promote positive recognition for whistleblowers. Supporting and upskilling MPs and their staff to identify and manage constituent whistleblower cases.
  17. Content Article
    A report for Norfolk and Suffolk NHS Foundation Trust by Verita.  Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for regulated organisations. 
  18. Content Article
    In 2016, a national review by the Care Quality Commission (CQC) found that the NHS was missing opportunities to learn from patient deaths and that too many families were not being included or listened to when an investigation happened. A key recommendation from this review was that a national framework be developed, so that NHS Trusts have clarity on the actions required when someone dies in their care. The National Guidance on Learning from Deaths published by the National Quality Board (NQB) in March 2017, recommended all Trusts to publish a policy on how the organisation responds to and learns from deaths of patients who die under their management and care. The frameworks purpose is to initiate a standardised approach for reporting, investigating and learning from deaths in care. 
  19. Content Article
    The National Guidance on Learning from Deaths was published by the National Quality Board in March 2017 to initiate a standardised approach, ensuring that learning from a review of the care provided to patients who die should be integral to a provider’s clinical governance and quality improvement work. To fulfil the standards and new reporting, this policy identifies and highlights: The Trust’s governance arrangements. The Trust’s processes on reporting, reviewing and investigation of deaths, including those deaths that are determined more likely than not to have resulted from problems in care. The Trust’s processes, to share and act upon any learning derived from these processes.
  20. Content Article
    The National Mortality Case Record Review Programme (NMCRR) aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. As well as improve understanding and learning about problems and processes in healthcare that are associated with mortality.
  21. Content Article
    This policy confirms the process for reviewing deaths within Lincolnshire Community Health Services (LCHS) to ensure a consistent approach is followed in order to identify if the patient’s needs were met during the end of life phase and that relatives and carers were supported appropriately. The aim of the mortality review process is to identify any areas of practice that require improvement and to identify areas of good practice. This process ensures that mortality within LCHS is managed and reviewed in a systematic way.
  22. Content Article
    The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America's health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions. This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report. This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety.
  23. Community Post
    @Yesh How do we engage patients in the Operating room?
  24. Content Article
    Inclusion Healthcare, a social enterprise, provides primary medical services for homeless people in Leicester. It was rated outstanding following its CQC inspection in November 2014. CQC inspectors found strong leadership at its heart and a positive culture that ensures patient safety is paramount. In this short film, we hear from service users and staff and find out how they are promoting patient safety. 
  25. Content Article
    Nurses can have a remarkable impact in the criminal justice system. In this film, we hear from three men who have had their lives changed by Jo Tomlinson, Lead Anxiety Nurse at HMP Stafford.
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