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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    In this blog for National Voices, Eamonn Dunne writes about working together for health service equity for blind and partially sighted people.
  2. News Article
    Artificial intelligence could be used to figure out the causes of “disgraceful” structural problems like the higher rates of maternal mortality for black women, a minister told a conference yesterday. Health minister Karin Smyth said AI could be used not only for clinical and administrative functions but also to “diagnose” issues. She also said the way government funded AI adoption needed to change. Ms Smyth, a former NHS manager, was giving her first speech as a minister at a Health Foundation conference on AI. The conference also heard from leading tech experts who said the UK was “exceptionally well placed for a global leadership role in health and AI”. Read full article (paywalled) Source: HSJ
  3. News Article
    Almost a quarter of people do not know the difference between a physician associate and a doctor, according to a new poll. While 52 per cent of people can differentiate between the two roles, some 23 per cent said they did not know the difference, the survey conducted for Healthwatch England has revealed. The organisation, which represents the interests of patients across England, has called for more clarity around the role of physician associates (PAs). Read full article Source: Independent
  4. News Article
    Health service IT systems are back online following Friday’s global outage, according to NHS England. However, it has warned that there may still be disruption, particularly with GP services who may need time to rebook appointments. Read full article Source: BBC News, 22 July 2024
  5. Content Article
    The Patient Safety Partner (PSP) role was introduced in 2022 by NHS England as part of its Framework for involving patients in patient safety and National Patient Safety Strategy. Trusts across England must recruit at least one Patient Safety Partner. They can be patients, carers or members of the public who want to support and contribute to an organisation’s governance and management processes for patient safety. In this blog, we draw on discussions from the Patient Safety Partners Network and a recent workshop, to highlight the need for role clarity and guidance for Patient Safety Partners. We share insights from areas of good practice, where the role has been well supported and integrated locally. These examples show how clarity and guidance has helped remove barriers, enabling Patient Safety Partners to have a positive impact for patient safety, as intended. 
  6. Community Post
    Patients are increasingly being asked to access online systems to: request prescriptions or make medication requests access healthcare records and test results make appointments communicate health concerns sign consent forms. These developments can have a positive impact but they can also carry potential challenges, as highlighted in this recent blog - Digital-only prescription requests: An elderly woman sent round the houses. We'd like to hear your experiences of using online systems in healthcare. Have they made things easier? Does it feel like your care is more joined up for it? Have any of these changes been challenging? If so why? Comment below (sign up first for free) or contact us directly at content@patentsafetylearning.org to share your experience.
  7. Content Article
    This blog is part of a series written by Dr Charlie*, taking a closer look at some of the patient safety issues affecting people's lives today. In this blog Dr Charlie describes how their homeless friend Robbie* has struggled to access the care and clarification he needed around his liver abscesses. Dr Charlie explains how important it is for healthcare professionals to take into account individual circumstances if they are to provide people with the information and care they need. *not their real name
  8. Content Article
    This article published by The Justice Gap highlights new research that has revealed the psychological toll of the inquest system on people whose loved ones die in contested circumstances, including struggling with a complicated legal process and suffering due to cuts to the system.
  9. Community Post
    @blueiii I am so sorry to hear about your painful and traumatic experience. The points that you and many others have raised, are incredibly important and we refer to this forum when we connect with others in the gynae space, highlighting the need for urgent improvement. More recently we have been seeking examples of good practice to share, with the aim of helping others learn from their work to provide safer care. We have also been working with researchers who have been exploring this area. I am including a few links below to content that may be of interest. Many of the issues raised by patients undergoing IUD procedures mirror those we have heard in relation to hysteroscopies. So I have also included a piece we wrote calling for action on that. Better data collection, patient reported outcomes and making sure women can have access to all of the available pain relief options (with the relevant information) would be a start to improving things. You'll see from the example in one of the links below that the team in Oxford also have a complex pathway for patients who they identify as having the potential to experience high levels of pain or trauma. It is a flexible system, based on listening to the patient - another key area for improvement. There is so much to learn in this space, to make sure patients don't continue to suffer as you have or lose trust. Fitting coils: developing a safe and supportive service Pain experiences during intrauterine device procedures: a thematic analysis of tweets (11 June 2024) Coil procedures: Exploring negative experiences through qualitative research (an interview with Sabrina Pilav) The ripples of trauma caused by severe pain during IUD procedures (BMJ Opinion, July 2021) Hysteroscopy: 6 calls for action to prevent avoidable harm
  10. Content Article
    The Framework serves to guide efforts to deliver safe and sustainable water, sanitation and hygiene (WASH), health care waste management and reliable electricity in all health care facilities. The ultimate aim is to provide quality care for all. The Framework reflects a global consultative process and includes data and recommendations articulated in recent WHO/UNICEF global reports on WASH, waste and electricity in health care facilities. It also provides an operational roadmap for implementing the 2023 United Nations General Assembly (UNGA) resolution on WASH, waste and electricity in health care facilities. The target audiences for this Framework include health leaders and programme managers at the global and national levels; policymakers; WASH, waste and energy leaders and technical experts; development partners and finance institutions; and actors and experts on gender equality, disability and social inclusion and climate; and, more generally, civil society. The Framework addresses the WASH, waste and electricity elements of the WHO comprehensive approach to build safe, climate-resilient and environmentally sustainable health care facilities.
  11. Content Article
    Antimicrobial resistance (AMR) is a major global health problem. Efforts to mitigate AMR prioritise antimicrobial stewardship (AMS) interventions. These interventions typically focus on deficiencies in practice and providing negative or normative feedback. This approach may miss opportunities to learn from success. Authors aimed to identify factors that enable success in AMS practices in the paediatric intensive care unit (PICU) by analysing the data obtained from interviews with staff members who had achieved success in AMS. The insights gained in this study originate from frontline staff who were interviewed about successful work-as-done. This strengths-based approach is an understudied area of healthcare, and therefore offers authentic intelligence which may be leveraged to effect tangible improvement changes. The methodology is not limited to AMS and could be applied to a wide range of healthcare settings.
  12. Content Article
    The combined pituitary clinic (CPC) at the Royal Victoria Infirmary is a unique ‘hybrid’ clinic that enables patients to attend a multi-professional clinic that mirrors that of a multidisciplinary team. Patients have the opportunity to interact with all members of the MDT, provide their personal values and preferences and discuss treatment options. Interestingly the professional viewpoint on this topic has been well characterised in the literature, however the patient experience and participation in an MDT setting has not been explored for any cancer. The CPC provides an exclusive and timely opportunity to characterise the patient response to an MDT-like setting. This PowerPoint slide (link below) explains more about the project and the findings.
  13. Content Article
    How are community groups bridging some of the gaps between Black mothers and health and care services? What can the health and care system learn in response? Siva Anandaciva speaks to Amanda Smith, founder and Chief Executive of Maternity Engagement Action CIC, Benash Nazmeen, Professor of Midwifery and co-founder and co-director of the Association of South Asian Midwives CIC, and Chrissy Brown, founder and Chief Executive of the Motivational Mums Club CIC, to find out.
  14. Content Article
    Tanya Buxton is a medical tattoo artist providing 3D areola-nipple tattoos within the NHS and private healthcare. In this Blog, she explains more about her work and how it can benefit a patient post-surgery. Tanya also raises a number of safety concerns relating to poor standards of education in this area of healthcare, highlighting the harm this can cause patients both physically and emotionally.
  15. Content Article
    During the diagnostic process, clinicians may make assumptions, prematurely judge or diagnose patients based on their appearance, their speech or how they are portrayed by other clinicians. Such judgements can be a major source of diagnostic error and are often linked to unconscious cognitive biases - faulty quick-fire thinking patterns that impact clinical reasoning. Patient safety is profoundly influenced by cognitive bias and language, i.e. how information is presented or gathered, and then synthesised by clinicians to form and communicate diagnostic decisions. Here, authors discuss the intricate links between interpersonal communication, cognitive bias, and diagnostic error from a patient's, a linguist's and clinician's perspective. They propose that through patient engagement and applied health communication research, we can enhance our understanding of how the interplay of communication behaviours, biases and errors can impact upon the patient experience and diagnostic error. In doing so, they provide new avenues for collaborative diagnostic error research striving towards healthcare improvements and safer diagnosis.
  16. Content Article
    The Voicing Loss project is a collaboration between the Institute for Crime & Justice Policy Research at Birkbeck, University of London, and the Centre for Death & Society at the University of Bath. The research was conducted from May 2021 to May 2024, with funding from the Economic and Social Research Council. The research examined the role of bereaved people in coroners’ investigations and inquests, as defined in law and policy and as experienced in practice. It also explored ways in which the inclusion and participation of bereaved people in the process can be better supported. A range of project outputs are available via the dedicated Voicing Loss project website. They include a short research summary, along with thematic research reports and policy and practice briefings. The website also has an information and resources section for the general public, and an Expert Insights blog to which many stakeholders have contributed.   Many of the study’s key findings, and the research context and methodology, are presented in the papers listed on the website. Implications of these findings for policy and practice are considered in a series of briefings also available through the website which you can access via the link below.
  17. Content Article
    Anthony O’Connor is a co-production and lived experience consultant. In Anthony's first blog for Patient Safety Learning, he looked lived experience, its definition, its usage, and its impact.   In this blog, he talks about the benefits of co-production and why it is essential to patient safety. Anthony gives examples of how co-production can be used more in healthcare and encourages everyone to develop their knowledge of co-production and start embedding it into their work. 
  18. Content Article
    I work primarily in the areas of lived experience and in co-production, and I strive to have both of these concepts better understood, and more effectively utilised wherever possible. Nowhere is this more important than the world of patient safety. In this first blog for Patient Safety Learning I will concentrate on lived experience, its definition, its usage, and its impact. 
  19. Content Article
    In June 2021, high-profile testimonials in the media about pain during intrauterine device (IUD) procedures in the UK prompted significant discussion across platforms including Twitter (subsequently renamed X). Authors of this study published in BMJ Sexual and Reproductive Health, examined a sample of Twitter postings (tweets) to gain insight into public perspectives and experiences. They harvested tweets posted or retweeted on 21–22 June 2021 which contained the search terms coil, intrauterine system, IUD or intrauterine. They analysed the dataset thematically and selected illustrative tweets with the authors’ consent for publication. They conclude that these findings attest to the need for strategies to improve the patient experience for those opting for IUD as a clinical priority. Further research should explore IUD users' experiences, expectations and wishes around pain management. Read the full paper via the link below.
  20. Content Article
    This report from National Voices called People’s experiences of diagnosis, brings together insights from people with lived experience and our members on the entire process of diagnosis – from trying to get an appointment for a diagnostic referral, to undergoing tests, and experiences post-diagnosis. The report covers the themes of challenges in diagnosis, inequalities in diagnosis, and new innovation in diagnosis, before concluding with nine recommendations for improving patient experience of diagnosis. These nine recommendations include:  Adjustments and adaptations to enable access  Provide better support while waiting  Listen to the patient  Better communication around diagnosis  Make sure people have a plan  Provide access to support groups  Collect better data to understand the driver of diagnostic health inequalities, and act on it rapidly  Upskill, coordinate and ultimately increase the workforce  Have health equity embedded into new innovations the start.
  21. Content Article
    Millions of unpaid carers across the UK provide support to a family member, friend or neighbour due to a disability, illness or frailty due to old age. Yet a majority of unpaid carers have no choice but to take on a caring role. While providing unpaid care can be rewarding, it also comes with significant negative impacts on carers’ lives. Carers Week commissioned YouGov to carry out polling of the general public, including adults who are currently providing unpaid care. 
  22. Community Post
    Have you or someone you know been affected by a: delayed diagnosis incorrect diagnosis missed diagnosis? Errors can happen at every stage of the diagnostic process and can happen in all healthcare settings. In some circumstances the impact is life-changing. If you have insights to share around diagnostic error and the impact on patient safety, please comment below (sign up first here, for free). Or you can contact us directly at content@pslhub.org.
  23. Content Article
    Inspired by the work of NYC Health + Hospitals' efforts to embed health equity into their adverse event analysis, WellSpan Health shares their self-assessment so others might likewise learn from their efforts.
  24. Content Article
    This study explored the beliefs and organisational contexts of nursing aide (caregivers henceforth) assaults and their subsequent reporting of these events. Although this data is a pretty specific cohort and setting (rural nursing homes), the social and systems lenses that the authors take, and the silence resulting from blame attributions have broader applications.
  25. Content Article
    One year on from the launch of the Health Innovation Network's Chronic Pain Experience-Based Co-Design (EBCD) project, Natasha Callender, Senior Project Manager at the Health Innovation Network South London (HIN), and Natasha Curran, HIN Medical Director and Consultant in Pain Medicine share reflections on their learnings from working with people living with chronic pain. 
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