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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    Whether you need information about the latest guidelines on group B Strep during pregnancy, labour and after birth, the key signs of GBS infection in babies, or information leaflets for families in your care, this section is for you. The group B Strep Support website has resources to support you and the families in your care.
  2. Content Article
    Delays in the detection or treatment of postpartum haemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum haemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. Authors of this study, published in the New England Journal of Medicine, conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum haemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum haemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group).
  3. Content Article
    Postpartum haemorrhage is a leading cause of maternal deaths. Now a new study points to a surprisingly simple and inexpensive solution. If the woman lies on a plastic sheet with a small transparent pouch at the other end to collect the blood, the medical team has an immediate sense of how much danger she's in and can take swift action. Read the full article, published by NPR, via the link below.
  4. Content Article
    New research showed how a national quality improvement programme called PReCePT (Preventing Cerebral Palsy in Pre Term labour) accelerated maternity units’ use of Magnesium sulphate for pre-term labour. The programme could serve as a blueprint for future efforts to get clinical guidelines into practice in other areas of care. The quality improvement programme involved training staff on the benefits of magnesium sulphate, and having a local midwife dedicated to encouraging and monitoring use of the medicine at their maternity unit. The programme was supported by Academic Health Science Networks (a regional and national organisation that encourages improvement and innovation in healthcare).  This article from the National Institute for Health and Care Research provides a plain English summary and short film about the project.
  5. Content Article
    This is a plain English summary from the National Institute for Health and Care Research (NIHR). Many women who have an assisted vaginal birth (using forceps or a vacuum cup) develop infections. A previous study showed that a single dose of preventive antibiotics protected women; this research led to a change in UK and WHO guidelines. However, most women in the study had an episiotomy (surgical cut), so it was unclear if antibiotics also protected those with a tear of the perineum (the area between vagina and anus). To address this uncertainty, researchers re-analysed the ANODE study data. They found that preventive antibiotics reduced infections after an assisted vaginal birth, irrespective of whether women had a perineal tear, an episiotomy, or both. Read the article in full and access the research via the link below.
  6. Content Article
    Authors of this article, published by Anaesthesia Patient Safety Foundation, look at various factors that exacerbate alarm fatigue and subsequent effects of nonoptimal medical alarms. They provide examples of a novel alarm versus a traditional alarm and conclude by saying: "By focusing on patient and provider safety, clinical workflow, and alarm technology, researchers, and policy makers can transform the medical alarm realm into one that is evidence-based and personnel-focused."
  7. Content Article
    The Cynefin® sense-making Framework, brainchild of innovative thinker Dave Snowden, empowers leaders across organizations, governments, and local communities, to work with uncertainty – to navigate complexity, create resilience, and thrive. As Snowden says, “The Framework guides us to make sense of the world, so that we can skillfully act in it.”
  8. Content Article
    Tim Fetherston provides background on the rates of critical incidences in hospitals and sets out the case for better reporting. He includes advice and examples for setting up reporting effective systems.
  9. Community Post
    The following account has been shared with Patient Safety Learning by Jen*: "My first coil insertion and later removal were both done at different GP surgeries and were both agonising. I have broken bones and torn ligaments before, yet nothing compared to the pain I experienced in and after those procedures. For my second coil insertion, I felt I was prepared as I was going to a health centre where I would receive a local anaesthetic and numbing gel, and the procedure would be done by expert nurses. I also took paracetamol beforehand. Still, the pain was so agonising that I screamed. When it came to getting up, they told me I was white as a sheet and then I fainted. There were two nurses there and they had no idea what to do with me. I couldn't stand without my legs collapsing under me. They offered me ibuprofen and visibly panicked when I reminded them I am allergic to it; it was like they had run out of options. Eventually they told me they needed to close so sent me on my way. I had no one with me and drove myself home - I convinced myself I was being very silly and weak because if it was that bad, they'd have called for an ambulance or at least advised me to call a friend, instead of allowing - in fact encouraging me - to drive myself home. I screamed and sobbed in pain all the way home, where I managed get myself a hot water bottle and to drag myself upstairs to bed. I found leftover tramadol from when I broke my ankle, and it didn't touch the pain. I eventually passed out again. The pain lasted for days, and I didn't feel able to tell anyone what was wrong - I had been told by many doctors for many years that I had a low pain threshold and thought that my experience was a reflection of that. I felt a bit pathetic and weak, to be honest. "During all of my coil appointments, I was told I had a tilted uterus which they said was very common, and why the insertions had been so 'tricky'. I was later diagnosed with endometriosis and adenomyosis and was told they were common causes for a tilted uterus! There was no mention of those conditions as a possible cause when previously discussed, it was just explained as being one of those things - which would suggest to me that there is a gap in education for healthcare providers. "To this day, that second coil fitting is of the most traumatic experiences I have ever had." *The patients name has been changed
  10. Content Article
    In this article, published by British Vogue, Alexa Chung shares her experiences of endometriosis and the barriers and attitudes she faced in seeking a diagnosis and treatment.
  11. Content Article
    The aim of this report, written in partnership with Fair Treatment for Women of Wales, is to provide NHS Wales with the service-user perspective of miscarriage care in Wales and how it could be improved to reduce the harm being caused by poor-quality, inconsistent care.
  12. Content Article
    This report, produced by Fair Treatment for Women of Wales, contains an outline of current practice in Wales, patient testimonies, and a series of recommendations for improved care provision for lupus and, by extension, other rare auto-immune diseases.
  13. Content Article
    This report, produced by Fair Treatment for Women of Wales, provides NHS Wales with invaluable insight on how to improve menopause services across the country, including the provision of factual, evidence-based information and skilled professionals, enabling every woman to make informed choices about how she manages her menopause symptoms.
  14. Content Article
    This report was prepared by the Endometriosis Task and Finish Group and submitted to the Welsh Government on 16 April 2018. Authors propose a robust care pathway based on NICE guidance using a life course approach to ensure that symptoms are recognised and responded to promptly and appropriately, as they emerge. 
  15. Content Article
    Women’s Health Wales: A Quality Statement for the Health of Women, Girls, and those Assigned Female at Birth is an an inclusive report co-produced by the Women Health Wales Coalition, which outlines physical and mental health issues which affect women across the life course. The report makes a series of recommendations which if implemented will improve women’s health, lives and wellbeing regardless of race, ethnicity, disability, socio-economic status, sexual orientation or gender identity.  Key Themes Access to specialist services Improved data collection Support for sustainable co-production Training for health and care professionals.
  16. Content Article
    This review published by the Modernisation Agency explores ‘social movements’ as a new way of thinking about large-scale systems change and assesses the potential contribution of applying this new perspective to NHS improvement programmes. This review has four objectives: to explore ‘social movements’ as a new way of thinking about large-scale systems change; to assess the potential contribution of applying this new perspective to NHS improvement; to enrich and extend NHS thinking in relation to large-scale, system wide change; and to begin to establish a research and evidence base to support the emergence of an improvement movement in the NHS.
  17. Content Article
    In this article, published by the British Journal of Nursing, John Tingle, Lecturer in Law, discusses recently published patient safety reports including Patient Safety Learning's Mind the Implementation Gap. Tingle concludes: "The two reports discussed here (Patient Safety Learning, 2022; Martin et al, 2023) show that 10 years after Francis (2013) there has been some improvement in NHS patient safety. This can be termed ‘measured improvement’, but this has been no big-bang trajectory. The arguments advanced in both reports need to be discussed more widely, and they provide an excellent basis for patient safety reform."
  18. Content Article
    THE MIND FULL MEDIC PODCAST speaks with Professor Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School. Amy is a world-renowned for her work in the area of psychological safety and team performance and author of The Fearless Organization. In this conversation, they discuss the origins of her research in healthcare teams and evolution over time.
  19. Event
    until
    Launch event for PHSO’s new report, A place of safety? Learning from avoidable harm in the NHS. Date: Thursday 29 June 2023 Time: 10.30am – 12.30pm Venue: Westminster Suite, Broadway House, London, SW1H 9NQ While there have been significant developments in patient safety over the last decade, there is a concerning disconnect between increasing activity and progress made in embedding a just and learning culture across the NHS. Statistics about patient safety remain stark and behind these numbers are the stories of families whose lives have been shattered as a result of avoidable harm. What more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice? Join PHSO as they bring together leading policymakers, professionals and those impacted by avoidable harm to discuss their findings and recommendations about improving patient safety. Chief Executive Amanda Amroliwala and the Ombudsman Rob Behrens CBE will give keynote addresses, followed by a panel discussion. Panellists confirmed so far include: Rosie Benneyworth, Chief Investigator, Healthcare Safety Investigation Branch Joanne Hughes, Harmed Patients Alliance Dr Bill Kirkup CBE, led investigations into public service failures including those investigating maternity services at Morecambe Bay and East Kent Please email publicaffairs@ombudsman.org.uk to reserve a place at the event. Please us at publicaffairs@ombudsman.org.uk to reserve a place at the event.
  20. Content Article
    Professor Mary Dixon Woods gave The Centre for Personalised Medicine 2023 Annual Lecture on 27th April 2023. Her lecture was titled 'Putting the person into improving quality and safety in healthcare'.
  21. Content Article
    The TEC Action Alliance, in partnership with over 30 organisations, has released a challenge paper titled “Technology-Enabled Lives: Delivering Outcomes for People and Providers.” The paper highlights the lack of widespread adoption of digital social care services despite the public’s desire for technology to better support those who draw on social care and health services. The paper reveals that only a handful of councils, housing, and care organisations are delivering digital care in people’s homes at scale. This is despite evidence that using technology in social care keeps people safe, healthy, and happy at home.
  22. Content Article
    Published in BMC Health Services Research, this is the first review to theorise how open disclosure (OD) works, for whom, in what circumstances, and why. Authors identify and examine from the secondary data the five key mechanisms for successful OD and the three contextual factors that influence this. The next study stage will use interview and ethnographic data to test, deepen, or overturn their five hypothesised programme theories to explain what is required to strengthen OD in maternity services.
  23. Content Article
    Appeals to give better resources to the NHS ‘front line’ are problematic when they divert attention away from more serious issues, especially when spending on more staff comes at the price of investing in other areas where the money may have a greater impact, emphasises Steve Black in this article published by HSJ.
  24. Community Post
    Hi @Flávia Thank you for responding. Your collaborative project sounds very interesting, we would love to hear more. Please do get in touch via content@pslhub.org.
  25. Content Article
    Partha Kar, National Specialty Advisor for NHS England, has led work that has had an enormous impact for patients and for patient safety. In this video podcast, Steph O'Donohue from Patient Safety Learning talks to Partha about his leadership style and how it has helped him drive forward significant change in an often challenging context.  Partha talks about the power of the patient community, workforce morale, sharing failures and leading with honesty. 
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