Patient_Safety_Learning

Women and birthing people from black, Asian, or mixed ethnic backgrounds are significantly more likely to experience poor outcomes during their maternity journey. Between September 2021 and October 2022, Darzi Fellow Rosie Murphy undertook work in Croydon to explore these inequalities and what could be done to improve local services. This is the first in a series of blogs published by the Health Innovation Network, reflecting on the learnings and experiences from her Fellowship.

In this book, Sandra Igwe shares her journey as a young Black mother, coping with sleepless nights, anxiety and loneliness after the birth of her first daughter. Burdened by cultural expectations of the 'good mother' and the 'strong Black woman' trope, her mental health struggles became an uphill battle. Black women are at higher risk of developing postnatal depression but are the least likely to be identified as depressed. Sharing the voices of other mothers, Sandra examines how culture, racism, stigma and a lack of trust in services prevent women getting the help they need. Breaking open the conversation on motherhood, race, and mental health, she demands that Black women are listened to, believed, and understood.

In this blog, published by What's The Pont, the author provides a summary of the The Swiss Cheese Model of Accident Causation, developed by Professor James T. Reason, and looks at what it means for learning from failure. Related reading: The Swiss cheese respiratory virus pandemic defence Reverse Swiss Cheese – Driving safety culture from the blunt end (24 June 2022) Good and bad reasons: The Swiss cheese model and its critics (June 2020)

In this blog, by LifeQI, author Suzie Creighton unpicks the driver diagram, linking to further resources to help readers understand the following: Driver diagram – definition and what is a driver diagram used for? The anatomy of a driver diagram Where does the driver diagram fit in the QI journey

Inadequate hand-off communication from hospital to skilled nursing facility (SNF) hinders SNF nurses’ ability to prepare for specific patient needs, including prescriptions for critical medications, such as controlled medications and intravenous (IV) antibiotics, resulting in delayed medication administration. This project, published in Patient Safety, aims to improve hand-off communication from hospital to SNF by utilising a standardised hand-off tool. Authors conclude that the use of standardised hand-off resulted in improved communication during the hospital-to-SNF hand-off and significantly decreased the wait time for the availability of prescriptions for controlled medications and IV antibiotics. Integrating standardised hand-off into the SNF policies can help sustain improved communication, medication management, and patient transition from hospital to SNF.

This qualitative study, published in Patient Safety, aims to describe the lived experiences of new nurses’ safe transition into practice and their perceptions of functioning as safe practitioners.

Research shows that access to green space can support mental and physical health and wellbeing, and reduce the incidence of chronic conditions such as cardiovascular disease, type 2 diabetes and Alzheimer's. Green Health Routes can be used by GPs and other health professionals as part of social prescribing initiatives. Green Health Routes support communities to connect with and get to know the parks, meadows and woodlands on their doorsteps. The projects begin with the creation of neighbourhood maps, developed in close consultation with communities, to highlight the areas’ publicly accessible green space.

This research study by Democratic Society, looks at involving people with lived experience in health and social care policy and decision-making. Key lines of enquiry: What approaches, design features and tools (including digital and platforms) are used to engage with people with lived experience, and what makes them effective? What barriers can we identify during different phases of engagement? When people with lived experience are active and equal partners, what does that look like? What is the impact on policy and practice of including people with lived experience in decision-making processes related to health and social care?

It is estimated that at least 65 million people worldwide have Long Covid. This research paper, published by Nature Reviews Microbiology, explores the current knowledge base of Long COVID as well as misconceptions surrounding long COVID and areas where additional research is needed.

Watch this short video to learn how Nurse Climate Champions are using the Nurses Climate Challenge resources to educate their colleagues about climate and health.

In this BMJ Editorial, author Sam Patel says that linking medicines information from all care settings into a shared digital medication record accessible to all health and care clinicians has the potential to substantially reduce medication errors and improve patient safety. 

In this blog, published by the Healthcare Safety Investigation Branch, Laura Pickup talks about the importance of considering the design of healthcare equipment and how it impacts on risk to patient safety. She highlights that there is a confusion between ‘use error’ and ‘abnormal use’ and questions whether it is really fair to hold NHS staff accountable when the use of equipment or devices has led to a safety incident.

In this review piece Siva Anandaciva, Chief Analyst at The Kings Fund, looks back at 2022. Reflecting through a health policy lens, Siva uses statistics and graphics to illustrate the activity month-by-month. He concludes that it was a year "dominated by yet more political change at the top of government, a cost-of-living crisis, a looming winter of strike action, growing fears of a two-tier health system based on ability to pay, and the continued second-class citizenship of an adult social care system that saw its charging reforms delayed once again."

During periods of extreme pressure, often exacerbated by a surge in respiratory conditions, demand on supplies of oxygen cylinders, especially the smaller sizes, increases in the NHS due to the need to provide essential oxygen treatment in areas without access to medical gas pipeline systems. This surge in demand increases the known risks associated with the use of oxygen gas cylinders, and introduces new risks, across three main areas: patient safety fire safety physical safety A search of incidents reported to the of the National Reporting and Learning System (NRLS) and Learn from Patient Safety Events (LFPSE) service in the last 12 months identified 120 patient safety incidents, including those with these themes: cylinder empty at point of use cylinder not switched on cylinders inappropriately transported cylinders inappropriately secured Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest. In addition there is a need to conserve oxygen cylinder use to ensure a robust supply chain process. As a result of current pressures on the NHS, NHS England issued providers with a summary of best practice guidance on the ‘Safe use of oxygen cylinders’ on Friday 06 January 2023 to support providers to optimise and maintain the safe use of oxygen cylinders. This guidance was issued via the Patient Safety Specialist and Emergency Preparedness, Resilience and Response (EPRR) networks. Actions To be completed as soon as possible, and not later than 20 January 2023. 1.  The chair of acute trust medical gas committee, working with key clinical/non-clinical colleagues including the local ambulance trust, should review the NHS England ‘Safe use of oxygen cylinders’ best practice guidance and ensure a risk assessment is undertaken in all areas where patients are being acutely cared for (either temporarily or permanently) without routine access to medical gas pipeline systems.  Risk assessment should pay particular attention to: avoiding unnecessary use of cylinder oxygen and excessive flow rates by ensuring oxygen treatment is optimised to recommended target saturation ranges. ensuring safe use of oxygen cylinders by clinical staff including; - safe activation of oxygen flow - initial and ongoing checks of flow to patient - initial and ongoing checks of amount of oxygen left in the cylinder - especially during transfer or whilst undergoing diagnostic tests. fire safety, including: - appropriate ventilation (both in physical environments and in ambulances),  safe storage of cylinders physical safety, including: - awareness of manual handling requirements - safe transportation of cylinders using appropriate equipment - safe storage of cylinders. 2. Once the risk assessments have been undertaken, convene the acute trust medical gas committee as soon as possible to review the findings of the risk assessments and formalise an action plan. Ensuring that the committee has executive director representation and ambulance trust input.

In this article, published by BMJ Opinion, author David Raven says:  "Emergency care staff have been working under the shadow of a slow moving catastrophe for years". David, emergency medicine consultant and divisional director of urgent care, provides several examples of data and high level concerns raised that attempted to forewarn of these dangers. He argues that blaming Covid and high levels of flu for the pressures provides a false narrative to the reality and that the relentless hard work of staff is not enough to compensate for the challenges they face in what he says is a dysfunctional system.