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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    This BMJ Opinion piece is written by Chris Ham (in a personal capacity)who was chief executive of The King’s Fund from 2010 to 2018. Chris talks about the recent funding announcement to support hospital discharges in order to free up bed space. He highlights a number of key considerations including: the impact on patient involvement in their discharge decisions staff shortages in care homes bed capacity in care homes. Chris questions whether these decisions are 'symbolic policy making' or whether they will actually make a difference to patients.
  2. Content Article
    This study, published in the International Urogynecology Journal, involved 18 interviews with women who had experienced vaginal mesh complications. Four themes were identified:perceived impact of mesh complicationsattitudes of medical professionalssocial support and positive growth. The impact of vaginal mesh complications were wide-reaching and varied, affecting many aspects of the participants lives including mental health, relationships and sexual intimacy. Authors conclude that a greater awareness would lead to better support for women experiencing mesh complications.
  3. Content Article
    This article, published by MendWell, looks at the benefits of stopping smoking before surgery and the risks of continuing to do so. It includes tips on how to stop smoking. 
  4. Content Article
    Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism (PE), following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review: Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns. Drawing on existing data, freedom of information requests and Jenny’s case, the report raises significant patient safety concerns relating to PE care across England and Wales. Tim calculated that from April 2021 to March 2022, there was a minimum of 400 excess deaths due to pulmonary embolism misdiagnosis. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 
  5. Community Post
    Hi Anne As part of informed consent you should be given all of the options available to you and talked through the pros of cons of each. This should include general anaesthetic. This will help you to make an informed decision that feels right for you. You could ask to speak to your GP about this and it is worth mentioning your previous experience in relation to pain. You can also request to have a chaperone with you for the procedure which may help you feel supported. If you are awake for the procedure, speak to the staff performing the procedure about how they will check in with you to make sure they obtain continued consent throughout and that you are happy for them to continue. Talk to them about your previous experiences and the importance of being able to pause or stop the procedure if you do need to. Some people have found it useful to have someone there with them to drive them home afterwards too, even if this hasn't been highlighted as a necessity in any of the info given to you beforehand. I am so sorry you have had a difficult experience previously and did not feel you had been informed of what what going to take place. That is not in line with informed consent and should not have happened to you.
  6. Content Article
    How did the fallout from the pandemic affect people across different ethnic groups, and was the impact of those cancelled procedures spread evenly? This Nuffield Trust analysis, supported by the NHS Race and Health Observatory, seeks to answer these questions.
  7. Content Article
    Cynefin, pronounced kuh-nev-in, is a Welsh word that signifies the multiple, intertwined factors in our environment and our experience that influence us (how we think, interpret and act) in ways we can never fully understand.  The Cynefin Framework was developed to help leaders understand their challenges and to make decisions in context. It has been applied to many different environments including healthcare and safety. To read more about the framework and to watch a 12-minute introductory film, follow the link below to the Cynefin Co website.
  8. Content Article
    Extravasation is the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue. This can cause harm and lead to complications for the patient. This guide, produced by the Royal Children's Hospital Melbourne, includes: Introduction Aim Definition of terms Risk factors Assessment Management Irrigation Procedure Follow-up/Review Special considerations Evidence Table Companion documents References
  9. Content Article
    Emergency medical technicians (EMTs) can operate as a single responder to an incident or support a paramedic on a double-crewed ambulance. They have many of the same skills as paramedics, such as being able to assess, triage and provide lifesaving treatment.[1]   In this account, an EMT describes their current experience of being on the frontline. They talk about patient care, getting stuck in ambulance queues and how they have adapted to new ways of working, beyond their training. Lastly, they offer insight into where the solutions might lie and how improvements could be made.
  10. Content Article
    In September 2022, The Care Quality Commission published four reports into the care provided by Spectrum a provider of Autism services in Cornwall. All four inspections concluded that the services were inadequate.
  11. Content Article
    In this article, published by Patient Satisfaction News, author Sarah Heath argues that more needs to be done to address the power imbalance between patients and providers. She discusses the dangers of a paternalistic approach and why patient engagement and shared decision making is key to patient safety.
  12. Content Article
    This article, published in The international journal for quality in healthcare, looks at the Hierarchy of Risk Controls approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems.
  13. Content Article
    What is resilience? What is resilience engineering? This 25-minute talk, published by devopsdays, will ground your understanding of those terms using the compelling example of bone.  Dr. Richard Cook is a Principal with Adaptive Capacity Labs and Research Scientist in the Department of Integrated Systems Engineering at The Ohio State University (OSU) in Columbus, Ohio.
  14. Content Article
    Resilience Engineering refers to building complex systems that are resilient to change and disruption. In this blog, the author reflects on his own reading around the topic and how we might apply resilience engineering.
  15. Content Article
    This paper has been produced by the Infection Management Coalition, provides an overview of the challenges in infection control and antimicrobial resistance. It offers recommendations for improving infection management in the following areas: Data Diagnostics and treatment End-to-end care Awareness and education.
  16. Content Article
    This newsletter from Psychological Safety, provides an overview of the two different concepts of Safety I and Safety II. Follow the link at the bottom of the page to read the article in full. 
  17. Content Article
    In this document, Charles Vincent and colleagues from Imperial College London, propose a new framework to help find the elusive answer to the question – how safe is care today?
  18. Content Article
    This paper, published in Applied Ergonomics, looks at how those in healthcare might select which technique to use to predict error. The author concludes: "there is a lack of practical experiences described in the literature to conclusively define a technique for selection and a need for a dedicated research in this area to make it accessible for healthcare and other novice users".
  19. Content Article
    This study, published in the Journal of Patient Safety, tells how Mackenzie Health responded to low safety culture scores by implementing a zero-harm strategy.
  20. Content Article
    This study, published in The Organization of Primary Healthcare during the COVID-19 Pandemic, aims to investigate the effect of being a training practice on a number of different outcomes related to the safety culture of primary care practices. It found that: "Training young GPs has an important positive impact on the health system. It safeguards the health workforce of the future (and the present), while also being associated with higher quality and safety of the practices involved in training while lowering the risk of distress for qualified GPs participating in vocational training".
  21. Content Article
    A report by Lord Young of Graffham to the Prime Minister (David Cameron) following a Whitehall‑wide review of the operation of health and safety laws and the growth of the compensation culture.
  22. Content Article
    Pulmonary embolism is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Although life-threatening, when diagnosed promptly survival rates are good.  This report, authored by risk expert Tim Edwards and published by Patient Safety Learning, highlights serious and widespread patient safety concerns relating to the misdiagnosis of pulmonary embolisms.  Drawing on existing data, freedom of information requests and his mother’s case, he outlines nine calls for action to improve pulmonary embolism care. 
  23. Content Article
    This briefing paper, from the Royal College of Radiologists, was produced to help inform an adjournment debate in the house of commons focusing on pulmonary embolism misdiagnosis. The briefing highlights concerns around staffing gaps, workforce planning and equipment shortages within this area, and the threat this poses to patient safety.
  24. Content Article
    Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient (NHS England, 2017). From 1 April 2011 until 31 March 2021 the NHS paid £15.6 million in damages relating to extravasation. This leaflet, published by NHS Resolution, aims to share learning from those claims.
  25. Content Article
    Supporting staff to speak up is essential to patient safety. The PACE communication tool is designed to help anyone in a team challenge an action or behaviour they feel is inappropriate. You can read more about PACE (probe, alert, challenge, emergency) and other communication tools on the Victorian Trauma System website via the link below.
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