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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. News Article
    An inquiry into traumatic childbirths has called for an overhaul of the UK's maternity and postnatal care after hearing "harrowing" stories from parents. The Birth Trauma Inquiry heard evidence from more than 1,300 women - some said they were left in blood-soaked sheets while others said their children had suffered life-changing injuries due to medical negligence. A new maternity commissioner who would report directly to the prime minister is a key recommendation in the group's report, along with ensuring safe levels of staffing. Read full story Source: BBC News, 13 May 2024
  2. News Article
    Dementia could cost the UK almost £91bn a year by 2040, as the number of people affected rises inexorably, a study has found. The “colossal” costs of the disease are likely to more than double from an already “staggering” £42.5bn today to £90.6bn, according to research undertaken for the Alzheimer’s Society. That projected rise will happen in line with an expected increase in the number of diagnosed cases from 981,575 to 1,402,010, related to an ageing and growing population. Read full story Source: Guardian, 13 May 2024
  3. Content Article
    Joy Mason is the Director of Operations, Services and Engagement at Mast Cell Action. In this blog, Joy tells us more about Mast Cell Activation Syndrome and how medication supply issues are impacting people’s lives and causing avoidable harm. 
  4. News Article
    The chair of the major inquiry into rogue surgeon Ian Paterson has raised concerns over a separate patient recall process conducted by Salford Royal Hospital, and suggested NHS England should intervene. Leaders in Salford have been resisting pressure to expand a review of patients treated by the former head of its spinal division, John Williamson, over his 23-year career at the hospital. A review of his last five years established clear problems with his surgical techniques and found multiple cases of avoidable harm. Read full story Source: HSJ, 7 May 2024
  5. Content Article
    To understand and improve the way that organisations work, we must think in systems. This means considering the interactions between the parts of the system (human, social, technical, information, political, economic and organisational) in light of system goals. There are concepts, theories and methods to help do this, but they are often not used in practice. We therefore continue to rely on outdated ways of thinking in our attempts to understand and influence how sociotechnical systems work. This White Paper distils some useful concepts as principles to encourage a ‘systems thinking’ approach to help make sense of – and improve – system performance. It is hoped that these will give new ways of thinking about systems, work and safety, and help to translate theory into practice
  6. News Article
    Parts of ceilings have fallen in at two key units of a decrepit NHS hospital, forcing it to evacuate patients and cancel X-rays and scans, the Guardian can reveal. The problems at Stepping Hill hospital in Stockport, which is plagued by leaks and major structural defects, have prompted claims it is “dangerous for both patients and staff”. Read full story Source: Guardian, 3 May
  7. Content Article
    In this article, published by Pragmatic Improvement, Pete Gordon discusses the 2023 NHS staff satisfaction survey and the link with emergency department performance.
  8. Content Article
    The MAPLE project led by the Bristol Biomedical Research Centre, aims to co-produce an accessible patient information leaflet (PIL) that will aim to improve diversity in those who choose to take part in clinical research. The first stage of this work is to understand the barriers preventing people taking part in clinical research and gain views on how existing, accessible PILs may address these barriers. National Voices was commissioned to work with relevant charities and the people they advocate for to understand barriers to participation in clinical research, including, but not limited to literacy.
  9. News Article
    A ransomware group has carried out its threat to NHS Dumfries and Galloway and released a "large volume" of patients' data on the dark web. A small amount of details were released in March as "proof" that the cyber criminals had accessed confidential information, with a warning that more would be published if a payment was not made to stop it. The new chief executive of NHS Dumfries and Galloway health board, Julie White, called the release an "utterly abhorrent criminal act". She said work was now beginning to with other national agencies including the Scottish government, police and National Cyber Security Centre to assess what has been published. Read full story Source: BBC News, 7 May 2024
  10. News Article
    Perinatal mental illness affects more than a quarter (27%) of new and expectant mothers across England and covers a range of conditions including postpartum depression and postpartum psychosis. A Guardian analysis of NHS figures has shown that for instances of perinatal mental illness that result in hospital admissions, black patients are more than twice as likely to be admitted than their white counterparts. Part of the reason why black mothers are more at risk of perinatal mental illness is because black people are more at risk of experiencing mental illness in general. Read full story Source: Guardian, 6 May 2024
  11. Content Article
    The following account and poem has been kindly shared with Patient Safety Learning by Tom Bell.
  12. Content Article
    A subjective, biased, and an open ended inquiry into one of the most famous accidents in the maritime history – the capsizing of the Costa Concordia.  Nippin Anand's first-hand interviews with the captain followed by a series of workshops around the world gradually became a source of learning and inner change. Read a foreword by Steven Shorrock Buy the book here
  13. Content Article
    David Stockwell, M.D., M.B.A., is Chief Medical Officer at Johns Hopkins Children’s Center and Associate Professor of Pediatrics and Anesthesiology and Critical Care Medicine at Johns Hopkins University School of Medicine. He is also Chief Clinical Officer at Pascal Metrics, a federally listed Patient Safety Organization working with the Betsy Lehman Center on a pilot to test the impact of automated safety event monitoring in a diverse set of six-to-eight acute care hospitals in Massachusetts. In this Q&A session, Stockwell talked with Patient Safety Beat about Pascal’s approach to using electronic data to transform safety.
  14. Content Article
    In this article for Health Service Journal, Lord Hunt updates readers on progress in revolutionising NHS procurement by focusing on value-based healthcare, patient outcomes and cost-effectiveness.
  15. News Article
    Twenty one serious security failures at hospital mortuaries were discovered by the Human Tissues Authority between April 2022 and March 2024, HSJ can reveal. These included seven cases where unauthorised people gained entry to the facilities, 13 other breaches in “mortuary security processes” and one case in which there was unrestricted access to post-mortem images. Last month, the HTA issued new guidance for mortuaries that carry out post-mortems after what it described as “an increase in both the severity and frequency of reported incidents”. Read full story Source: HSJ, 7 May 2024
  16. News Article
    Ministers are preparing to announce a compensation package of at least £10 billion for contaminated blood victims after a Sunday Times campaign for justice was backed across the political divide. The announcement is expected to be made within hours of the public inquiry’s report into the scandal later this month and will establish a hierarchy of payments, with priority given to those with infectious diseases, including hepatitis C and HIV. The money, promised to be “northwards of £10 billion”, is yet to be signed off by Rishi Sunak but has the support of the Treasury and the Cabinet Office. It is expected to be funded through government borrowing. Read full story Source: The Times, 5 May 2024
  17. News Article
    Hospitals are being forced to cut medical staff, threatening their ability to care for patients, senior health leaders have warned. NHS trusts are reporting budget deficits after the chancellor Jeremy Hunt gave England’s health service £2.5bn extra funding, which only covers inflation and pay increases. The UK’s ageing population and the impact of having more than 6 million patients waiting for more than 7.5m treatments means that demand on the health service has increased substantially. Read full story Source: Guardian, 5 May 2024
  18. News Article
    A 999 call handler incorrectly categorised a call made by the wife of a man who died from a heart attack, an inquest has heard. The Welsh Ambulance Service Trust (WAST) handler should have escalated the call for Robert Weekley, 75, who died in his flat in Barry, to the most urgent level of 'red', which requires an ambulance to be sent within eight minutes. Instead they wrongly categorised it as the second-highest level, 'amber one', which has no set response time, an inquest into Mr Weekley's death at Pontypridd Coroners' Court was told. Read full story Source: Wales Online, 3 May 2024
  19. News Article
    Sajid Javid has revealed details of his young relative’s “brave battle” against myalgic encephalomyelitis, warning that patients with the condition are being “dismissed entirely” by doctors. During a debate held in Westminster Hall on Wednesday, the former health secretary spoke of the distressing experience of his cousin’s “amazing” daughter who developed the debilitating illness seven years ago, aged 13. ME is a complex neurological disorder that affects about 250,000 people in the UK and leads to symptoms including exhaustion and pain. Severe cases can be fatal, with patients bedridden and unable to eat or drink, and care held back by a lack of specialist NHS services. Read full story Source: The Times, 2 May 2024
  20. Event
    until
    Professor Steven Yule, and the Surgical Sabermetrics Lab Group, invite you to a research seminar from Professor Denny Yu on: Innovative Approaches for Assessment of Non-Technical Skills in Surgery - Objective Metrics and Sensing. The seminar will take place on Friday, 10th of May at the Usher Institute (and virtual), from 2-3pm Edinburgh time (9-10am EST). This promises to be a fascinating talk. Please see the attached poster for further detail, and Professor Yu's bio. For those joining virtually, please find the meeting link below: https://ed-ac-uk.zoom.us/j/83539499634 Meeting ID: 835 3949 9634 Passcode: s7hs8fSq Surgical Sabermetrics Research Seminar Invite - Prof Denny Yu.pdf
  21. Content Article
    Abbie experienced a high-risk pregnancy with her twin girls. They were born at 27 weeks gestation and weighed in at just 677g and 500g. After 150 nights in Neonatal Intensive Care Unit (NICU), both of Abbie’s daughters came safely home.  In this blog, Abbie highlights the importance of building a trauma-informed, clinical network around women whose babies have spent time in NICU. Drawing on her own experience and insights, she offers suggestions for how midwives, GPs and health visitors can support their mental health postnatally. 
  22. Content Article
    In this blog Dr Henrietta Hughes, Patient Safety Commissioner for England, outlines the activities included in the Patient Safety Commissioner Business Plan 2024-25.
  23. Community Post
    In 2010, it emerged that implants manufactured by the French company Poly Implant Prothese (PIP) had been made with cheap silicone that had not been approved for cosmetic surgery, and had a high splitting rate. The French authorities closed PIP and the company's founder was convicted of aggravated fraud and imprisoned. Patient groups say there has been little support, recognition or information for those affected in the UK, and that thousands of women continue to experience health problems.[1] Have you had a PIP implant? What has your experience been? What could be done now to make sure those affected are supported? Please comment below (sign up here first, for free) or get in touch with the team at content@pslhub.org [1] Woman pays £11,000 to fix ruptured breast implant
  24. Content Article
    One of the core ambitions of Care Quality Commission is to ensure that the services it regulates have a stronger safety and learning culture. Through their new quality statements, they are looking to assess both ‘safety through learning’ and ‘learning culture’. To ensure they take the best approach to assessing providers on this topic and to ensure they are able to give providers the best quality information on what good looks like in this area, the CQC would like your feedback through this short survey.
  25. Content Article
    Sands is the UK's leading charity working to save babies' lives and support bereaved families. In this blog, Julia Clark and Mehali Patel from the Sands Saving Babies’ Lives research team, draw on their recent Listening Project to illustrate the value of working with bereaved parents. Julia and Mehali argue that hearing and amplifying these unique insights is vital to developing safer, more equitable neonatal and maternity care.
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