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  1. Yesterday
  2. Content Article
    In 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation. This research, published by Lund Universities Libraries, comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinising five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's categorisation regarding incident investigation models, which delineates three models: sequential, epidemiological, and systemic. The findings show that there are distinctions in both the nature and effects of the investigation reports. Investigations conducted pre-2017 exhibit characteristics of the sequential model due to a focus on what went wrong, (broken) components and measures that mostly aim at the sharp end operator (train drivers, conductors, train dispatcher) such as training and discussing specific findings of the investigations with those involved only.
  3. Content Article
    In its manifesto ahead of the 2024 UK general election, the NHS Race & Health Observatory calls for a unification of efforts towards eradicating racial and ethnic health disparities in the nation’s healthcare system.
  4. News Article
    One in five recent inspections of maternity services have raised concerns over “essential” breathing equipment for newborn babies, HSJ has found. Care Quality Commission (CQC) inspectors have flagged fears over shortages and overdue maintenance of resuscitaire, a device commonly used by midwives if babies require additional support with breathing. Experts say the equipment should be immediately available to ensure safe resuscitation. The CQC itself said the lack of such equipment was impacting patient safety at some hospitals. Read the full story (paywalled) Source: HSJ, 31 May 2024
  5. Last week
  6. Content Article
    The first ever World Health Organization (WHO) global report on patient safety aims to provide a foundational understanding of the current state of patient safety across the world, aligned with the Global Patient Safety Action Plan 2021-2030. It contains insights and information beneficial to health care professionals, policy-makers, patients and patient safety advocates, researchers – essentially anyone involved or interested in the improvement of health care and patient safety globally.
  7. Content Article
    Secure and immediate access to health and care data helps to prevent avoidable delays in diagnosis and unnecessary repeat tests and examinations that can slow down the speed at which patients are able to begin treatment. In an emergency situation, the right information at the right time can be life saving. This NHS England webage looks improving individual care and patient safety, within the context of the Data Saves Lives: Reshaping health and social care with data strategy. Content includes: Video: Why do shared care records matter? Video: Why does data matter to adult social care? Case studies
  8. News Article
    IT system failures have been linked to the deaths of three patients and more than 100 instances of serious harm at NHS hospital trusts in England, BBC News has found. A Freedom of Information request also found 200,000 medical letters had gone unsent due to widespread problems with NHS computer systems. Nearly half of hospital trusts with electronic patient systems reported issues that could affect patients. NHS England says it has invested £900m over the past two years to help introduce new and improved systems. Some hospital trusts have spent hundreds of millions of pounds on new electronic patient record (EPR) systems, but BBC News has discovered many are experiencing major problems with how they work. Quoted in this article, Clive Flashman, Chief Digital Officer of Patient Safety Learning, said, “If you look at the sorts of serious issues that are coming out around the country where patients are being harmed, in some cases dying, as a result of these systems not working properly, I would imagine there are tens of thousands of these that are happening that probably never get discussed”. Read the full story. Source: BBC News, 30 May 2024 Read more about Patient Safety Learning's reflections on these issues and the importance of patient safety being at the heart of the development and implementation of EPRs here.
  9. Content Article
    In this joint statement, National Voices, The Richmond Group of Charities and 68 other health and social care organisations are calling on the Department of Health and Social Care to pause or extend the consultation process for the 10-year review of the NHS Constitution, ensuring that everyone is able to respond. Patient Safety Learning is one of the signatories of this statement.
  10. Content Article
    An investigation published by BBC News has revealed that Electronic patient record (EPR) system failures have been linked to the death of three patients and more than 100 instances of serious harm at NHS hospitals trusts in England. In this short blog, Patient Safety Learning reflects of these issues and the importance of patient safety being at the heart of the development and implementation of EPRs.
  11. Content Article
    Quality improvement and patient safety (QIPS) practitioners aspire to improve care for all patients, caregivers and families using improvement methods. While teams are trained to carefully implement the science of improvement, less is known of how to effectively incorporate equity into QIPS work. In this editorial for BMJ Quality and Safety authors ask; should there be more projects focused specifically on equity, or should equity be embedded into all quality improvement? 
  12. Content Article
    Following the release of the Australian National Safety and Quality Digital Mental Health (NSQDMH) Standards in November 2020, the objective of this study, published in Australas Psychiatry, was to ensure effective implementation of the Standards. This included the development of an accreditation scheme to allow digital mental health services to be formally assessed against the Standards and provide service users with an assurance of safe and high-quality services. Conclusion: The NSQDMH Standards accreditation scheme provides an assurance of safety and quality for digital mental health service users.
  13. Content Article
    Data Saves Lives is a multi-stakeholder initiative with the aim of raising wider patient and public awareness about the importance of health data, improving understanding of how it is used and establishing a trusted environment for multi-stakeholder dialogue about responsible use and good practices across Europe. Read more on the Data Saves Lives website Read more on the European Patients forum website
  14. Content Article
    In this editorial for BMJ Quality and Safety, Richard Lilford looks at a A paper from Ferguson and colleagues. Lilford concludes by saying that the paper provides useful findings regarding locums and their impact on patient safety. "The paper should not be simply curated among the voluminous safety literature. It should be considered as a call to action by senior policy makers."
  15. Content Article
    One of the enduring lessons of the pandemic has been the pivotal role that nursing plays in health care--vital work that isn't widely understood or, sadly, appreciated. Sara Fung and Amie Archibald-Varley started the wildly popular The Gritty Nurse podcast to give voice to nurses all over the world, including more than 400,000 nurses in Canada. The authors have quickly become sought-after speakers and advocates for nurses and are called on regularly by the media to talk about a wide range of issues around the profession. In their first book, they take you to the front line of nursing to show the compassion, selflessness and dedication of professionals who not only give it all for their patients, but get up and do it over and over again.
  16. Content Article
    The Gritty Nurse Nursing Podcast examines hot topics related to health and healthcare. We shy away from nothing, discussing topics such as mental health, social justice, women's health and women's rights. Hosts Amie Archibald-Varley and Sara Fung are story-tellers and love hearing how healthcare has impacted individuals' lives. They want to discuss the good, bad and ugly . They also provide a platform for empowerment and shared experiences, where they represent voices that have been silenced, underrepresented and marginalized --so they can share their stories of hope, change and inspiration.
  17. Content Article
    In this article for Healthcare Quarterly, Leslee Thompson argues that Health Quality 5.0 moves people-centred, integrated health and social care systems to the forefront of our post-COVID-19 agenda – and that cannot happen without addressing our global workforce crisis. Building back a stronger, healthier workforce is the first of the five big challenges we address in our special series. Starting with the global health workforce crisis is fitting, given it is the most fundamental and formidable barrier to health and quality today. As we put the pieces of the Health Quality 5.0 puzzle together, a picture of a more resilient health system will emerge and a new leadership agenda to get there will take shape.
  18. Content Article
    Deborah Filipek, author of this article for the Healthcare Financial Managment Assication (US), looks at research linking staff burnout to patient safety. Key points: Authors of two published studies reviewing clinician burnout found increased burnout affecting clinician mental and physical health and posing concerns for patient care and safety. One of the studies also looked at which interventions clinicians preferredImprovement in care delivery was rated by both physicians and nurses as more important to their mental health and well-being than interventions directed at improving clinicians’ mental health. On average, under single coverage, female employees have approximately $266 more in out-of-pocket spending per year than male employees, excluding pregnancy-related services. Only 227 American Indian/Alaska Native students entered U.S. medical schools during the 2021-22 academic year. Click on the link below to see the full article.
  19. Event
    until
    About this webinar In many pharmaceutical companies, human error is still addressed reactively through compliance by Deviation Management. While people are involved, they are NOT the root cause in the majority of deviations. There's an opportunity to set people up for success proactively in regards to risk prevention in a complex work environment through, for example: Recognition of risk and techniques for prevention of error. A roadmap for investigating repeated, human-related deviations. A means of integrating human performance into operational excellence, such as Gemba and leader standard work. Techniques for interviewing, coaching and improved communication. Recommendations for addressing system-related problems. Who would this be of interest to? Leaders and supporters of those that perform complex work in any regulated Good Manufacturing Practice (GMP) environment and anyone interested in human and organisational performance. About the speakers Bill Farmer has a BS in Microbiology and is an Associate Director for Deviation Management at Merck in North Carolina, USA. He's an experienced pharmaceutical scientist and has had many roles in technical and quality organisations. His philosophy to 'Help others, make it easier to do the 'right' thing, harder to do the 'wrong' thing, drives Bill to continuously improve the Merck Deviation Management Process. Julie Avery (chair) is former Global Lead for human factors at GSK, with over 20 years in Quality and Operational Excellence. As an independent practitioner, Julie now integrates human performance into existing systems strategically and tactically supporting business goals and KPIs. Julie leads the CIEHF Human Factors Pharmaceutical Manufacturing COP and is a Trustee of the CIEHF representing Associate Members. Register here
  20. Content Article
    6B is a technology and engineering consultancy. It has produced a list of all 214 NHS Trusts in England and the Electronic Patient Record (EPR) they have implemented (as of May 2024).
  21. News Article
    A mental health trust and a band seven ward manager it employed have denied manslaughter charges over a death on an inpatient ward. North East London Foundation Trust and Benjamin Aninakwa entered not guilty pleas to manslaughter by gross negligence at the Old Bailey on Friday (24 May). It is believed to be the first time a named NHS manager at a trust has faced corporate manslaughter charges, alongside the organisation that employed them. Read full story (paywalled) Source: HSJ, 29 May 2024
  22. Content Article
    In 1990, 10-year-old Robbie Powell died due to undiagnosed Addison’s disease. Tragically, his death was preventable. Concerns that Robbie may have had Addison’s disease had been raised following a previous hospital admission and a diagnostic test requested, but this was not followed up or shared with his parents, Will and Diane. In the two weeks before Robbie died, Robbie was seen by five GPs on seven occasions, but his parents were consistently told that there was nothing seriously wrong with their son. Robbie’s father Will has worked for decades to uncover why his son died and how the doctors and organisations involved responded following Robbie’s death. In this long-read interview, Will describes the events that led to Robbie’s death and his subsequent fight for justice, including his role in the successful campaign which resulted in organisational legal duty of candour. He talks about the devastating impact that having the truth withheld continues to have on his family and other families. Will then outlines what needs to be done to better protect families and ensure they get the full truth when a child dies due to avoidable harm. Please note: readers may find the following content distressing.
  23. Content Article
    This systematic literature review looks at the international evidence on how interventions to improve safety culture may benefit hospital staff and how they can be designed and implemented. In its conclusion, the authors note that the impact of safety culture interventions on staff outcomes, evidence on staff experiences is scarce. They suggested that a greater focus on staff outcomes would provide more meaningful insight into staff experience within safety culture and results from the safety culture.
  24. Content Article
    In this paper, published by Healthcare, authors proceed in two steps. First, they expand the existing base of literature on the interpersonal aspect of a safety climate by presenting a conceptual model of psychological safety and joint problem-solving orientation and proposing how, individually and together, they promote safety improvement and worker retention in healthcare. Second, they conduct an exploratory test of these relationships using empirical data from a large healthcare organization in the US.
  25. Content Article
    In this editorial for BMJ Quality and Safety, Kate Kirk explains why staff well-being is the foundation to improving patient safety.
  26. Content Article
    This seminal study by Cabral et al delves into the transformative potential of artificial intelligence (AI) in oncology, highlighting its pivotal role in enhancing healthcare quality and safety. The study aligns with the broader discourse on AI’s capacity to revolutionise healthcare outcomes, drawing from insights previously proposed on the synergy between human expertise and AI across various medical disciplines.
  27. Content Article Comment
    Thank you for sharing this powerful account of your experience. and Thanks you for being courageous and sticking to your values and clinical professionalism.
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