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  1. Yesterday
  2. Content Article Comment
    Who where is prioritising even just identifying the nature of exclusion of patient narratives, their impact and trying to address it systemically? I am working on this concept in reference to 4 cases and welcome any analytic, policy, academic or even philosophic insights! Please contact me via PSL
  3. Content Article Comment
    This is very useful advice. I have been communicating since 2019 within my NHS Trust regarding the use of a reference guide (NEWT Guidelines) published in 2010. Pharmacists have access to a more current online resource advising how medication can be administered via enteral feeding tubes. Out of hours and weekends, nurses utilise the reference book mentioned above, which is so old that there are newer medications not included. We can contact an on-call pharmacist, but I feel that in order to optimise patient safety Trust managers need to work towards providing a more up to date resource for nurses. Despite the occasional suggestion of change, it has not occurred. Last year, I sent an email pushing for a change and included a quote from the WHO medication without harm campaign. I believe that modification of medications is an important area to get things right and do no harm.
  4. Content Article
    More health systems and hospitals are looking to expand options to care for patients at home, but a new report points to some obstacles that threaten the safety of patients. ECRI, a nonprofit organisation focused on patient safety, released its annual list of the 10 leading healthcare technology hazards Wednesday. Safety challenges involving medical devices at home topped the 2024 list of technology trouble spots. ECRI also cites other challenges, including poor instruction in cleaning medical devices, sterile drug compounding, the insufficient governance of artificial intelligence in healthcare, and cybersecurity. But the concerns over the use of medical devices at home rose above all others. Marcus Schabacker, MD, president and CEO of ECRI, talked with Chief Healthcare Executive® about the potential hazards in patients using medical devices and tools at home.
  5. Content Article
    While climate change is a big threat to health, implementing solutions to address climate change presents a huge opportunity to promote better health and protect people from climate-sensitive diseases. Communicating the health risks of climate change and the health benefits of climate solutions is both necessary and helpful. Health professionals are well-placed to play a unique role in helping their communities understand climate change, protect themselves, and realize the health benefits of climate solutions. This toolkit from the World Health Organization (WHO) aims to help health professionals effectively communicate about climate change and health.
  6. Content Article
    Evidence-informed decision-making (EIDM) entails identifying, appraising, and mobilising the best available evidence for safe and effective health policy and programmes. EIDM is a mainstay of the World Health Organization’s science-based mandate, and a pivotal steppingstone towards achieving the Triple WHO’s triple billion targets and the 2030 Agenda for Sustainable Development. This guide and associated tool repository provide WHO staff, Member States and partner organisations with vetted methods and tools to better leverage diverse forms of evidence for more effective policy and practice in the clinical, public health and health system fields. Introducing a comprehensive, multidisciplinary framework to plan and implement evidence-to-policy processes, the guide also aims to foster better collaboration and create synergies among actors and workstreams of the evidence ecosystem.
  7. Content Article
    This study examines associations of provider burnout with their perspectives on quality improvement (QI), patient experience measurement, clinic culture and job satisfaction. The authors conducted a cross-sectional provider survey about their perspectives including the single-item burnout measure. 30% of providers reported burnout and providers in clinics with more facilitative leadership reported not being burned out (compared to those reporting burnout. More pressures related to patient care and lower job satisfaction were also associated with burnout.
  8. Content Article
    This study examines the variability in how different anaesthesia providers approach patient care, to provide insight into the source and necessity of variations in practice, the implications of different individual preferences and the subsequent consequences on approaches to safety that emphasise standardisation. The authors argue that the differences in how anaesthesia providers approach their work call into question whether ‘standardisation’ is always the best approach to improve safety in anaesthesia. They state that this work reinforces the idea that it is the humans in the system, with their flexibility and expertise, who are the primary source of everyday safety.
  9. Content Article
    Italian law No. 24/2017 focused on patient safety and medical liability in the Italian National Health Service. The law required the establishment of healthcare risk management and patient safety centres in all Italian regions and the appointment of a Clinical Risk Manager (CRM) in all Italian public and private healthcare facilities. Through a survey, this study in Healthcare looks at the law's implementation since it was passed five years ago. The results demonstrate that it has not yet been fully implemented, revealing: a lack of adequate permanent staff in all the Regional Centres, with two employees on average per Centre. few meetings were held with the Regional Healthcare System decision-makers with less than four meetings per year. This reduces the capacity to carry out functions. the role of the CRMs is weak in most healthcare facilities, with over 20% of CRMs have other roles in the same organisation. some important tasks have reduced application, e.g., assessment of the inappropriateness risk (reported only by 35.3% of CRM) and use of patient safety indicators for monitoring hospitals (20.6% of CRM). the function of the Regional Centres during the Covid-19 pandemic was limited despite the CRMs being very committed. the CRMs' units undertake limited research and have reduced collaboration with citizen associations. Despite most of the CRMs believing that the law has had an important role in improving patient safety, 70% of them identified clinicians’ resistance to change and lack of funding dedicated to implementing the law as the main barriers to the management of risk.
  10. Community Post
    This new qualitative study might be of interest to those who have experienced dental diagnostic error or diagnostic failure. It's a start in building research evidence around the harms that can be caused. Patients’ experiences of dental diagnostic failures: A qualitative study using social media (April 2024)
  11. Content Article
    This qualitative study in the Journal of Patient Safety aimed to understand the perception of dental patients who have experienced a dental diagnostic error and to identify patient-centred strategies to help reduce future occurrences. Recruiting patients via social media, the researchers conducted a screening survey, initial assessment and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis or delayed diagnosis on patient lives. They found that dental patients endured prolonged suffering, disease progression, unnecessary treatments and the development of new symptoms as a result of diagnostic errors. Patients believed that the following factors contributed to diagnostic errors: Poor provider communication Inadequate time with provider Lack of patient self-advocacy and health literacy. Patients suggested that future diagnostic errors could be mitigated through: improvements in provider chairside manners more detailed patient diagnostic workups improving personal self-advocacy enhanced reporting systems.
  12. Content Article
    Official data on whooping cough show that reports of suspected cases are at a 15-year high in the first three months of 2024. This article in the Pharmaceutical Journal looks at why cases are increasing, including falling rates of children receiving the childhood 6-in-1 vaccine and maternal vaccination. It outlines the symptoms of whooping cough, describes how it can be treated and includes a map identifying infection 'hot spots' in England and Wales. This article is free to read but you will need to sign up for a free Pharmaceutical Journal online account.
  13. Content Article
    Ensuring the safe and effective use of medicines is a central function of the pharmacy team. This article in the Pharmaceutical Journal outlines how pharmacists can support the implementation of the Patient Safety Incident Response Framework (PSIRF). It aims to help pharmacists: understand the role of the Patient Safety Incident Response Framework (PSIRF). understand the difference between the PSIRF and the Serious Incident Framework. Know how the PSIRF can be applied to the pharmacy profession. This content is free to access but you will need to sign up for a Pharmaceutical Journal free online account.
  14. Content Article
    When ECRI unveiled its list of the leading threats to patient safety for 2024, some items are likely to be expected, such as physician burnout, delays in care due to drug shortages or falls in the hospital. However, ECRI, a non-profit group focused on patient safety, placed one item atop all others: the challenges in helping new clinicians move from training to caring for patients. In an interview with Chief Healthcare Executive®, Dr. Marcus Schabacker, president and CEO of ECRI, explained that workforce shortages are making it more difficult for newer doctors and nurses to make the transition and grow comfortably. “We think that that is a challenging situation, even the best of times,” Schabacker says. “But in this time, these clinicians who are coming to practice now had a very difficult time during the pandemic, which was only a couple years ago, to get the necessary hands-on training. And so we're concerned about that.”
  15. News Article
    NHS teams are giving up on patients with severe eating disorders, sending them for care reserved for the dying rather than trying to treat them, a watchdog has warned the government. In a letter to minister Maria Caulfield, the parliamentary health service ombudsman Rob Behrens has hit out at the government and the NHS for failures in care for adults with eating disorders despite warnings first made by his office in 2017. The letter, seen by The Independent, urged the minister to act after Mr Behrens heard evidence that eating disorder patients deemed “too difficult to treat” are being offered palliative care instead of treatment to help them recover. The ombudsman first warned the government that “avoidable harm” was occurring and patients were being repeatedly failed by NHS systems in 2017, following an investigation into the death of Averil Hart. The 19-year-old died while under the care of adult eating disorder services in Norfolk and Cambridge. In 2021, following an inquest into her death and the deaths of four other women, a senior coroner for Cambridge, Sean Horstead, also sent warnings to the government about adult community eating disorder services. Read full story Source: The Independent, 27 March 2024
  16. News Article
    An investigation published by The BMJ today reveals new details of requests to recall striking junior doctors from picket lines for patient safety reasons. Documents show that while most trusts in England did not make such requests, those that did were rejected by the BMA in most cases. Some of these trusts warned of potential harm to patients from cancelling operations at the last minute and short staffing, reports assistant news editor Gareth Iacobucci. However, the BMA said it takes concerns about patient safety “incredibly seriously” and provided The BMJ with summaries of why requests were turned down. The union’s chair of council Phil Banfield said, “Throughout industrial action we have engaged thoroughly and in good faith with the derogation process, considering each request carefully to ensure that granting a derogation is necessary and the last and only option.” He said that poor planning by some trusts had led to some routine care being inappropriately booked in on strike days. In other instances, he said trusts had failed to make sufficient effort to draft in the necessary cover for strike days. Read full story Source: BMJ, 28 March 2024
  17. Content Article
    With a record number of patients stuck in A&E, Healthwatch England’s CEO Louise Ansari wants to see a longer-term plan to improve conditions in which people wait for life-saving care. This should include real-life monitoring and reporting on patient experience.
  18. News Article
    Patients at the hospital that treated killer Valdo Calocane were discharged too soon and released in a worse state into the community, the NHS safety watchdog has found. Serious failings by Nottinghamshire Hospital Foundation Trust in keeping patients and the public safe have been identified in a review from the Care Quality Commission (CQC). More than 1,200 patients are waiting to be seen by community services, the report found. Meanwhile, several hundred who are receiving treatment did not have a clinician overseeing their care,the CQC found. The review was launched by the government following the conviction of killer Valdo Calocane, who was under the care of the NHS trust’s community services. The CQC review said patients reported that crisis services are either “useless” or detrimental to their health. The three broad areas of concern, highlighted in the CQC’s report, were: High demand for services was leading to long waiting times for care and a lack of oversight of those waiting. The trust does not have enough staff to keep patients safe in the community and within some hospital services. Senior leaders at the trust do not have clear oversight of the risks and issues within the service. Read full story Source: The Independent, 27 March 2024
  19. Content Article
    Far from being a drain, equality, diversity and inclusion (EDI) is an investment that can improve workforce wellbeing and experience, and enhance service design and delivery. It also ensures patients are involved in designing care. NHS Confederation sought the views of healthcare leaders to understand their perspectives on the value of an EDI approach to tackling inequalities in the NHS. This briefing captures what they found and what leaders need as a result.
  20. Content Article
    Improving maternity care is a key Government and National Institute for Health and Care Research (NIHR) priority. In March 2024, an NIHR Evidence webinar showcased research from their recent Collection, Maternity services: evidence to support improvement.  This summary includes videos of researchers’ presentations and captures some of the points raised in the webinar Q&A. It highlights seven features of safety in the maternity units, kind and compassionate care around the induction of labour, and the role of hospital boards in improving maternity care.
  21. Event
    Our Human Factors – Applying to Incident Investigation programme is designed to equip staff with the knowledge and skills to use a systems approach to incident investigation. This is a great opportunity for programme participants to develop their understanding of Human Factors and apply this methodology to case studies with peers. The programme introduces the concept of system thinking and provides participants with the opportunity to discuss their own work context. Participants will grow their investigative mindset, whilst developing their knowledge and skills of the investigative process from the event timeline to recommendations for improvement. The programme also includes the opportunity to discuss and reflect on the essential components of good investigation, including; Being open and honest. Duty of candour. Co-designing investigations. Just culture. Systems based frameworks. Closing the loop from recommendations to action. Human Factors – Applying to Incident Investigation will take place on 9, 16 and 23 May 2024. Who is this for? The programme is aimed at all staff who are required to carry out or oversee incident investigation. Programme duration This is a 3 day programme. Delivery methods This programme is delivered virtually.
  22. Event
    This introductory course from AQUA is aimed at those who are new to Human Factors or those who are interested in refreshing existing knowledge. You will gain the fundamental knowledge and skills for Human Factors in health and care. Taking place online over two half days, this course will blend guided independent study with facilitated discussion and activities. You will be encouraged to apply your learning to your own role and environment, to reduce error, improve processes that underpin patient safety, and support organisational safety culture. Learning objectives: Understand the basic concept of Human Factors Understand the importance of Human Factors for safety and quality improvement Have awareness of what influences human and system performance Understand the basic concepts of systems thinking Who is this for? This programme is ideal for any staff who wish to develop a basic knowledge/awareness of human factors. Programme duration This programme consists of two sessions which will each last for three hours. Delivery methods This programme is delivered virtually through online sessions. Register
  23. Event
    This introductory course from AQUA is aimed at those who are new to Human Factors or those who are interested in refreshing existing knowledge. You will gain the fundamental knowledge and skills for Human Factors in health and care. Taking place online over two half days, this course will blend guided independent study with facilitated discussion and activities. You will be encouraged to apply your learning to your own role and environment, to reduce error, improve processes that underpin patient safety, and support organisational safety culture. Learning objectives: Understand the basic concept of Human Factors Understand the importance of Human Factors for safety and quality improvement Have awareness of what influences human and system performance Understand the basic concepts of systems thinking Who is this for? This programme is ideal for any staff who wish to develop a basic knowledge/awareness of human factors. Programme duration This programme consists of two sessions which will each last for three hours. Delivery methods This programme is delivered virtually through online sessions. Register
  24. Content Article
    This cohort study in JAMA Network explored the incidence of and factors associated with inappropriate diagnosis of pneumonia in hospitalised patients. The results showed that older patients, those with dementia and those presenting with altered mental status had the highest risk of being inappropriately diagnosed. For those who were inappropriately diagnosed, full antibiotic duration was associated with antibiotic-associated adverse events.
  25. Content Article
    This article by the Patient Experience Library summarises the findings of an independent review of services at University Hospitals Sussex Trust by the Royal College of Surgeons. The article highlights that it is a positive sign to see the Trust publishing a sensitive report publicly, noting that in the past other trusts have suppressed reviews of this kind. The review highlighted some concerning findings, including: A high volume of complaints from patients and delays in responding. Consultant surgeons being dismissive and disrespectful towards other members of staff and displaying hierarchical behaviours towards allied healthcare professionals, particularly junior members of staff. Reports of two trainees being physically assaulted by a consultant surgeon in theatre during surgery. A culture of fear amongst staff when it came to the executive leadership team, with instances of confrontational meetings where consultant surgeons were told to 'sit down, shut up and listen'.
  26. Event
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    The Patient Information Forum (PIF) is hosting a new two-day workshop offering key data on health literacy and digital exclusion, plus top tips and examples of good practice. This streamlined health and digital literacy training has been developed in response to feedback from PIF members. It explores the key health and digital literacy challenges facing the UK and the potential solutions. Examples of good practice will be shared throughout. Key topics An introduction to health literacy What is the health literacy challenge and who is affected? Solutions to the health literacy challenge Becoming a health-literacy friendly organisation An introduction to digital literacy The challenge of digital exclusion Carrying out a digital inequalities assessment Overcoming digital inequalities Cost Members - £250 Non-members - £400 including VAT Register for the workshop
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