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- Yesterday
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Content ArticleIn this blog, Siva Anandaciva, Chief Policy Analyst at The King's Fund, examines NHS productivity—a top political priority. He highlights the difficulties in understanding the reasons for low productivity in the NHS after the Covid-19 pandemic and outlines the need to distinguish between productivity and delivery in order to really understand the issues.
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Content ArticleThis report from the BME Leadership Network comprises examples of anti-racist initiatives from BME Leadership Network members, to help advance equality within the workforce and for service users.
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Content ArticleHow we talk about health is important, and even those with the best intentions don't always do it well. Krista Lamb is an author and science communicator in Toronto. For years she has helped scientists, physicians, advocates and others share their healthcare stories effectively. Along the way, some of them have taught her how we can and should talk about health in ways that are empathetic, understandable and accurate. In this podcast she asks those people to share their tips and tricks to help everyone communicate better.
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Content Article
WHO: Patient safety rights charter (18 April 2024)
Patient Safety Learning posted an article in WHO
The Patient safety rights charter is a key resource intended to support the implementation of the Global Patient Safety Action Plan 2021–2030: Towards eliminating avoidable harm in health care. The Charter aims to outline patients’ rights in the context of safety and promotes the upholding of these rights, as established by international human rights standards, for everyone, everywhere, at all times. - Last week
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Content ArticleDiagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. Newman-Toker and colleague previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. In this study they estimated the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. They found that an estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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Content ArticleA study published in the BMJ has investigated the risks of multiple adverse outcomes associated with use of antipsychotics in people with dementia. The authors of the study found that antipsychotic use compared with non-use in adults with dementia was associated with increased risks of stroke, venous thromboembolism, myocardial infarction, heart failure, fracture, pneumonia, and acute kidney injury, but not ventricular arrhythmia. The range of adverse outcomes was wider than previously highlighted in regulatory alerts, with the highest risks soon after initiation of treatment.
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Content ArticleThere have been two turning points in trends in life expectancy in England this century. From 2011, increases in life expectancy slowed after decades of steady improvement, prompting much debate about the causes. Then, in 2020, the Covid-19 pandemic was a more significant turning point, causing a sharp fall in life expectancy, the magnitude of which has not been seen since World War II. This article from the King's Fund examines trends in life expectancy at birth up to 2022, the impact of Covid-19 on life expectancy, gender differences and inequalities in life expectancy, causes of the changing trends since 2011, and how life expectancy in the UK compares with other countries.
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Content ArticlePatient Safety Learning has designed a set of unique Patient Safety Standards and support tools that can help organisations not only establish clearly defined safety aims and goals, but also demonstrate their achievement. Our 'Organisational Snapshot' is an easily implemented diagnostic focused on our patient safety Foundations and Aims and cross-referenced to our full Standards. Using a mix of one-on-one interviews and workshops with a small number of selected individuals, our 'Snapshot' can quickly identify: Where your strengths and weaknesses are on patient safety. Where your focus should be on patient safety improvement. How to create or update a strategic plan and goals reflecting the diagnostic. If you need or want to undertake a more detailed assessment against our Standards.
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Content ArticleThe Health Services Safety Investigations Body (HSSIB) came into operation on 1 October 2023. One of the organisation's key priorities is to develop a new strategy, outlining the long-term goals and themes that underpin its objectives. This consultation is an opportunity to engage and shape HSSIB's strategy and investigation criteria for the future. The organisation is inviting comments and suggestions for improvement from all stakeholders. Comments can be submitted via this online survey. The deadline for submissions to the consultation is 16 May 2024.
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Content ArticleThe Nuffield Trust's Health and International Relations Monitor project, supported by the Health Foundation, tracks issues that are important for the delivery of health and care in the UK. It aims to understand how our changing relationship with Europe is changing the picture for the NHS and health more generally, and what the prospects are for the future. This latest report shows that global medicine shortages are being felt particularly acutely in the UK, and the country's reliance on migration as a source of health and social care staff is intensifying.
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Content ArticleSurgical Site Infections (SSIs) can have subtle, early signs that are not readily identifiable. This study aimed to develop a machine learning algorithm that could identify early SSIs based on thermal images. Images were taken of surgical incisions on 193 patients who underwent a variety of surgical procedures, but only five of these patients developed SSIs, which limited testing of the models developed. However, the authors were able to generate two models to successfully segment wounds. This proof-of-concept demonstrates that computer vision has the potential to support future surgical applications.
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Content ArticleThis research letter in JAMA Internal Medicine describes a multicentre retrospective cohort study that investigated associations between stigmatising language, errors in the diagnostic process and demographics for hospitalised patients. The study found that stigmatising language in patient documentation was associated with diagnostic error and multiple diagnostic process errors. The prevalence of stigmatising language was higher in documentation relating to Black patients and patients with housing instability. The authors argue that this may be indicative of clinician biases that interfere with data gathering, communication and clinical reasoning. They call for further research to explore the mechanisms behind this and to understand how clinician use of stigmatising language can be reduced.
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Content ArticleBreast cancer related lymphoedema (BRCL) is an under-recognised health condition that occurs in 20% of women after receiving breast cancer treatment. BRCL can affect a patient's physical and mental health and is costly to the NHS. In this blog, James Moore, a biomedical engineering researcher at Imperial College, talks about how he has involved patients in designing an innovative solution to this issue.
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Content ArticleThe Nursing & Midwifery Council (NMC) is commissioning independent research into nursing and midwifery students’ practice learning to ensure members of the public can shape this work from the start and throughout. One way people can get involved is by being part of a new Public Advisory Group on practice learning.
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Content ArticleThis systematic review and meta-analysis in JAMA Internal Medicine aimed to assess the rates of complications from central venous catheter (CVC) use. The authors found that rates of complications varied substantially across studies, but on average, the rate of serious complications (arterial cannulation, pneumothorax, infection or deep vein thrombosis) from a CVC placed for three days was estimated to be 30 events per 1000 catheters placed (3%). Use of ultrasonography was associated with lower rates of immediate insertion-related complications.
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Content ArticleIn this blog, Peter Provonost MD, Chief Quality and Transformation Officer at University Hospitals Cleveland Medical Center, offers advice about what patients and their families can do to prevent health risks associated with hospital stays. He looks ways to mitigate against medication errors, surgical errors, infections, blood clots and other medical complications.
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Content ArticleAs the NHS’s digital transformation journey enters a new phase, there are opportunities to improve the quality and productivity of the healthcare system. This phase is not just about advancing the maturity of electronic health records (EHRs) but also about embracing the vast potential of generative artificial intelligence tools. In this HSJ article, Robert Wachter and Harpreet Sood explore the reasons why EHRs have not yet delivered promised productivity improvements and look at how GenAI offers opportunities for the NHS to realise productivity benefits faster, cheaper and at a greater scale.
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Content ArticleThis French cohort study in JAMA Internal Medicine aimed to find out whether spending a night in the emergency department (ED) associated with increased in-hospital mortality and morbidity among older patients. The results showed that older patients who spent a night in the ED showed a higher in-hospital mortality rate and increased risk of adverse events compared with patients admitted to a ward before midnight. This finding was particularly notable among patients with limited autonomy.
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Content ArticleIn this report for Stat, technology correspondent Casey Ross looks at the dangers involved in using AI to predict patient outcomes, especially in life-or-death situations such as suspected sepsis. He looks at the recent case of US electronic health record provider Epic who were force to rewrite the algorithm being used by tens of thousands of US clinicians to predict sepsis.
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Content ArticleThe use of temporary doctors, known as locums, has been common practice for managing staffing shortages and maintaining service delivery internationally. However, there has been little empirical research on the implications of locum working for quality and safety. This study aimed to investigate the implications of locum working for quality and safety. The participants of the study described the implications of locum working for quality and safety across five themes: (1) ‘familiarity’ with an organisation and its patients and staff was essential to delivering safe care; (2) ‘balance and stability’ of services reliant on locums were seen as at risk of destabilisation and lacking leadership for quality improvement; (3) ‘discrimination and exclusion’ experienced by locums had negative implications for morale, retention and patient outcomes; (4) ‘defensive practice’ by locums as a result of perceptions of increased vulnerability and decreased support; (5) clinical governance arrangements, which often did not adequately cover locum doctors. The study concluded that locum working and how locums were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care. Organisations should take stock of how they work with the locum workforce to improve not only quality and safety but also locum experience and retention.
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Content ArticleIncident reports of medication errors are valuable learning resources for improving patient safety. However, key information is often contained within unstructured free text, which prevents automated analysis and limits the usefulness of these data. Natural language processing can be used to structure this free text automatically and retrieve relevant past incidents and learning materials, but this requires a large, fully annotated and validated set of incident reports. This study in Nature used a set of 58,658 machine-annotated incident reports of medication errors to test a natural language processing model. The authors provide access to the validation datasets and machine annotator for labelling future incident reports of medication errors.
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Content Article
Consumer perspectives enable a broader understanding of how harm occurs. This webpage by Te Tāhū Hauora, the Health Quality & Safety Commission of New Zealand, contains guidance on engaging patients and consumers who have experienced harm and wish to be involved in learning and improvement in the healthcare system. It describes how patients and family will be supported to work in partnership with health care workers. -
Content ArticleThe US Leapfrog Group has released Recognizing excellence in diagnosis: Leapfrog’s national pilot survey report, which analyses responses from 95 hospitals on their implementation of recommended practices to address diagnostic errors, defined as delayed, wrong or missed diagnoses or diagnoses not effectively communicated to the patient or family. The National Academy of Medicine has warned that virtually every American will suffer the consequences of a diagnostic error at least once in their lifetime and noted that 250,000 hospital inpatients will experience a diagnostic error every year. While progress varies considerably, more than 60% of hospitals responded that they were either already implementing or preparing to implement each of 29 evidence-based practices known to prevent harm from diagnostic error. The practices were identified in an earlier Leapfrog report, Recognizing excellence in diagnosis: Recommended practices for hospitals. The hospitals reported barriers to putting the practices in place that include staffing shortages and budgetary pressure.
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Content ArticleTommy Gillman died on 8 December 2022 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7 December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 17:00 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis.
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Content ArticleThis Health Foundation report explores how patterns of diagnosed ill health vary by socioeconomic deprivation in England. This report is the second output from the REAL Centre’s programme of research with the University of Liverpool. Building on the projections in Health in 2040, this report is one of the first studies to unpack patterns of inequalities in diagnosed illness by socioeconomic deprivation across England and project them into the future. Stark inequalities are projected to stubbornly persist up to 2040, with profound implications not only for people’s quality of life, but also their ability to work and the wider economy. The report also finds that health inequality is largely due to a small group of long-term conditions, with chronic pain, type 2 diabetes and anxiety and depression projected to increase at a faster rate in the most deprived areas.
