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Patient Safety Learning



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  1. Content Article
    The 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.
  2. Event
    Riphah Institute of Healthcare Improvement & Safety (RIHIS) has been organizing the region’s largest International Conference on Patient Safety (ICPS) annually for the last 5 years which draws key opinion leaders, domain experts, regulators, academia, and other stakeholders working in this space from all over the world. ICPS provides a platform to allow experts in Patient Safety to come together to create a momentum in the advancement of Healthcare Quality and Patient safety. Objectives of the Conference are: To create awareness about patient safety, medical errors and healthcare quality in Pakistan and the region. To help in developing a patient-centric mindset. To build a capacity of professionals, involved in the process of delivering quality healthcare and managing patient safety in their institutions. To bring together the stakeholders in Pakistan on this important subject objectives. Register
  3. Event
    Decades of research has shown that the health of the population in England is unequal, with people who live in more deprived areas experiencing illness earlier in life and dying younger. Previous Health Foundation analysis has projected that 9.3 million people could be living with major illness by 2040, which is 2.6 million, or 39%, more people than in 2019. In April, the Health Foundation’s REAL Centre published its second report in their ‘Health in 2040’ series, this time exploring how current patterns of ill health vary with deprivation across England, and to what extent this is projected to change by 2040. The findings have important implications for health inequality among the working age population and how it poses a challenge to labour supply and economic growth. This webinar will convene experts to explore what the findings mean for how we might need to change as a society, and what can we do to better prepare for the future. Register
  4. Content Article
    The 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.
  5. News Article
    The parents of a baby who died from sepsis said their son deserved a "fighting chance" after concerns were raised over his care in hospital. Ten-week-old Tommy Gillman was admitted to King's Mill hospital on 7 December 2022 but died the next day. Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be Salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT. His assessment was delayed, and then the severity of his condition missed, meaning correct treatment with antibiotics and fluids did not start until 17:00. A coroner's report identified a lack of experienced paediatric nurses and confusion in handovers between staff. "I am not reassured that necessary actions to address these serious issues identified are in place," the coroner said. Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review and a "rapid" programme of improvements was being worked on. Tamzin Myers and Charlie Gillman said their son deserved "a fighting chance" by getting prompt treatment Read full story Source: BBC News, 17 April 2024
  6. Content Article
    The 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.  
  7. Content Article
    Tommy 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.
  8. News Article
    Investigators have applied artificial intelligence (AI) techniques to gait analyses and medical records data to provide insights about individuals with leg fractures and aspects of their recovery. The study, published in the Journal of Orthopaedic Research, uncovered a significant association between the rates of hospital readmission after fracture surgery and the presence of underlying medical conditions. Correlations were also found between underlying medical conditions and orthopedic complications, although these links were not significant. It was also apparent that gait analyses in the early postinjury phase offer valuable insights into the injury’s impact on locomotion and recovery. For clinical professionals, these patterns were key to optimizing rehabilitation strategies. "Our findings demonstrate the profound impact that integrating machine learning and gait analysis into orthopaedic practice can have, not only in improving the accuracy of post-injury complication predictions but also in tailoring rehabilitation strategies to individual patient needs," said corresponding author Mostafa Rezapour, PhD, of Wake Forest University School of Medicine. "This approach represents a pivotal shift towards more personalised, predictive, and ultimately more effective orthopaedic care." Read full story Source: Digital Health News, 12 April 2024
  9. News Article
    A record 3.7 million workers in England will have a major illness by 2040, according to research. On current trends, 700,000 more working-age adults will be living with high healthcare needs or substantial risk of mortality by 2040 – up nearly 25% from 2019 levels, according to a report by the Health Foundation charity. But the authors predicted no improvement in health inequalities for working-age adults by 2040, with 80% of the increase in major illness in more deprived areas. Researchers at the Health Foundation’s research arm and the University of Liverpool examined 1.7m GP and hospital records, alongside mortality data, which was then linked to geographical data to estimate the difference in diagnosed illness by level of deprivation in England in 2019, the last year of health data before the pandemic. They then projected how levels of ill health are predicted to change in England between 2019 and 2040 based on trends in risk factors such as smoking, alcohol use, obesity, diet and physical activity, as well as rates of illness, life expectancy and population changes. Without action, the authors warn, people in the most deprived areas of England are likely to develop a major illness 10 years earlier than those in the least deprived areas and are also three times more likely to die by the age of 70. Read full story Source: The Guardian, 17 April 2024
  10. Content Article
    There 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.
  11. Content Article
    This 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.
  12. Content Article
    Those who use any type of health or social care service have a right to be informed about all elements of their care and treatment. Health and social care providers have that fundamental responsibility to be open and honest with those who are under their management and care. In particular, when things go wrong during the provision of care and treatment, patients and service users and their families or caregivers expect to be informed honestly about what happened, what can be done to deal with any harm caused, and to know what will be done to prevent a recurrence to someone else. In November 2014, the government introduced a statutory (organisational) duty of candour for NHS trusts and NHS foundation trusts via Regulation 20 of the Health and Social Care Act 2008. In essence, the duty places a direct obligation upon trusts to be open and honest with patients and service users, and their families, when something goes wrong that appears to have caused or could lead to moderate harm or worse in the future (known as a ‘notifiable safety incident’). The Department of Health and Social Care (DHSC) are seeking views on the statutory duty of candour for health and social care providers in England. This call for evidence closes at 11:59 pm on 29 May 2024.
  13. News Article
    The UK’s data protection regulator has published new guidance for health and social care organisations it says will help them be more transparent about how personal information is being used. The Information Commissioner’s Office (ICO) said the new guidance would provide regulatory certainty to organisations on how they should keep people properly informed as technology is increasingly used to deliver care and carry out research. The regulator said focus on the issue was needed as the health and social care sector routinely handles sensitive information about the most intimate aspects of peoples’ health, and that under data protection law, people have a right to know what is happening to their personal information. Being transparent is essential to building public trust in health and social care services Anne Russell, head of regulatory policy projects at the ICO, said the ever-increasing use of technology meant personal data was more important than ever, and so therefore was more transparency. “Being transparent is essential to building public trust in health and social care services,” she said. “If people clearly understand how and why their personal information is being used, they are likely to feel empowered to share their health information to both access care and support initiatives such as medical research. “As new technologies are developed and deployed in the health sector, our personal information is becoming more important than ever to boost the efficiency and public benefit of these systems. “With this bespoke guidance, we want to support health and social care organisations by improving their understanding of effective transparency, ensuring that they are clear, open and honest with everyone whose personal information is being used.” Read full story Source: The Independent, 15 April 2024
  14. Content Article
    We know from several reports, reviews, and inquiries over recent years that the patient and family voice has not been heard. These voices are essential to learning and improvement because of their unique insight into how care is delivered. To improve safety we must understand its reality as experienced by patients. In a blog for the Patient Safety Commissioner website, Rosie Benneyworth, interim chief executive officer of the Health Services Safety Investigations Body (HSSIB), explains how HSSIB involves families in its investigations.
  15. Content Article
    The Information Commissioner’s Office (ICO) is supporting health and social care organisations to ensure they are being transparent with people about how their personal information is being used. The UK data protection regulator has today published new guidance to provide regulatory certainty on how these organisations should keep people properly informed. The health and social care sectors routinely handle sensitive information about the most intimate aspects of someone’s health, which is provided in confidence to trusted practitioners. Under data protection law, people have a right to know what is happening to their personal information, which is particularly important when accessing vital services. The guidance will help organisations to understand the definition of transparency and assess appropriate levels of transparency, as well as providing practical steps to developing effective transparency information.
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