Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

Everything posted by Patient Safety Learning

  1. Event
    until
    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
  2. 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
  3. 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.
  4. 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
  5. 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.  
  6. 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.
  7. 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
  8. 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
  9. 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.
  10. 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.
  11. Content Article
    Patient 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.
  12. 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
  13. 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.
  14. 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.
  15. Content Article
    Download this complimentary report and discover how the NHS is paving the way to becoming the world's first net zero health service by 2040. Learn about groundbreaking initiatives such as the first net zero surgery, sustainable tech adoption, and partnerships with energy experts like E.ON. This guide showcases the NHS's efforts in tackling climate change, enhancing healthcare, and overcoming economic hurdles through innovation and strategic energy management.
  16. News Article
    Researchers at the National Institutes of Health applied artificial intelligence (AI) to a technique that produces high-resolution images of cells in the eye. They report that with AI, imaging is 100 times faster and improves image contrast 3.5-fold. The advance, they say, will provide researchers with a better tool to evaluate age-related macular degeneration (AMD) and other retinal diseases. "Artificial intelligence helps overcome a key limitation of imaging cells in the retina, which is time," said Johnny Tam, Ph.D., who leads the Clinical and Translational Imaging Section at NIH's National Eye Institute. Tam is developing a technology called adaptive optics (AO) to improve imaging devices based on optical coherence tomography (OCT). Like ultrasound, OCT is noninvasive, quick, painless, and standard equipment in most eye clinics. "Our results suggest that AI can fundamentally change how images are captured," said Tam. "Our P-GAN artificial intelligence will make AO imaging more accessible for routine clinical applications and for studies aimed at understanding the structure, function, and pathophysiology of blinding retinal diseases. Thinking about AI as a part of the overall imaging system, as opposed to a tool that is only applied after images have been captured, is a paradigm shift for the field of AI." Read full story Source: Digital Health News, 11 April 2024
  17. News Article
    The number of people dying needlessly in A&E soars on a Monday as hospitals are stretched to the limit and failing to discharge patients at the weekend, new data shows. Figures uncovered by The Independent show an average of 126 patients died every Monday between 2020-2023 – 25% higher than any other day. On a Saturday, the average number of deaths drops as low as 90. Waiting times are also shown to spike massively at the start of the week, with an average of 9,300 patients spending more than 12 hours waiting on a Monday – up to 2,000 more than any other day. Medical experts said the rise in A&E waits can be attributed to people staying away from hospitals during weekends and patients not being discharged from medical care, causing a bottleneck in an already buckling system. The stark statistics also directly contradict repeated government efforts to make the NHS a seven-day service. Multiple coroners have warned the government and health leaders about delays to patients’ treatment and diagnosis due to variations in staffing and access to specialists – particularly over the weekend. Adrian Boyle, president of the Royal College of Emergency Medicine, said the NHS England data clearly signposted an “increased risk” at the start of the week. Another expert said the sharp rise in deaths on Mondays showed an A&E “running constantly in the red zone”. Read full story Source: The Independent, 8 April 2024
  18. News Article
    Many people with breast cancer are being “systematically left behind” due to inaction on inequities and hidden suffering, experts have said. A new global report suggests people with the condition are continuing to face glaring inequalities and significant adversity, much of which remains unacknowledged by wider society and policymakers. The Lancet Breast Cancer Commission highlights a need for better communication between medical staff and patients, and stresses the importance of early detection. It also highlights the need for improved awareness of breast cancer risk factors, with almost one in four cases (23%) of the disease estimated to be preventable. The Lancet Commission’s lead author, Professor Charlotte Coles, department of oncology, University of Cambridge, said: “Recent improvements in breast cancer survival represent a great success of modern medicine. “However, we can’t ignore how many patients are being systematically left behind. “Our commission builds on previous evidence, presents new data and integrates patient voices to shed light on a large unseen burden. “We hope that by highlighting these inequities and hidden costs and suffering in breast cancer, they can be better recognised and addressed by healthcare professionals and policymakers in partnership with patients and the public around the world.” Read full story Source: The Independent, 15 April 2024
  19. Content Article
    When operating on a patient, a surgeon may put swabs (pieces of gauze that come in a range of types, shapes and sizes) into the patient’s body to absorb bodily fluids such as blood. The operating theatre team count the swabs in and out, using a process known as reconciliation, to ensure all swabs are accounted for at the end of the operation. However, sometimes a swab can be unintentionally retained (left inside a patient’s body). This type of patient safety incident is known as a ‘Never Event’ – that is, an event that NHS England considers to be wholly preventable. This report is intended for healthcare organisations, policymakers, and the public to help improve patient safety in relation to retained swabs following invasive procedures.
  20. Event
    until
    The only nursing event of its kind in the UK, Nursing Live brings thousands of nurses together to enjoy two days of high-quality professional development, peer-to-peer collaboration, well-being activities and more. As well as bringing senior nursing leaders together to debate key issues and policy, Nursing Live featured some of the sector’s most respected frontline practitioners, such as Nicola Bailey OBE (RCN Nurse of the Year 2021), and Ana Waddington (RCN Nurse of the Year 2020). With dedicated workshops offering guidance on personal mental and physical health, the well-being of nurses was a core theme running throughout Nursing Live. This was complemented by an extensive range of accredited CPD masterclasses covering topics as diverse as equality and inclusion, safeguarding, leadership, medicine management, and innovation. Recruitment opportunities, and exploring different nursing career pathways, were also highlighted, with many exhibitors using Nursing Live to meet prospective employees, and promote live vacancies. Further information
  21. Content Article
    Despite tremendous advances in breast cancer research and treatment over the past three decades—leading to a reduction in breast cancer mortality of over 40% in some high-income countries—gross inequities remain, with many groups being systematically left behind, ignored, and even forgotten. The work of the Lancet Breast Cancer Commission highlights crucial groups, such as those living with metastatic breast cancer, and identifies how the hidden costs of breast cancer and associated suffering are considerable, varied, and have far-reaching effects. The Commission offers a forward-looking and optimistic road map for how the health community can course correct to address these urgent challenges in breast cancer.
  22. Content Article
    This year’s World Patient Safety Day on 17 September 2024 is focused on the theme “Improving diagnosis for patient safety”. This article explains the aims of the event and the areas it will cover.
  23. Content Article
    About 40,000 patient pathways have disappeared. But on the plus side, a new and better data series has begun. The referral-to-treatment (RTT) waiting list data has now changed in two important ways. First, about 40,000 patient pathways in community services are now excluded from the RTT data collections, and this accounted for all of the apparent reduction in list size in the latest (February) official RTT data. Second, NHS England has started regular publication of the more detailed and timely (though – for now – less complete and accurate) Waiting List Minimum Data set. This HSJ article looks at those changes in more detail.
  24. News Article
    Some people having a lung transplant on the NHS will receive a skin patch graft from their donor too as a way of spotting organ rejection sooner. Rejection could show as a rash on the donated skin patch, say experts, allowing early treatment to stop problems escalating. The trial, by University of Oxford and NHS Blood and Transplant, will enrol 152 patients in England. It follows earlier success with some other transplant patients, including Adam Alderson, 44, who received a donor skin graft on his abdomen in 2015 when he had eight organs replaced – including a pancreas, stomach and spleen – after treatment for a rare cancer. He says the graft has already helped guide his treatment a few times to prevent his body rejecting his many new organs. He said: "It's a really comforting thing to have - I feel safer knowing that I have a tool available to tell if something is going wrong before it becomes too serious. It's almost like an oil warning light on your car. Plus, having that visible reminder of how lucky I am is really special." Read full story Source: BBC News, 16 April 2024
  25. News Article
    Public protection and support for bereaved families are at the heart of a government overhaul of how deaths are certified. From September, medical examiners will look at the cause of death in all cases that haven’t been referred to the coroner in a move designed to help strengthen safeguards and prevent criminal activity. They will also consult with families or representatives of the deceased, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the person who died. The changes demonstrate the government’s commitment to providing greater transparency after a death and will ensure the right deaths are referred to coroners for further investigation. Health Minister, Maria Caulfield said: Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right. At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way. The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses. From 9 September 2024 it will become a requirement that all deaths in any health setting that are not referred to the coroner in the first instance are subject to medical examiner scrutiny. Welcoming the announcement today, Dr Suzy Lishman CBE, Senior Advisor on Medical Examiners for Royal College of Pathologists, said: “As the lead college for medical examiners, the Royal College of Pathologists welcomes the announcement of the statutory implementation date for these important death certification reforms. “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.” Read full story Source: Gov.UK, 15 April 2024
×
×
  • Create New...