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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Controlling exposures to occupational hazards is the fundamental method of protecting workers. Traditionally, a hierarchy of controls has been used as a means of determining how to implement feasible and effective control solutions.This Centers for Disease Control and Prevention (CDC) summarises the hierarchy of controls.
  2. Content Article
    Despite the increasing availability of mobile health services, clinical engagement remains minimal. This study from Leigh et al. aimed to identify and weight barriers to and drivers of health app use among health care professions (HCPs) from the UK. They found an NHS stamp of approval, published studies, and recommendations from fellow HCPs are significant facilitators of digital prescribing, whereas increasing costs and patient age are significant barriers to engagement. These findings suggest that demonstrating assurances of health apps and supporting both the dissemination and peer-to-peer recommendation of evidence-based technologies are critical if the NHS is to achieve its long-term digital transformation ambitions.
  3. Content Article
    This issue of Hindsight concerns ‘the new reality’ that we are facing. It includes a wide variety of articles from frontline staff and specialists in safety, human factors, psychology, aeromedical, and human and organisational performance in aviation. There are also insights from healthcare, shipping, rail, community development and psychotherapy. 
  4. Content Article
    Clinical pharmacists reduce medication errors and optimise the use of medication in critically ill patients, although actual staffing level and deployment of UK pharmacists is unknown. The primary aim of this study was to investigate the UK deployment of the clinical pharmacy workforce in critical care and compare this with published standards. The authors conclude that investment in pharmacy services is required to improve access to clinical pharmacy expertise at weekends, on MDT ward rounds and for other critical care activities.
  5. Content Article
    Artificial intelligence tools and deep learning models are a powerful tool in cancer treatment. They can be used to analyse digital images of tumour biopsy samples, helping physicians quickly classify the type of cancer, predict prognosis and guide a course of treatment for the patient. However, unless these algorithms are properly calibrated, they can sometimes make inaccurate or biased predictions, as Howard et al. demonstrate in this study.
  6. News Article
    Artificial intelligence (AI) tools and deep learning models are a powerful tool in cancer treatment. They can be used to analyse digital images of tumour biopsy samples, helping doctors quickly classify the type of cancer, predict prognosis and guide a course of treatment for the patient. However, unless these algorithms are properly calibrated, they can sometimes make inaccurate or biased predictions. A new study led by researchers from the University of Chicago shows that deep learning models trained on large sets of cancer genetic and tissue histology data can easily identify the institution that submitted the images. The models, which use machine learning methods to "teach" themselves how to recognise certain cancer signatures, end up using the submitting site as a shortcut to predicting outcomes for the patient, lumping them together with other patients from the same location instead of relying on the biology of individual patients. This in turn may lead to bias and missed opportunities for treatment in patients from racial or ethnic minority groups who may be more likely to be represented in certain medical centres and already struggle with access to care. "We identified a glaring hole in the in the current methodology for deep learning model development which makes certain regions and patient populations more susceptible to be included in inaccurate algorithmic predictions," said Alexander Pearson, one of the authors of the study. Read full story Source: Digital Health News, 22 July 2021
  7. Content Article
    Engaging with company executives over how their decisions affect employees’ performance further down the line could help improve safety at sea. An 18-month study found investigations of maritime accidents tend to “blame the ship”, often resulting in the punishment of seafarers.  Authors Barry Kirwan, Ben Wood and Beatrice Bettignies-Thiebaux of Eurocontrol, argue that this approach hampers learning and more attention needs to be paid to contributory factors from higher up the chain. They say that a deeper understanding of organisational influences and how company culture contributes to accidents will help promote safety across the business and better address problems.  They have developed a ‘Reverse Swiss Cheese Maritime Model’ which moves from organisation through design and fleet support to vessel operations. To facilitate this, they believe there needs to be greater engagement between analysts and the industry’s decision makers and are hoping to trial their approach with several organisations over the next year. Barry, who presented the findings at our recent conference, said: “We need to look not only at how ‘work is done’ but how ‘business is done’.”
  8. Content Article
    The Patient-Centered Outcomes Research Institute (PCORI) is an independent, non-profit research organisation that seeks to empower patients and others with actionable information about their health and healthcare choices. It funds comparative clinical effectiveness research (CER), which compares two or more medical treatments, services, or health practices to help patients and other stakeholders make better informed decisions. The PCORI Strategic Plan provides a roadmap for its activities in the years ahead as they pursue their vision and mission. Developed with extensive stakeholder input, the Plan articulates a refined focus on generating patient-centered evidence that has the greatest positive impact on health outcomes.
  9. Content Article
    Complications of surgical mesh procedures have led to legal cases against manufacturers worldwide and to national inquiries about their safety. The aim of this study from Keltie K et al. was to investigate the rate of adverse events of these procedures for stress urinary incontinence in England over 8 years.
  10. Content Article
    Many of us are hoping vaccines against coronavirus will be our route out of lockdown, enabling us to reclaim our old lives. But scientists say jabs alone will not currently be enough and other measures are still needed. The problem is that no single measure to prevent the spread of coronavirus is 100% effective, and that includes vaccines. This animated BBC article uses the Swiss Cheese respiratory panedemic defence model, first created by Ian M Mackay, a virologist at the University of Queensland, Australia, to explain.
  11. Content Article
    The Freedom to Speak Up (FTSU) Index is a key metric for organisations to monitor their speaking up culture. Measuring the effect of culture change can be difficult. The acid test is the view of workers. The NHS Annual Staff Survey can help to give some indication as to whether Freedom to Speak Up is embedded within Trusts detailing whether staff feel knowledgeable, encouraged and supported to raise concerns and if they agree they would be treated fairly if involved in an error, near miss or incident.
  12. Content Article
    The use of graded exercise therapy and cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome has attracted considerable controversy. This controversy relates not only to the disputed evidence for treatment efficacy but also to widespread reports from patients that graded exercise therapy, in particular, has caused them harm. The authors of this study surveyed the NHS–affiliated myalgic encephalomyelitis/chronic fatigue syndrome specialist clinics in England to assess how harms following treatment are detected and to examine how patients are warned about the potential for harms. The study found that clinics were highly inconsistent in their approaches to the issue of treatment-related harm. They placed little or no focus on the potential for treatment-related harm in their written information for patients and for staff. Furthermore, no clinic reported any cases of treatment-related harm, despite acknowledging that many patients dropped out of treatment. The authors recommend that clinics develop standardised protocols for anticipating, recording, and remedying harms, and that these protocols allow for therapies to be discontinued immediately whenever harm is identified.
  13. Content Article
    The aim of this study from Avery et al. was to determine the prevalence and nature of prescribing errors in general practice; to explore the causes, and to identify defences against error. The study involved examination of 6,048 unique prescription items for 1,777 patients. Prescribing or monitoring errors were detected for 1 in 8 patients, involving around 1 in 20 of all prescription items. The vast majority of the errors were of mild to moderate severity, with 1 in 550 items being associated with a severe error. The following factors were associated with increased risk of prescribing or monitoring errors: male gender, age less than 15 years or greater than 64 years, number of unique medication items prescribed, and being prescribed preparations in the following therapeutic areas: cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin. Prescribing or monitoring errors were not associated with the grade of GP or whether prescriptions were issued as acute or repeat items. A wide range of underlying causes of error were identified relating to the prescriber, patient, the team, the working environment, the task, the computer system and the primary/secondary care interface. Many defences against error were also identified, including strategies employed by individual prescribers and primary care teams, and making best use of health information technology.
  14. Content Article
    These professional standards describe good practice and good systems of care for reporting, learning, sharing, taking action and review as part of a patient safety culture. The accompanying guidance and information support the implementation of the standards. These professional standards are for pharmacists, pharmacy technicians and the wider pharmacy team across the United Kingdom. This may also be of interest to the public, to people who use pharmacy and healthcare services, healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
  15. Content Article
    Disruptive and unprofessional behaviours occur frequently in healthcare and adversely affect patient care and health #care worker job satisfaction. These behaviours have rarely been evaluated at a work setting level, nor do we fully understand how disruptive behaviours (DBs) are associated with important metrics such as teamwork and safety climate, work-life balance, burnout and depression. Using a cross-sectional survey of all health ]care workers in a large US health system, this study from Redher et al. aimed to introduce a brief scale for evaluating DBs at a work setting level, evaluate the scale’s psychometric properties and provide benchmarking prevalence data from the health care system, and investigate associations between DBs and other validated measures of safety culture and well-being.
  16. Content Article
    Every day we use tools and resources to manage our lives, both personally and professionally. As a healthcare professional, you are committed to providing safe quality healthcare to all individuals. The checklists in this book are designed to help you succeed in that effort. You may be a first-time reader who has not had the opportunity to put these tools to the test, or you could be a returning reader interested in what new checklists you can use. In either instance, if you’re reading this book, then you are searching for tools to help your healthcare organisation navigate the increasing complexities of providing quality health care and maintaining the physical environment where healthcare is delivered.
  17. Content Article
    Design is a structured process for identifying problems and developing and evaluating user-focussed solutions. It has been successfully used to transform products, services, systems and even entire organisations. Based on the extensive experience of the aviation, military and nuclear industries, it is clear that effective design thinking can facilitate the delivery of products, services, processes and environments that are intuitive, simple to understand, simple to use, convenient, comfortable and consequently less likely to lead to error and accidents. Confusing, complex and unwieldy designs, which are all too often present in healthcare, are at best less effective than they could be. At worst, they are potentially dangerous to medical staff or the patient - or both. The contribution of design to improving safety in the context of medical systems is an area which remains relatively unexplored.  This scoping review is a joint report from the Robens Centre for Health Ergonomics at the University of Surrey; The Helen Hamlyn Research Centre at the Royal College of Art; and The Cambridge Engineering Design Centre at the University of Cambridge to identify how the effective use of design could help to reduce medical accidents.
  18. Content Article
    Scientific and policy bodies’ failure to acknowledge and act on the evidence base for airborne transmission of SARS-CoV-2 in a timely way is both a mystery and a scandal. In this study, Greenhalgh et al. applied theories from Bourdieu to address the question, “How was a partial and partisan scientific account of SARS-CoV-2 transmission constructed and maintained, leading to widespread imposition of infection control policies which de-emphasised airborne transmission?”.
  19. Content Article
    Medicines play a crucial role in maintaining health, preventing illness, managing chronic conditions and curing disease. However, there is a growing body of evidence that shows us that there is an urgent need to get the fundamentals of medicines use right. Medicines use today is too often sub-optimal and we need a step change in the way that all healthcare professionals support patients to get the best possible outcomes from their medicines. Medicines optimisation represents that step change. It is a patient-focused approach to getting the best from investment in and use of medicines that requires a holistic approach, an enhanced level of patient centred professionalism, and partnership between clinical professionals and a patient. Medicines optimisation is about ensuring that the right patients get the right choice of medicine, at the right time.
  20. Content Article
    Group B Streptococcus (Group B Strep, Strep B, Beta Strep, or GBS) is a type of bacteria which lives in the intestines, rectum and vagina of around 2-4 in every 10 women in the UK (20-40%). Most women carrying GBS will have no symptoms and although it is not harmful to pregnant women, it can affect babies around the time of birth. Read Poppy's story.
  21. Content Article
    Group B Streptococcus (GBS, group B Strep or Strep B) is a type of bacteria which lives in the intestines, rectum, or vagina of 2 to 4 in every ten women in the UK (20 to 40%). This is often referred to as ‘carrying’ or being ‘colonised with’ group B Strep.  Most women carrying GBS will have no symptoms. Carrying GBS is not harmful to you, but there is a small chance it can affect your baby around the time of birth. GBS can occasionally cause serious infection in young babies and, very rarely, in babies before they are born. Carrying GBS can also sometimes lead to serious infections for pregnant women, though this is also rare. Find out more about Group B Strep in pregnancy on the Group B Strep Support website or by watching the video via the link below. 
  22. Content Article
    This article from the Transforming Maternity Care Collaborative discusses midwifery a public health strategy, highlighting midwives in continuity of care models, evidence on midwifery public health interventions, and how the COVID-19 pandemic has shown the importance of investing in public health care to meet population health needs.
  23. Content Article
    Would you like to become more involved with the hub? Do you want to make a difference to patient safety? If so, we are looking for volunteers to give a minimum of 4 hours a month to source and upload content to the hub and our Instagram account. This role would suit someone who is looking to work in the patient safety area or to work for a charity, or someone looking for experience in digital communications or content management. You don’t necessarily need a clinical background, although if you have then that’s great. "I enjoy volunteering for the hub because it allows me to explore different interesting healthcare issues through writing original blogs, as well as uploading existing content to the website. I’ve learnt so much through my reading and research of topics as diverse as maternal care to men’s health to needlestick injuries. I’ve always had an interest in healthcare and public engagement, and it feels important to me to contribute to an organisation that is passionate about patient care and safety, after being a patient myself for many years. I'd recommend volunteering with the hub to anyone who has some free time to do something that is interesting, rewarding and worthwhile." Becky, hub volunteer See attachments for further information.
  24. Content Article
    In addition to older individuals and those with underlying chronic health conditions, maternal and newborn populations have been identified as being at greater risk from COVID-19. It became critical for hospitals and clinicians to maintain the safety of individuals in the facility and minimise the transmission of COVID-19 while continuing to strive for optimised outcomes by providing family-centered care. Rapid change during the pandemic made it appropriate to use the plan–do–study–act (PDSA) cycle to continually evaluate proposed and standard practices. Patrick and Johnson describe how their team established an obstetric COVID-19 unit for women and newborns, developed guidelines for visitation and for the use of personal protective equipment, initiated universal COVID-19 testing, and provided health education to emphasize shared decision making.
  25. Content Article
    This Rapid Evidence Scan from Moore et al. examined the effectiveness of virtual hospital models of care. While no reviews evaluated a complete model, tele-healthcare only and tele-healthcare with remote telemonitoring interventions demonstrated similar or significantly better clinical or health system outcomes including reduced hospitalisations, readmissions, emergency department visits and length of stay, compared to usual care, including those delivered without home visits or face-to-face care. The use of the Internet showed mixed but promising results. The strongest evidence was for cardiac failure, coronary heart disease, diabetes and stroke rehabilitation. Nurses played a central role in home visiting, providing telephone support and education. However, the studies were heterogenous and the results should be interpreted with caution.
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