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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. 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.
  2. 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)
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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'.
  9. Event
    until
    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
  10. 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.
  11. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Rachel speaks to us about how patient partnership is key to tackling major issues facing the healthcare system and describes the central role of communication in improving patient safety.
  12. 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.
  13. Content Article
    This leaflet produced by East London NHS Foundation Trust (ELFT) explains the Patient Safety Incident Response Framework (PSIRF) to patients and families, outlining the aims of PSIRF and what they can expect from the process.
  14. Content Article
    This report was put together by two charities, Pathway and Crisis, and reveals how the national crisis facing both our health and housing systems leads to worsening health for people in inclusion health groups. Drawing on 85 pieces of published literature from the past two years, and a survey of frontline medical and healthcare professionals, the findings reveal how those who are most excluded in our society struggle to access health services due to inflexibility, discrimination and stigma. It calls on the Government, along with NHS England, to lead reform of mainstream health services and to increase the availability of specialist care. It further calls for a commitment to deliver the social housing needed to ensure that everyone has a safe and healthy home.
  15. Content Article
    The use of patient portals to send messages to healthcare teams is increasing. This JAMA Network Open cross-sectional study of nearly 40,000 US patients aimed to find out whether there are differences in how care teams respond to messages from Asian, Black and Hispanic patients compared with similar White patients. The authors found that messages asking for medical advice sent by patients who belong to minoritised racial and ethnic groups were less likely to receive a response from doctors and more likely to receive a response from registered nurses. This suggests these patients receive lower prioritisation during triaging. The differences observed were similar among Asian, Black and Hispanic patients.
  16. Content Article
    Severe myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) in children and young people is a little-understood condition which significantly impacts education, development and quality of life. This study in BMJ Paediatrics Open used data from a population-wide surveillance study to explore the screening investigation, referral and management of suspected cases of paediatric severe ME/CFS. The authors found that full investigation is frequently incomplete in children and young people with suspected severe ME/CFS. Recommendations for referral and management are poorly implemented—in particular the needs of children and young people who are unable to leave their home might be poorly met.
  17. Content Article
    This JAMA Network Open study aimed to explore whether standardised patients in a simulated environment can be effectively used to explore racial implicit bias and communication skills among doctors. For this cross-sectional study, 60 doctors were placed in an environment calibrated with cognitive stressors common to clinical environments. The results reflected expected communication patterns based on prior research (performed in actual clinical environments) on racial implicit bias and physician communication. The authors believe that this simulation and the process of its development can inform interventions that provide opportunities for skills development and assessment of skills in addressing racial implicit bias.
  18. Content Article
    This report outlines the findings of an independent investigation into the conduct of a spinal consultant, Doctor F, who formerly worked at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust).
  19. Content Article
    This Medscape article looks at misconceptions about the impact of diet on cancer progression that are being spread on social media platforms such as TikTok. Examples of these ideas include the idea that you can 'starve' cancer by cutting out carbohydrates, or that an alkaline diet will stop cancer by neutralising the acid environment around a tumour. The author, John Kerr, asks whether there should be a rallying call for cancer health professionals to do more to "push these scientifically illiterate concepts away." He suggests, "Rather than just shrugging our shoulders, perhaps we should be thinking more about it?"
  20. Content Article
    Women and people born biologically female have unique health needs across the life span, and their health outcomes often differ from those of men. Although women make up greater than half of the world’s population, these unique needs remain both insufficiently understood, due to decades of exclusion from scientific and medical research, and inadequately addressed, due to systems and cultures that often dismiss or devalue their experiences. This article discusses highlights from the National Academy of Medicine's Annual Meeting Scientific Symposium in October 2023 on the subject of women’s health. It looks at improving representation in research, bridging the gap in terms of social determinants of health and the need to reassess and research the female chromosomal makeup.
  21. Content Article
    This webpage provides information about the Phramacy First service, launched in England in January 2024. Pharmacy First builds on the NHS Community Pharmacist Consultation Service which enables patients to be referred into community pharmacy for a minor illness or an urgent repeat medicine supply. Pharmacy First adds to this by enabling community pharmacies to complete episodes of care for seven common conditions following defined clinical pathways: Acute otitis media (middle ear infection) Impetigo Infected insect bites Shingles Sinusitis Sore throat Uncomplicated urinary tract infections
  22. Content Article
    In this opinion piece, Partha Kar describes patient safety issues relating to a planned increase in the number of Physician Associates (PAs) working in the NHS in England. Highlighting safety concerns being raised by healthcare professionals and members of the public, he calls for a pause to the planned expansion to allow these issues to be investigated. He outlines the need for a clear scope of practice, standardised training, full regulation and clear communication with all stakeholders, including the public.
  23. Content Article
    In this Guardian interview, Rob Behrens, the outgoing NHS Ombudsman for England, says that too much unsafe care is still happening in the health service and that a culture of cover up makes it hard for bereaved families to find out the truth about their loved one's death. He describes the NHS as a complex institution run by mostly excellent, committed staff that is beset by cultural issues and a focus on limiting reputational damage at the expense of transparency and fair treatment of staff who speak up.
  24. Content Article
    Serious incident management and organisational learning are international patient safety priorities. However, little is known about the quality of suicide investigations and the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. This study reviewed research in this area and found that recent literature proposes a Safety-II approach in response to the limitations of RCA.
  25. Content Article
    This Twitter thread summarises the views of Dr Ian Jackson, a retired consultant anaesthetist and former Foundation Training Programme Director, on the patient safety and training issues relating to Anaesthesia Associates (AAs). He highlights issues with the length of training AAs receive compared with anaesthetists, the difference in training individuals who have experience in healthcare and theatre roles and those who have not and the supervision model in the current AA scope of practice.
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