Patient-Safety-Learning
PSL ModeratorsContent Type
Communities
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleThrough online health portals, patients receive complex medical reports without interpretation from their healthcare provider. This study evaluated the usability of MedEd, a patient engagement tool providing definitions of medical terminology in breast pathology and radiology reports. People who underwent a normal screening mammogram were invited to complete semi-structured interviews where they downloaded MedEd and discussed their download experience. The authors then evaluated the acceptability, appropriateness and feasibility of MedEd. Participants reported ease of downloading and navigating MedEd while raising concerns about privacy and others’ abilities to download.
-
Content Article
The correct and timely diagnosis of a health condition is a first step in ensuring that it is properly treated or managed. However, most people will experience at least one diagnostic error in their lifetime, sometimes resulting in severe patient harm. Research shows that up to 80% of all harm caused by delayed or misdiagnosis could be preventable. Deficits in health system design and governance, clinical environments and individual provider competencies can drive poor diagnostic outcomes. This brief introduces work being done by the Organisation for Economic Co-operation and Development (OECD) to assess key drivers and barriers of diagnostic safety and estimate the economic impacts of poor diagnostic safety practices on health systems. Key findings Most people will experience at least one diagnostic error in their lifetime, sometimes resulting in severe patient harm and up to 80% of all harm caused by delayed or misdiagnosis could be preventable. Findings from the United Kingdom show that asthma overdiagnosis and underdiagnosis among children were potentially as high as 15% and 40% respectively. Globally, up to 70% of persons with chronic obstructive pulmonary disease (COPD) or asthma do not receive a formal diagnosis of the condition. A growing number of tests, tools, and systems are now available across healthcare settings to help patients and providers identify health problems, resulting in increased use of diagnostic tests and procedures. Despite new tools and technology, health systems still fail to identify health conditions due to poor clinical skills, decision making, organisation and integration of care deliver and limitations of information systems in a correct and timely way. In the Netherlands, repeated laboratory testing of normal test results occurred in up to 85% of hospitalised patients. Costs associated with false-positive mammograms and breast cancer overdiagnoses exceed USD 4 billion annually in the United States. Deficits in health system design and governance, clinical environments, and individual provider competencies can drive poor diagnostic outcomes, while improvements can influence better diagnostic performance. -
Content ArticleIn this article for the Independent, James Moore describes his experience of a diabetes technology failure and outlines the risks associated with these medical devices. James has type 1 diabetes and was using a continuous glucose monitor (CGM) to track his blood glucose levels via an app on his iPhone. The graph showed that his blood glucose had been within the target range for many days. However, after noticing a lack of response from the CGM, he checked his blood sugar using a 'finger prick' test and discovered that his blood glucose level was actually dangerously high. Although James managed to get his levels back under control, he notes that it could have been much worse, had he not realised the error. Having high blood glucose for a period of time can lead to dangerous and life-threatening complications. The article also looks at the risks associated with insulin pump failures. James notes the huge benefits of wider access to diabetes technology, but highlights the need for healthcare professionals to ensure patients understand the risks and how to manage them. Related reading Diabetes tech: Do national aspirations and local practice align? Diabetes technology is life-changing, but we need to be prepared when it fails - A blog by Andrew Stroud How safe are closed loop artificial pancreas systems? Diabetes - What the tech? poster (June 2024)
-
Content ArticleThis opinion paper looks at how healthcare organisations identify and act upon different types of risk signals. These signals may be acknowledged, but they might not be because they have become a part of normal practice. The authors outline why risk signals from patients and families should be acknowledged as system-level safety critical information, which can contribute to understanding and changing safety culture in healthcare. They discuss how healthcare organisations could work more proactively with patient experience data in identifying risks and improving system safety.
-
Content ArticleBiomedical research has long struggled to reflect the demographic balance of the general population. Certain communities are under-represented, including people from minority ethnic groups, rural populations, disabled people and sexual and gender minorities. Meanwhile, adoption of digital technologies has increased in the past decade, particularly since the Covid-19 pandemic. This Lancet article argues that this expansion of smartphone adoption and digital literacy needs to be more widely harnessed to improve access to clinical research. Remote, self-directed, digitally enabled participant experiences can expand core outreach efforts in health research and clinical trials. The authors suggest that digital pathways can help improve accessibility and representation, making research participation available to populations who face barriers in engaging with healthcare.
-
Content ArticleLearning from excellence is a philosophy and practice designed to capture positive events in healthcare in order to improve quality and safety, while also providing positive feedback to staff. This study aimed to identify themes in staff-reported excellence to understand the conditions and behaviours that can allow excellence to occur. The study identified five overarching, interdependent themes: Pro-social behaviours could have a positive impact on staff experience and patient care. Witnessed expertise in technical and non-technical skills were a source of appreciation and gratitude for staff. A positive work ethic could benefit patient experience, staff productivity and morale. Staff appreciated personalised patient care that deviates from the norm but results in a positive outcome. Effective leadership and teamwork were often characterised by resilience and excellent interpersonal skills.
-
Content ArticleThere are more than 350,000 health apps available in public app stores. The stated benefits of health apps are numerous and well documented. However, there are also concerns that poor-quality apps, marketed directly to consumers, threaten the tenets of evidence-based medicine and expose individuals to the risk of harm. This study aimed to address this issue by assessing the overall quality of evidence publicly available to support the effectiveness claims of health apps marketed directly to consumers. The authors found the quality of evidence available to support the effectiveness claims of health apps marketed directly to consumers to be poor. Less than half of the 220 apps (44%) audited state that they have evidence to support their claims of effectiveness and, of these allegedly evidence-based apps, more than 70% rely on either very low or low-quality evidence.
-
Content ArticleGP Margaret McCartney looks at the influence big pharma has on the NHS—through payments and payments-in-kind to doctors, health charities and medical royal colleges. She discusses how this leads to conflicts of interest and a lack of independence, eroding the health system's commitment to evidence-based medicine.
-
Content ArticleLearning from excellence is a non-hierarchical system for staff to report episodes of good practice that they observe in the workplace, aiming to share learning from good practice, in line with the Safety-II approach. This study aimed to analyse staff perspectives of the impact of a learning from excellence system in place at a hospital in the south east of England. The results showed that perspectives on the impact of learning from excellence were generally positive, particularly regarding the benefits for staff morale and motivation.
-
Content ArticleElectronic health records (EHRs) are now used for many functions in healthcare beyond simply record keeping. For healthcare professionals, the EHR is a central platform for pulling together, organising and visualising diagnostic information. It helps with clinical reasoning, record management and communication between the care team. This issue brief by the Agency for Healthcare Research and Quality (AHRQ) reviews the history of EHR documentation legislation, including rules and regulations, and outstanding challenges and best practices to improve documentation. It also identifies future developments and opportunities for improvement, including emerging technology-based strategies to improve the traditional documentation process.
-
Content ArticleEvery year, over 70,000 people in England, Wales and Northern Ireland will fall and fracture their hip. This report by the Falls and Fragility Fractures Audit Programme (FFFAP) provides a simple guide for healthcare services to the data and resources available. It also describes the care that hip fracture patients should receive on their journey to recovery. Key findings More people than in 2022 get to an appropriate ward and receive the care of a team with an orthogeriatrician, though these figures are still poorer than pre-Covid. As in past years, four out of five patients get out of bed by the day after surgery. The number shown to be free of delirium has improved to nearly two thirds. More people than ever are returning home and successfully being supported to continue with osteoporosis treatment to prevent future fractures. Recommendations NHS England and the Welsh Government should use NHFD data to monitor hospitals’ delivery of three key stages of care to ensure that: hospitals are ready for the people they know will present each day hospitals provide both prompt surgery and optimal peri-operative care rehabilitation and recovery is planned and started early, and continues beyond the hospital. they take a standardised approach to the collection of ethnicity data across all patients’ pathways and provider organisations. people with other injuries benefit from the improvements that have been pioneered among those with hip fracture.
-
Content ArticleThe hierarchy of effectiveness model illustrates which risk-mitigation strategies are more effective than others in addressing factors that contribute to patient safety incidents. This illustration of the model was produced by Cassie McDaniel.
-
Content ArticleThis report outlines the findings of the Directors of Adult Social Services (ADASS) spring 2024 survey. It calls on the new Government for a change of approach, warning that without major reform, the challenges it highlights will continue to intensify and have a negative impact on people’s lives. Key findings The financial situation facing Directors of Adult Social Care is as bad as it has been in recent history. This challenging financial situation, coupled with the increasing complexity of need, means that Directors’ confidence in delivering on their legal duties is faltering. The complexity of people’s adult social care needs means that more people now require more intensive care and support. Directors want to invest more in early support and care closer to home. However, the stretched funding available for adult social care means this has to be prioritised towards those people with the most complex needs. Funding and service pressures in the NHS are having a knock-on effect in adult social care. Adult social care staff are increasingly undertaking tasks that were previously delivered by NHS staff on an unfunded basis. There are fewer people waiting for assessment, care and support to begin or for a review of their care plan. Councils continue to invest in care closer to home, increasing the amount of homecare hours available and reducing reliance on residential care. Care markets remain unstable, with many providers struggling. Unpaid carers are being left to pick up the pieces of shortages in health and social care support to the detriment of their own health and wellbeing.
-
Content ArticleSimulation—where scenarios are recreated in a practice environment as a tool for learning—can be used to improve patient safety. Simulation has a number of functions in healthcare, including helping identify and mitigate latent safety threats, testing quality improvement changes before they are implemented and revealing information that would not have otherwise been discovered. This issue brief from the Agency for Healthcare Research and Quality (AHRQ) discusses practical strategies to advance patient safety through simulation and debriefing.
-
Content ArticleShoulder dystocia is an uncommon but high-risk obstetric emergency that happens when a baby's shoulders fail to deliver spontaneously following delivery of their head. When it happens, the healthcare team has to carry out specialised obstetric manoeuvres designed to correct the positioning of the baby. This guide was co-produced by the Pennsylvania Patient Safety Authority (PSA), the Institute for Safe Medication Practices (ISMP) Patient Safety Organization and ECRI. It records the findings of a 'safe table' meeting—a protected environment where Pennsylvania healthcare professionals had an opportunity to discuss the risk factors, challenges and mitigation strategies associated with shoulder dystocia. The guide includes comments and recommendations relating to debriefing and documentation after a shoulder dystocia event, reporting and legal concerns, risk assessment and simulation and training.
-
Content ArticleIn this short video, Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, talks about the importance of teaming in health and care.
- Posted
- 1 comment
-
1
-
-
Content ArticleThis study assessed the impact of Schwartz Center Rounds, an interdisciplinary forum where attendees discuss psychosocial and emotional aspects of patient care. The authors investigated changes in attendees' self-reported behaviours and beliefs about patient care, sense of teamwork, stress and personal support.
-
Content ArticleIn this study in the International Journal of Environmental Research and Public Health, Rodney Jones examines different methods for understanding hospital bed numbers and their impact on patient outcomes. Using the NHS in England as a case study, Jones demonstrates the relative benefits of different approaches to modelling hospital bed numbers.
-
Content ArticleIn this article, Siva Anandaciva, Co-Director of Policy, Events, and Partnerships at The King's Fund, takes a look at the practical issues NHS staff face at work that a major impact on morale. He highlights issues with the physical work environment, such as lack of availability of food and drink, broken toilet facilities and lack of accommodation for staff on call, and suggests that many of these issues can be fixed on a local level to greatly improve staff wellbeing and satisfaction.
-
Content ArticleIn this episode of the Royal College of Surgeons in Ireland's Safe & Sound podcast, Dr Chris Turner, founder of Civility Saves Live, talks about the impact of interpersonal behaviour on performance and patient safety. He discusses his interest in governance and high-performing teams and how this has led him on a journey from focusing on blame and process to exploring the power of relationships and behaviour.
-
Content Article
Scottish Hospitals Inquiry
Patient-Safety-Learning posted an article in Other reports and inquiries
In September 2019, the Cabinet Secretary for Health and Sport announced that a public inquiry would be held to look at issues at Glasgow's Queen Elizabeth University Hospital Campus (QEUH), the Royal Hospital for Children and Young People (RHCYP) and Department of Clinical Neurosciences sites following concerns about patient safety and wellbeing. The Inquiry aims to determine: how vital issues relating to ventilation and other key building systems gave rise to those concerns how they occurred what steps can be taken to prevent this being repeated in future projects. Lord Brodie was appointed as chair of the Inquiry in November 2019 and the Inquiry was launched on 3 August 2020. Anyone can submit evidence to the Inquiry in the form of a written statement and/or by providing documents. Someone who has done this or who has otherwise been identified as having potentially useful information may be asked by the Inquiry to give oral evidence at a hearing. Members of the public can watch the live stream of hearings or to attend in person, if that is practical. You can also view Inquiry documents such as transcripts of evidence given at hearings and witness statements. -
News Article
Hospital Inquiry hears health boss tried to stop whistleblower
Patient-Safety-Learning posted a news article in News
The boss of Scotland's biggest health board tried to persuade a top doctor not to blow the whistle about patient safety concerns, a public inquiry has heard. Dr Penelope Redding, a former clinical director at NHS Greater Glasgow and Clyde (GGC), claimed the board's chief executive Jane Grant "urged me not to do it". Dr Redding was one of a number senior doctors who raised infection control concerns at the Queen Elizabeth University Hospital (QEUH) in Glasgow. In a submission to the Scottish Hospitals Inquiry, Dr Redding claimed there was a "profound culture of fear and bullying" at the board which put more people off speaking out. The inquiry is investigating the construction of the £870m QEUH campus in Glasgow, which includes the Royal Hospital for Children. It was set up after a number of patient deaths including that of 10-year-old cancer patient Milly Main. Dr Redding worked as an infection control doctor until 2008. She was involved in the preliminary planning for the QEUH, which opened in 2015, and was a whistleblower before she stepped down as a consultant microbiologist in 2018. In evidence to the hearing, the retired doctor criticised "a culture of not putting things in writing, in emails, not putting things in minutes, an atmosphere of intimidation and bullying" within the NHS. She said she only felt comfortable speaking out as she was approaching retirement. A spokesperson for NHS GGC said: "The current Scottish Hospitals Inquiry hearings have yet to hear from various key staff. A number of staff being mentioned during these hearings will also provide evidence and will endeavour to support the Inquiry to fully establish the facts." Read more about the Scottish Hospitals Inquiry on the hub. Read full story Source: BBC News, 4 September 2024 -
Content ArticleShared decision making is when healthcare professionals work together with a patient to make choices about their care and treatment, the medicines the take and any operations they have. This short animation by The Patients Association explains what shared decision making is and how you can make it happen when you're seeing your doctor or other healthcare professional.
-
Content ArticleThis leaflet produced by Bridgwater Community Healthcare NHS Foundation Trust explains what to expect from the Patient Safety Incident Investigation (PSII) process. it aims to help patients better understand what will happen, why the incident is being investigated and how the trust will tell them about the investigation outcome. The leaflet answers the following questions: What is a patient safety incident? How will I know if a patient safety incident has happened to me? What should I do if I think something has gone wrong? Who investigates a patient safety incident? What does the family liaison officer do? Do I need to be involved? What happens at the meeting with the family liaison officer? How long does it take to do the investigation? What happens at the end of the investigation? How can I help?
-
News Article
‘I’m an NHS whistleblower. Patients are dying needlessly’
Patient-Safety-Learning posted a news article in News
The number of deaths and patients seriously harmed due to alleged clinical negligence at a scandal-hit trust is “just the tip of the iceberg”, an NHS whistleblower has claimed. Several hundred more cases are likely to come under Operation Bamber, a formal investigation into multiple deaths and injuries at the Royal Sussex County Hospital between 2015 and 2021, according to sources close to the inquiry. The operation was initially launched in June 2023 after two consultant surgeons who reported concerns over surgical standards were dismissed by the University Hospital Sussex NHS trust (UHS), which runs the hospital. Police then expanded the operation to investigate 105 cases of alleged medical negligence but, insiders have said they expect that number to reach “many hundreds” the longer the inquiry goes on. Michael Swinn, a Surrey-based consultant urological surgeon who blew the whistle on bad practice at his own trust, said he has been approached by senior clinical staff across the country, including Brighton, since publishing a book about his own experience. Some have blown the whistle on poor practice already, others are considering it and seeking advice. Mr Swinn, 58, told inews: “The reports about Brighton say the police are looking at around 100 cases. I’m told it is many, many more. Potentially several hundred." Sussex Police said it is continuing to investigate allegations of medical negligence relating to neurosurgery and general surgery at the Royal Sussex. A spokesperson for the force said: “A number of cases from within the specified NHS departments and during the specified time period have been assessed and are forming part of the ongoing investigation… Sussex Police is committed to conducting a thorough and transparent investigation. Due to the complex nature of the enquiries, this is likely to take some time to complete.” Among the cases forming part of the investigation is the death of Lewis Chilcott, 23, who suffered a fatal arterial haemorrhage after an alleged error in his tracheostomy led to infection. A review by the Royal College of Surgeons found that it was likely that the low position of the inserted tube caused the fatal damage. Read full story Source: inews, 2 September 2024
