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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This study aimed to assess whether the risk of 90-day mortality is comparable for individuals who switch early to oral antibiotics and those who continue intravenous (IV) antibiotics in the treatment of uncomplicated gram-negative bacteremia. The results suggest that transition to oral antibiotics within four days after initial blood culture may be an effective alternative to prolonged IV antibiotic treatment for uncomplicated gram-negative bacteremia.
  2. Content Article
    Studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. This study in the American Journal of Surgery aimed to identify determinants of post-intensive care physical and mental health outcomes 6–12 months after injury. The authors found that: Delirium during an intensive care unit (ICU) stay is linked with long-term physical impairment in injury survivors who spent three or more days in the ICU. The use of ventilators in the ICU is another factor associated with long-term physical impairment and mental health symptoms in these patients. Delirium and ventilator use are potentially modifiable, suggesting opportunities for improving patient outcomes. They suggest that that this knowledge can inform the development of interventions that specifically target delirium and ventilator use to mitigate long-term impairments.
  3. Content Article
    The use of AI in medical devices, patient screening and other areas of healthcare is increasing. This Medscape article looks at some of the risks associated with the use of AI in healthcare. It outlines the difficulties regulators face in monitoring adaptive systems, the inbuilt bias that can exist in algorithms and cybersecurity and liability issues.
  4. Content Article
    This study aimed to explore the experience and psychological impact on nursing students of sustaining a sharps injury. A qualitative approach was taken, using two methods to gather data, namely a Twitter chat and interviews. Some nursing students reported psychological impacts after sustaining the sharps injury, which affected both their professional and personal life. The qualitative findings were synthesised into eight themes.
  5. Content Article
    Emergency general surgery (EGS) involves care and treatment of a patient's often previously unknown disease in an unplanned interaction with the healthcare system. This leads to challenges in collecting and interpreting patient reported outcome measures (PROMs). This study in the American Journal of Surgery aimed to capture the peri-operative experiences of 30 patients at 6 to 12 months after their treatment. The authors found that: two-thirds reported feeling no choice but to pursue emergency surgery with many reporting exclusion from decision-making. Females reported these themes more commonly. patients with minor complications less frequently reported trust in their team and discussed communication issues and delays in care. patients with major complications more frequently reported confidence in their team and gratefulness, but also communication limitations. patients not admitted to the ICU more frequently discussed good communication and expeditious treatment.
  6. Content Article
    Doctors in Distress is a UK-based independent charity that promotes and protects the mental health of all healthcare workers and prevents suicides in the medical profession. It was set up in 2018 by Amandip Sidhu following the suicide of his brother Jagdip, a consultant cardiologist, with the aim of providing support for healthcare staff facing burnout and mental health difficulties. The charity runs free online support groups and webinars for healthcare professionals and students. Previous webinars can be viewed on the Doctors in Distress YouTube channel.
  7. Content Article
    This Lancet article highlights new evidence from analysis of population-based electronic health records for almost the entire population of the UK. The analysis showed that, as of 1 June 2022, a high proportion of the population had received fewer than the recommended number of Covid-19 vaccinations: 45·8% in England, 49·8% in Northern Ireland, 34·2% in Scotland and 32·8% in Wales. Combining the results across countries suggests that a substantial number of severe Covid-19 outcomes, including hospital admissions or deaths from Covid-19, might be prevented if recommended vaccination schedules were fully implemented. These findings reinforce the message that the role of vaccination in Covid-19 is to mitigate the severity of the illness, reducing the risk of complications and mortality, rather than avoiding all Covid-19 infections.
  8. Event
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    Professor Sir Chris Whitty will deliver a live-streamed lecture on health inequalities to launch Talk 200, the University's bicentenary lecture and podcast series. ‘Health inequalities past, present and future’ will consider the main drivers of inequalities and disparities in health, how these have changed over time and why addressing them remains a major public health priority. As a society we face the hard truth that the more socio-economically disadvantaged someone is, the higher their risk of poor health. The world’s greatest killer is not any one individual disease, but the unequal way in which people are born, grow, live, work and age. In Greater Manchester, our unique health and social care ecosystem means we can rapidly drive innovation and translate breakthroughs into real-world solutions – which can be scaled-up and replicated across the globe. Professor Whitty is Chief Medical Officer for England, the UK government’s Chief Medical Adviser, and head of the public health profession. His lecture is the first in our Talk 200 series: a mix of in-person and live-streamed lectures and recorded podcast episodes to be released throughout 2024, our bicentenary year. This event will also include a panel discussion and Q&A, with those joining online able to submit questions using Slido and the code Talk200ChrisWhitty (page not active until 13 February). Watch the lecture live
  9. Content Article
    This population-based cohort study from Sweden and Norway aimed to explore whether exposure to mRNA Covid-19 vaccination during pregnancy increases the risk of adverse events in newborn infants. The cohort included 94,303 infants exposed to Covid-19 vaccination during pregnancy and 102,167 control infants born between June 2021 and January 2023. The authors found that vaccination during pregnancy was associated with lower odds of neonatal intracranial haemorrhage, cerebral ischemia and hypoxic-ischemic encephalopathy, and neonatal mortality.
  10. Content Article
    This study examines the prevalence of advanced care planning (ACP) for patients undergoing endoscopic, fluoroscopic, laparoscopic or open surgical gastrostomy tube procedures at an academic hospital in the USA. The authors found that only 10.6% of included patients had accessible ACP documents available within their electronic medical record (EMR) and that Black patients had lower rates of ACP documentation. They also highlight an association between ACP documentation and decreased hospital length of stay, with no difference in mortality. The authors recommend the expansion of ACP in perioperative settings.
  11. Content Article
    This blog by Healthwatch outlines research conducted by the organisation that shows the issues homeless people face accessing the health and social care they need. The research demonstrates that homeless people: have particular problems accessing GPs and other services. experience serious problems accessing NHS dentistry. may forgo care because of the costs of travelling to appointments. often feel judged by healthcare professionals and not well cared for. The blog also discusses the impact that integrated care systems could have in improving accessibility and quality of care for homeless people.
  12. Content Article
    Although disparities in surgical outcomes are well-documented, understanding of how socioecological factors drive these disparities remains limited. This US study’s objective was to develop and assess the acceptability and feasibility of a comprehensive tool to evaluate socioecological determinants of health in patients requiring colorectal surgery. The authors developed an 88-item assessment tool measuring 31 socioecological determinants of health. It was assessed as having high acceptability and feasibility for patients who required colorectal surgery. The authors concluded that this work will help to identify what research is needed to understand and address surgical disparities.
  13. Content Article
    Bibliometric analysis is a research technique that allows a macroscopic study of the literature surrounding a subject, enabling a prediction of themes that will arise in future research on the subject. In this book chapter, Hülya Saray Kiliç, Assistant Professor at the Bilecik Şeyh Edebali University in Turkey outlines the approach taken in his bibliometric analysis of patient safety in the operating room. His analysis anticipates that the following subjects will be explored in the coming years in relation to patient safety in the operating room. Technology integration and digital solutions Communication and team collaboration Patient education and information Staff training and skill development Risk management and error analysis 
  14. Content Article
    This paper aims to explore the insights provided by Safety-I and Safety-II approaches by examining the practical application of two frequently used methods: Systematic Human Error Reduction and Prediction Approach (SHERPA) and Functional Resonance Analysis Method (FRAM). Neither method should be uniquely labelled as a Safety-I or Safety-II approach, however, SHERPA is traditionally used within a Safety-I context, and FRAM is frequently used within a Safety-II context. By examining the application of these two methods to the management of post-surgical deterioration, the authors critically reflect on the analysis logic embedded in each method and their potential contribution to improving patient safety.
  15. Content Article
    Participants are vital to the success of any clinical trial. Without the data they provide, our research system would collapse. But being a clinical trial participant is not easy. Financial barriers, transport challenges, and a lack of engagement and support can leave patients feeling marginalised and disconnected. This article looks at what needs to be done to ensure diverse patients from around the world can engage with studies and remain engaged from screening until study completion, regardless of their personal circumstances.
  16. Content Article
    In this blog, Patient Safety Partners Anne Rouse and Chris Wardley and Patient Safety Learning’s Chief Executive, Helen Hughes, examine the results of a recent survey of Patient Safety Partners (PSPs). The results reveal significant variation in how the PSP role is being implemented in NHS organisations in England and highlight frustration, barriers and successes that people in the role are experiencing.
  17. Content Article
    Most research examining the association between blood pressure and cardiovascular disease (CVD) is does not take sex into account. This research study aimed assess sex-specific associations between blood pressure and CVD mortality.by estimating sex-stratified, multivariable-adjusted incidence rate ratios (IRRs) for CVD mortality. The authors found that the association between blood pressure and CVD mortality differed by sex, with increased CVD mortality risk present at lower levels of systolic blood pressure among women, compared with men.
  18. Content Article
    Coloplast UK is a manufacturer of ostomy, continence, urology and wound care products. They commissioned the Patients Association to conduct a project to explore and recommend ways to better engage patients and carers in policymaking and the assessment of medical technologies for intimate healthcare. The Patients Association held a roundtable meeting and case study interviews with patients with intimate healthcare conditions and other stakeholders. They also conducted a survey of third-sector organisations who represent those patients and carried out desk-based research. This report summarises the findings of the project, which include that the existing mechanisms of engagement typically adopt a “patient involvement” approach where patients and carers do not have equal status as partners in the decision-making process. The report makes a number of recommendations to improve the way in which patients and their carers are engaged.
  19. Content Article
    This infographic is a visual representation of the WHO Emergency Care System Framework, designed to support policy-makers wishing to assess or strengthen national emergency care systems. It is the result of global consultations with policy-makers and emergency care providers and provides a reference framework to: characterise system capacity. set planning and funding priorities. establish monitoring and evaluation strategies.
  20. Event
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    The Patient Safety Incident Response Framework (PSIRF) is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and ensuring learning and improvement in patient safety. This national conference looks at the practicalities of implementing and using PSIRF. The day will provide an update on best practice in incident investigation under PSIRF and ensuring the focus is on a systems based approach to learning from patient safety incidents and delivering safety actions for improvement. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Book your place
  21. 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. Chidiebere is passionate about increasing representation of Black people in all forms of medical literature. In this interview, he explains how lack of representation at all levels of the healthcare system leads to disparities in healthcare experiences and outcomes. He outlines the importance of speaking openly about how racial bias affects patient safety, and argues that dispelling damaging myths about particular patient groups starts with equipping people with accurate health knowledge from a young age.
  22. Content Article
    In this blog, Louise Roe, an investigator at the Maternity and Newborn Safety Investigations (MNSI) programme, looks at how the questions you ask as a patient safety investigator can affect the quality of the information you receive from staff, as well as having an impact on how they feel about the interview. Louise lays out her journey to obtain higher-quality information from interviews while protecting staff involved in patient safety incidents. She discusses how to ask questions that uncover the 'whys' around decision making at the time of an incident.
  23. Content Article
    Children are more than twice as likely as adults to experience a medication error at home. In this interview for the journal Patient Safety, Dr Kathleen Walsh, paediatrician at Boston Children’s Hospital, discusses why that is the case and provides some tips to keep children—and adults—safe.
  24. Content Article
    This article outlines a recent improvement put in place by a ward at Sir Robert Peel Community Hospital, part of University Hospitals of Derby and Burton NHS Foundation Trust. The team won an award for implementing learning following a patient fall to help drastically reduce the frequency of incidents and improving patient safety.
  25. Content Article
    This article looks at the judgements made by experts in the cases that are not covered by rules, focusing on the key role of stories and storytelling. Drawing on literature related to high-reliability theory, organisational learning and naturalistic decision-making, it examines how experts working in diverse critical contexts use stories to share and make sense of their experiences.
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