Patient-Safety-Learning
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Everything posted by Patient-Safety-Learning
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Content ArticleThis randomised clinical trial aimed to find out whether crowdsourced feedback from members of the public is an effective educational intervention to improve resident doctors’ error disclosure communication skills. 146 second-year internal medicine and family medicine residents practiced disclosure with video simulation software. Crowdsourced laypeople then provided feedback on their responses. When residents who participated reviewed the feedback, it was associated with higher ratings of error disclosure skill, particularly for those without real-life experience of disclosing errors. This suggests that this kind of feedback may be an effective way for residency programs to address their requirement to prepare trainees for communicating with patients after medical harm.
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Content ArticleOlder women are underrepresented in healthcare research, which has serious implications for the safety and effectiveness of the treatment they receive. In 2023, the US Government promised to address this problem through the White House Initiative on Women’s Health Research. This article examines some of the issues caused by lack of knowledge about how common health issues affect older women. It suggests priorities that should be included in the new initiative, including mental health, heart disease, brain health, cancer and bone health and frailty. More research in these areas will improve the safety and effectiveness of care and treatment for older women.
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Content ArticleWomen in the United States experience a higher prevalence of many chronic conditions, including Alzheimer's disease, depression and osteoporosis, than men. They also experience female-specific conditions, such as endometriosis and pelvic floor disorders. A lack of research into both the biological and social factors that influence these conditions is a significant barrier to diagnosis, treatment and prevention efforts, contributing to poorer health outcomes for women and substantial costs to individuals and society. The US National Institutes of Health's Office of Research on Women's Health asked the National Academies of Sciences, Engineering and Medicine to host an expert committee to identify gaps in the science on chronic conditions that are specific to or predominantly impact women, or affect women differently, and propose a research agenda. This report presents the committee's conclusions and recommendations.
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The Public Policy Projects Cancer Care conference 2024 will build on last year’s programme as well as looking at some of the emerging policies in cancer care in 2024 especially in light of political changes. We will host five panels that focus on some key aspects of cancer policy, highlight examples of best practice and better understand what strategies can be harnessed and implemented to improve patient outcomes. Throughout the day delegates will have time to network and also learn about how innovation, sometimes through industry partnerships, is impacting cancer care. Topics to be discussed Given our understanding of the risk factors for cancer, how can we address these and work towards prevention of cancer How can genomics be harnessed in cancer prevention without creating greater health inequalities? How can we work towards earlier diagnosis across cancer types using women’s cancers to explore this How can we address the backlogs in cancer pathways (through the lens of prostate cancer)? What strategies can be implemented that effectively reduce health inequalities in cancer? Given the advances in digital technologies, what are the opportunities for future screening? What innovations can be implemented now to speed up diagnostics? Can screening become equitable? Register for the conference -
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This conference will provide a focus on the pivotal issues concerning the future strategies of both the NHS Long Term Plan (LTP) and and integrated care systems (ICS) and will incorporate key elements of the 'Major Conditions Strategy' that is currently being developed. This major conditions strategy theme within the conference begins with one question: how should our approach to health and care delivery evolve to improve outcomes and better meet the needs of our population, which is becoming older and living with multimorbidity? With varying groups of conditions being explored in our plenaries and workshop sessions: cancers, cardiovascular disease (CVD) (including stroke and diabetes), mental ill health, and chronic respiratory disease. There are signs of positivity with exciting new technologies and sources of data that enable staff to better see and treat disease at an earlier stage. Our conference and its dedicated plenaries, evidence-based case studies and educational workshops will explore how to supercharge this agenda. Amongst our core themes will be the exploration of the potential of AI and technology to deliver digital transformations, and position the UK as a world leader in virtual health and social care. As such topics such as Virtual Wards, Remote Patient and Whole Patient Management systems will be at the forefront of certain plenaries. Also underpinning the conference's focus are the strong desires to tackle health disparities and promoting inclusion in health, as articulated through the NHS Core20PLUS5 framework, and detailed by senior host speakers on the day. The event is free for NHS staff, who can use code JBVIP100 when registering to remove all costs. Register for the conference -
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Standing for ‘For Patients, By Patients’, PxP 2024 is entirely led by an international team of patient and public partners and is a Patients Included™ event. Our purpose is to share resources, mentorship and community with patient partners and others involved in health research. Ultimately, our goal is partnering to make research stronger. This free, virtual event aims to bring you a wealth of knowledge, skills and resources on patient engagement in health research. Patient engagement in health research, also known as patient and public involvement (in the UK) or consumer involvement (in Australia). 'Patient engagement’ in health research is where patients are research team members. This is different from volunteering to be a research participant where you might help advance research or healthcare, but a research participant generally does not give input into the research study itself. Whatever language you prefer, we warmly welcome everyone to attend. PxP is a must-attend event for these two reasons: PxP is specifically For Patients. While there has been excellent progress in the available patient engagement resources, many of these are designed for other members of the research team. Although we welcome health researchers to join us at the event in September, our key priority will be patient partners and other people with lived experience. We are led entirely By Patients. Every topic and speaker on the PxP conference program has been chosen by our experienced international committee of patient partners. For those based in Europe, Africa and America, the dates are September 10-12, and for those in parts of Asia and Oceania the dates are September 11-13. Please note the timings for Day 3 are different from Days 1 and 2. This is because we would like as many people as possible from across the globe to have a chance to join us live. We would love you to join us! After the event, we will be hosting recordings on the PxP website which will be freely available. 2024 Steering Committee hope statement: To unite, inspire, and empower patients on their journey to health and wellness. May this summit be a beacon of hope fostering community, knowledge, and resilience as we navigate challenges together. Let us stand strong, advocate boldly, and transform research and healthcare for a brighter, healthier future. Work on the agenda is nearly complete, and we look forward to sharing the session and speaker details with you soon. Do not hesitate to reach out if you have any questions at [email protected] -
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The Experience and Partnerships Team at NHSE is hosting a Shine a Light on Co-production online event. This event aims to shine a light on the art of the possible in relation to co-produced improvements and demonstrate what can be achieved when we work together with people with lived experience. At each event people with lived and learnt experience share their experience of co-producing their improvement together. This will include the difference co-production made to them and their organisation, their top tips, what went well and the challenges they faced. Register for the event -
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This webinar from GovConnect will look at: Developing a successful Virtual Ward CUH Virtual Ward @ home (Cambridge University Hospitals) Challenges CUH faced and why they implemented Virtual Wards The journey so far and working with stakeholders What equipment is needed? Platform/technology selection Daily management: referral, on-boarding, care plan Performance and pathways Patient experience Challenges and obstacles Next steps Agenda Welcome and introduction with moderator Dr Iain Goodhart Developing a Virtual Ward @ home with Gemma Czech, Clinical Nurse Lead for Virtual Wards at Cambridge University Hospitals NHS Foundation Trust Outcomes, performance and next steps for CUH Virtual Ward @ home with Andy Bailey, Operations Manager Virtual Wards, Cambridge University Hospitals NHS Foundation Trust will cover how Interactive panel discussion Register for the webinar -
Content ArticleUS doctor Victoria Johnson recalls a medication error she made during one of her first shifts as a senior internal medicine resident. She describes the incident and how the compassionate response and honesty of her supervisor meant that she was able to forgive herself for her mistake. By telling her about a similar error he had made years before, he enabled Victoria to reflect on the toxic culture of perfection that had shaped her view of how she should be as a doctor. "In medicine, we don’t often talk about our errors. Yet in the wake of a serious error, the most healing conversations I’ve had have been with other physicians who have told me about their mistakes. Their vulnerability and empathy in sharing these difficult stories has proved to be the only true antidote to my shame." This article is free to access when you create a free online account with the New England Journal of Medicine.
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Content ArticleHumans are consuming more medications than ever before as a result of technological innovation transforming the treatment of ageing-related and chronic diseases. This article looks at the environmental impact of inappropriate prescribing in older people, including on carbon emissions, the pollution of rivers and disposal of waste to landfill. Its authors argue that tackling inappropriate polypharmacy in older people will both improve quality of life and mitigate the environmental effects of medicines.
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Content ArticleLoeys-Dietz syndrome (LDS) is a genetic disorder affecting connective tissue, which supports, protects and gives structure to various tissues and organs. While it shares some characteristics with Marfan syndrome, LDS has distinct differences and presents unique challenges. LDS results from a variant in one of several genes, impacting multiple body systems and leading to potentially life-threatening complications. One of the most severe risks is aortic enlargement, which can cause an aneurysm or dissection. The aorta, the main blood vessel transporting blood from the heart, can become dangerously enlarged, increasing the risk of a tear that requires immediate medical attention. This article tells the story of Sharon, a 53-year-old woman from Bristol, who died in December 2022. Her family now advocates for greater awareness of LDS to prevent similar tragedies. Sharon’s death, attributed to natural causes compounded by neglect, highlights systemic failures in promptly recognising and treating her aortic dissection. When she first went to hospital with severe chest pain, Sharon faced significant delays and inadequate care in the Emergency Department. The coroner’s inquest revealed that Sharon’s care was marred by a series of systemic and operational failures. She should have been assessed within an hour of arrival and transferred to a specialist centre for cardiothoracic surgery within four hours. Instead, she remained for over twelve hours in the Emergency Department,
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Content ArticleGeneral practitioners (GPs) work in varied environment where diagnostic errors are common. Previous research indicates that combining independent diagnoses from different GPs can improve diagnostic accuracy in a range of settings. This study examined whether aggregating independent diagnoses can also improve diagnostic accuracy for GP decision making. In addition, it looked at the potential benefit of this approach in combination with a decision support system (DSS). The authors found that combining independent diagnoses may substantially improve a GP’s diagnostic accuracy and subsequent patient outcomes. This approach did, however, not improve accuracy in all patient cases. Therefore, future work should focus on determining the conditions in which collective intelligence is most beneficial in general practice. This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.
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Content ArticleAlthough most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. This study in Annals of Internal Medicine aimed to measure AEs in the outpatient setting through retrospective review of electronic health records (EHR). The results showed that outpatient harm was relatively common and often serious. Adverse drug events were most frequent and rates of harm were higher among older adults. The study demonstrates that Interventions to reduce outpatient harm are urgently needed.
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Content ArticleFalls are the most common cause of injury-related morbidity and mortality in older adults. This JAMA Network study aimed to systematically review evidence on the effectiveness and harms of fall prevention interventions in older adults living in the community. The study identified that multifactorial and exercise interventions were associated with reduced falls in multiple good-quality trials. Exercise demonstrated the most consistent statistically significant benefit across multiple fall-related outcomes.
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Content ArticleThe health of the UK is declining—improvements in life expectancy have stalled, more people are living with preventable health conditions for longer periods of their lives and record numbers are unable to access the care they need. Health inequalities are widening, with people living in more deprived areas living for longer in poor health and dying earlier than those in less deprived areas. This report by The Health Foundation looks at how the new government can take a prevention-led approach that enables people to stay healthy for longer, prioritises the reduction of health inequalities and that detects and treats health problems early to reduce harm.
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Content ArticleThis BMJ cohort study aimed to quantify the prevalence, harms and NHS costs in England of problematic oral non-steroidal anti-inflammatory drug (NSAID) prescribing in high risk groups. It found that NSAIDs continue to be a source of avoidable harm and healthcare cost in five high risk populations—older adults with no gastroprotection, people who concurrently took oral anticoagulants, people with heart failure, those with chronic kidney disease and those with a history of peptic ulcer. Harm was common in people with chronic conditions and people taking oral anticoagulants.
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Content ArticleThis report by The Health Foundation’s REAL Centre (research and economic analysis for the long term) looks at pressure points in the nursing workforce. It aims to examine the supply of nurses to the NHS in England in light of the ongoing shortfall of registered nurses, which represents a major long-term and growing problem for the NHS.
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Content ArticleThis article presents an overview of the research evidence on nurse staffing levels in acute hospitals and how it has been applied to policy and practice, focusing primarily on the UK. Drawing on research reviews and examples of specific studies, the authors outline the current state of knowledge, much of which comes from cross-sectional studies. More recently, longitudinal studies allow a causal link between staffing and outcomes to be inferred. The authors argue that there is a lack of specificity on staffing levels, which has prevented research findings being effectively applied to nursing practice—research rarely specifies how many nurses are needed for safe and effective care. The most significant barrier to achieving safe staffing has been an underestimation of the number of registered nurses needed and overestimation of the potential for substitution, resulting in low baseline staffing and a national shortage of registered nurses. Repeatedly, new staffing solutions have been sought rather than tackling the problem of too few registered nurses head-on.
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Content ArticleThis article published by the Anesthesia Patient Safety Foundation looks at a concerning trend in which anaesthetists have inadvertently administered tranexamic acid (TXA) intrathecally when performing neuraxial blocks. The mortality rate of this medication error is approximately 50%. The article examines a case involving a TXA-bupivacaine mix-up, offering perspectives from a multidisciplinary group of contributors. It also provides recommendations to avoid these catastrophic medication errors happening again.
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Content ArticleIn this blog, retired doctor Nadeem Moghal looks at the impact Martha's Rule will have on the NHS. He asks whether the new policy will prevent the medical profession looking at much wider issues relating to candour and professionalism, acting as a bypass mechanism for organisations to avoid dealing with deeper cultural problems. He also raises concerns that Martha's Rule will damage the trust between patients and their doctors and that there are not sufficient teams in place to provide the expert second opinions patients and families will request.
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Content ArticleIn this blog, Judy Walker unpicks the findings of the Irish Safety Culture and After Action Review Experience study (iCAARE) which describes the enablers and barriers to the successful integration of After Action Review (AAR). The paper highlights the gaps between the expectations held by newly trained AAR Conductors and the reality of implementing AAR. The blog highlights the following recommended actions from the paper: Reduce the time lag between equipping staff with the skills to lead AARs and the immediate reinforcement and promotion of AAR following training. Invest in structures and processes to make access to AAR easy and widely understood. Ensure there is a pipeline of AAR work to be done for those newly trained. Provide active and visible leadership for the AAR approach. Recognise the emotional reaction pattern that participants may have as they start to use AAR, building confidence in individuals and providing support as they move from novice to expert.
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Content ArticleIn the spring of 2022 and 2023, Covid-19 vaccine boosters were recommended for those aged over 75 years in England as well as those in an immunosuppression high risk group. This study in the Journal of Infection aimed to assess the impact of vaccination on preventing Covid-19 hospitalisations in this group. The results show that a clear impact of vaccination on preventing Covid-19 hospitalisations.
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Content ArticleThe rapid growth of interest in and use of large language models (LLMs) across various industries is raising some crucial and profound ethical concerns, especially in the field of healthcare. This Lancet article highlights ethical concerns from the perspectives of users, developers and regulators. It focuses on data privacy and rights of use, data provenance, intellectual property contamination, broad applications and plasticity of LLMs. The authors argue that a comprehensive framework and mitigating strategies will be vital to ensure LLMs are responsibly integrated into medical practice, ensuring alignment with ethical principles and safeguarding against potential societal risks.
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Content ArticleThis is the interim report of a review led by Dr Penelope Dash into the operational effectiveness and culture of the Care Quality Commission (CQC). The review spoke to 170 senior managers, caregivers and clinicians working in the health and care sector, along with over 40 senior managers and national professional advisors at CQC. All shared considerable concerns about the functioning of the CQC, with a high degree of consistency in the comments made. At the same time, there was widespread recognition of the need for a strong, credible and effective regulator of health and social care services. A more detailed report will be published in autumn 2024.
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Content ArticleMichelle Heffer first started seeing her GP for very heavy periods as a teenager. After having her first ultrasound in 2020, she was diagnosed with two cysts on her ovaries caused by endometriosis. In this Independent article, she tells journalist Maya Oppenheim about the impact of having to wait over three years for surgery to deal with her endometriosis, during which time her condition worsened. Michelle had to give up her job and was at times unable to leave the house because the pain was so debilitating. The article also looks at a new report by the Royal College of Obstetricians and Gynaecologists (RCOG) has found gynaecology waiting lists in England have grown more quickly than any other elective specialty and are now over twice the size they were before the Covid-19 pandemic.
