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Content ArticleIn this personal blog, an NHS volunteer describes her experience of supporting a patient dying in hospital of Covid-19. She highlights the role that volunteers can play in giving compassion and comfort to patients in an overwhelmed health system. She also draws attention to the lack of training she had before taking on the role, and the mental and emotional toll of volunteering in such environments.
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Content ArticleThis chapter from the 'Textbook of Patient Safety and Clinical Risk Management' reviews the most common adverse events that happen in a psychiatric unit and the safety measures that are needed to decrease the risk of errors and adverse events. It also highlights the role of staff members and patients in preventing or causing the error.
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Content ArticleDiagnosis is one of the most important tasks performed by primary care doctors and the World Health Organization (WHO) has highlighted diagnostic errors in primary care as a high-priority patient safety problem. In this narrative review in BMJ Quality & Safety, the authors discuss the global significance, burden and contributory factors related to diagnostic errors in primary care.
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Content ArticleThis animation by the Rockefeller Foundation explains how the 'Swiss Cheese' model can be applied to containing the spread of COVID-19. Combining different methods of infection control such as wearing face masks, social distancing and vaccination, creates a more solid and resilient barrier to transmission.
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Content ArticleThis report by the Patient Experience Library explores the reasons why the healthcare system in the UK has failed to listen to and learn from patient experience. It highlights how the NHS – at an institutional and cultural level – fails to take patient experience evidence seriously enough. It also identifies steps that would strengthen evidence-based practice and ensure that the patient voice is better heard.
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Content ArticleThis study in BMC Medicine aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. It is the largest meta-analysis to assess preventable medication harm to date. The authors found that one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Their results support the World Health Organization’s priority of detecting and mitigating medication-related harm and highlight other potential intervention targets that should be a priority research focus.
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Content Article
Patient blog - A tale of two MRIs (10 July 2020)
Patient-Safety-Learning posted an article in Patient stories
This blog by patient Lelainia Lloyd in the Journal of Medical Imaging and Radiation Sciences is a personal account of two starkly different MRI appointment experiences. In the first scan, the technologist said very little to Lelainia and the experience left her with significant anxiety about future MRIs. But her second experience was completely different, with the technologist communicating clearly, asking questions and making sure she felt comfortable throughout the process. Lelainia highlights the importance of communicating clearly and compassionately with patients to make them feel safe and able to ask for help. She outlines some practical steps for healthcare workers to help them engage with patients and ensure they are clearly consenting to all aspects of care and treatment. -
Content ArticleThis charter published by the Australian Commission on Safety and Quality in Healthcare describes the rights that consumers, or someone they care for, can expect when receiving health care. These rights apply to all people in all places where healthcare is provided in Australia. This includes public and private hospitals, day procedure services, general practice and other community health services. Topics covered include access, safety, respect, partnership, information, privacy and feedback.
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Content ArticleIn this blog for CNN health, Blake Ellis and Melanie Hicken discuss the exponential increase in the prescription of the drug Nuedexta to care home residents with dementia in the US. A CNN investigation found that the number of Nuedexta pills dispensed to care home facilities increased by nearly 400% in four years, prompting concerns that it is being inappropriately prescribed. The drug is designed to treat a rare disorder called pseudobulbar affect (PBA) which occurs in only 5% patients with dementia. State regulators have found doctors inappropriately diagnosing nursing home residents with PBA to justify using Nuedexta to treat patients whose confusion and agitation make them difficult to manage. Analysis by CNN also found that nearly half the Nuedexta claims filed with Medicare in 2015 came from doctors who had received money or other perks from the manufacturer.
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Content ArticleThis paper from The Partnership for Health IT Patient Safety examines the need to integrate IT safety into healthcare organisations' safety programs. It aims to create a framework for recognising often-unappreciated technology-related safety issues and highlights both the unintended consequences of using different technologies and the potential to improve safety by incorporating technology.
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Content ArticleThis study in AIDS and Behavior looked at patient-provider communication in HIV care and the role of shared decision making in improving health outcomes. The authors found that good quality engagement between patients and their healthcare providers was associated with better health-related outcomes. A substantial proportion of patients did not report having good quality engagement and this was associated with significantly poorer outcomes.
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Content ArticleThis blog by consultancy firm Gallup highlights seven questions leaders should ask to about their huddles, to ensure they are effective in improving patient safety and preventing staff burnout.
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Content ArticleThe report of the Independent Inquiry into Inequalities in Health chaired by Sir Donald Acheson was published in 1998. The purpose of the inquiry was to inform the development of the government's public health strategy and to contribute to the forthcoming white paper, Our healthier nation. The report made a number of specific recommendations on a range of areas relating to health, environmental and social factors including: introducing health impact assessments for all policies that were likely to have a direct or indirect impact on health and health inequalities. appointing directors of public health in every health authority. placing a partnership duty on the NHS executive and regional government to ensure local partnerships between health and local government.
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Content ArticleThis is the second part of webinar three in a series designed to help the NHS respond to the Covid-19 pandemic, hosted by the Faculty of Clinical Informatics. It is hosted by Sebastian Alexander, Founding Fellow of the FCI, NHS Digital, Safety, SME Apps Programme, and features presentations on the work of the National Pathology Xchange and The National Pathology Programme.
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Content ArticleThis is the first part of webinar three in a series designed to help the NHS respond to the Covid-19 pandemic, hosted by the Faculty of Clinical Informatics. It is hosted by Sebastian Alexander, Founding Fellow of the FCI, NHS Digital, Safety, SME Apps Programme, and features presentations on the NHS Digital Apps and Wearables Programme and the Kryptowire app assessment.
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Content ArticleThis case study looks at how implementing a daily emergency call safety huddle at Surrey and Sussex Healthcare NHS Trust has increased efficiency in team working and improved patient safety. A safety huddle is a short multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk. By implementing the ten-minute daily safety huddle, the medical emergency and cardiac arrest teams improved patient outcomes and staff experience, and were able to make better use of resources.
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Content ArticleThe Serious Incident framework describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again. This framework explains the responsibilities involved when dealing with serious incidents and includes actions staff are required to take, and the tools available. It is designed to inform staff providing and commissioning NHS funded services in England who may be involved in identifying, investigating or managing a serious incident. It is relevant to all NHS-funded care in the primary, community, secondary and tertiary sectors, including private sector organisations providing NHS-funded services. At some point in 2022, the Serious Incident framework will be replaced by the Patient Safety Incident Response Framework
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Content Article
Article: Culture, kinship and intelligent kindness (2013)
Patient-Safety-Learning posted an article in Culture
This article by Penny Campling for the Royal College of Psychiatrists suggests that cultivating a culture of 'intelligent kindness' within the NHS will result in more safe and humane care. The author proposes a 'virtuous circle of compassionate care' and highlights systemic barriers that prevent organisations achieving this ideal. She argues that to create this virtuous circle, healthcare professionals need to acknowledge - and consciously work against - structures that undermine kindness. This requires a greater understanding the emotional impact of healthcare work, an acknowledgement that market culture undermines compassionate care and a renewed focus on relationships between professionals. -
Content ArticleThis article from the book 'Patient Safety and Quality: An Evidence-Based Handbook for Nurses' looks at the impact of the architectural design of a hospital facility on patient safety. This includes considering the design of hospital technology and equipment. The authors highlight the ways in which physical design can make healthcare systems and processes safer for patients and staff. They also identify indirect benefits of system design that may contribute to this, including improved staff wellbeing and making patients feel safer while in care environments.
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Content ArticleThis study in BMJ Open considers how the usefulness of internal whistleblowing is affected by other institutional processes in healthcare organisations. The authors examine how the effectiveness of formal inquiries (in response to employees raising concerns) affects the utility of whistleblowing. The study used computer simulations to test the utility of several whistleblowing policies in a variety of organisational contexts. This study found that: organisational inefficiencies can have a negative impact on the benefits of speaking up about poor patient care where resources are limited and reviews less efficient, it can actually improve patient care if whistleblowing rates are limited including 'softer' mechanisms for reporting concerns (for example, peer to peer conversation) alongside whistleblowing policies, can overcome these organisational limitations.
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Content ArticleThis editorial in BMJ Quality & Safety suggests that individual doctors' conduct, performance and responsibility are important factors in improving patient safety. The authors argue that although a 'systems approach' is important, it is necessary to examine the role of individuals within those systems. They highlight recent research that points to small numbers of individual doctors who contribute repeatedly to patient dissatisfaction and harm, and to difficult working environments for other staff. They suggest that identifying and intervening with these individuals plays a role in the wider systems approach to patient safety. They also highlight an urgent need for further research into identifying and responding to problematic clinicians.
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Content ArticleThis paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
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Content ArticleThis review in the Journal of Clinical and Diagnostic Research explains the basics of audit and describes in detail how a clinical audit should be performed and monitored. It includes information on the 'Audit Cycle' and 'Ten Tips for Successful Audits'.
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Content ArticleGetting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
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Implementation Approaches for Closing the Loop (2019)
Patient-Safety-Learning posted an article in Diagnostic error
Delayed, missed and incorrect diagnoses are common causes of errors that result in patient harm and inappropriate care. However, some diagnostic errors may be avoided by effectively using health information technology. These resources from the Emergency Care Research Institute provide information on how to implement IT processes to close the loop on diagnostic evaluations.
