Patient-Safety-Learning
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Join Fallon Hughes, DNP, RN, senior director of Nursing Practice, Innovation, Research and EBP for WellSpan Health, and Alisha Wike, RN, bedside nurse at WellSpan Good Samaritan Hospital, in an educational webinar on virtual nursing. They will discuss current evidence on the role of virtual nursing in healthcare and the role of the virtual nurse in an acute care setting, compare virtual nurse operational considerations to those of a traditional nurse staffing model, identify implications for patient safety, and interpret virtual nurse implementation outcomes for application at your own facility. Register for this webinar, hosted by the Pennsylvania Patient Safety Authority. -
Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)In these presentation slides, Erik Hollnagel, Professor at the University of Southern Denmark, explains what is meant by the terms 'work as done' and 'work as imagined'. The presentation looks at the implications of designing with the two concepts in mind and highlights ways to better align system design with the realities of work as done.
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Content ArticleSurgical conditions are common in older patient and often require major surgery on frail patients. Strong understanding of the risks for different patients is crucial for decision-making and establishing goals of care. This study in the American Journal of Surgery aimed to find out which clinical factors increase the risk of older patients dying within 30 days of a colectomy or small bowel resection. The results showed that the highest predictors of mortality were American Society of Anesthesiologists (ASA) status 5, septic shock and dialysis. Without risk factors, mortality rates were 11.9% after colectomy and 10.2% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4% following colectomy and 100% following small bowel resection.
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Content ArticleUS doctor Frederick Gibson describes his experience having a sudden cardiac arrest as a 26 year-old medical student. It took paramedics 45 minutes to resuscitate him in his kitchen and two further rounds of CPR before he reached the hospital to keep him alive. Frederick describes the profound impact the experience has had on him and his partner and reflects on how it has changed his attitude to the experience of being a patient. He highlights the significance of interactions between doctors and their patients—a doctor's words, tone and attitude are carried by the patient in their everyday life, outside of the consultation room, for the next few months and years.
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Content ArticleIn this webinar, Tracey Herlihey, Head of patient safety incident response policy, NHS England, looks at how the Patient Safety Incident Response Framework (PSIRF) is changing the culture amongst healthcare workers and what this means for individuals. Dr Henrietta Hughes discusses the events leading up to the creation of the Patient Safety Commissioner role, her priorities and the role of leaders. She also explores the importance of ‘what matters to you'—that is, why we must listen to patients and what happens if we don’t.
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Content ArticleThis study in the International Journal of Infectious Diseases aimed to identify the highest-risk subgroups for Covid-19 and Long Covid, particularly relating to influenza and cardiovascular disease (CVD). The authors looked at the records of patients with Covid-19 and Long Covid in linked electronic health records for England. They compared all-cause hospitalisation and mortality by prior CVD, high CV risk, vaccination status (Covid-19/influenza) and CVD drugs, to investigate the impact of vaccination and CVD prevention. The results of the study showed that prior CVD and high CV risk are associated with increased hospitalisation and mortality in Covid-19 and Long Covid. The authors call for targeted Covid-19 vaccination and CVD prevention to be prioritised.
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Content ArticleThis film demonstrates how using SEIPS can help illuminate contributory factors within a work system, such as unconscious bias, stereotyping, workload, incivility, societal pressures and environmental factors under the six entity headings. Staff watch an animated explanation of SEIPS and then a short fictional maternity scenario looking out for relevant contributory factors. After viewing the film staff take part in a facilitated discussion to reflect. It is hoped that those using this film will be able to build on this experience, and then reflect on their own clinical service through the SEIPS lens, as taking a systems-based approach will strengthen a Just Culture, reduce blame and supports the PSIRF process.
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Content ArticleThis video provides an in-depth look at how Patient and Public Involvement (PPI) can enhance quality improvement projects. Involving patients and the public ensures transparency and enriches the team dynamic, bringing new thinking and ideas. It looks at the collaborative approach adopted in an HDR-UK funded initiative which demonstrates the significant impact of PPI and co-production. The video was produced by the Healthcare Quality Improvement Partnership (HQIP) to mark Clinical Audit Awareness Week 2024.
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Community PostHi Kim, Thanks for sharing your experience - I'm sorry to hear you are living with these symptoms. We have an existing forum related to vaccine injury on the hub - if you post your experience there you may get some response from people in a similar situation. There is also information about a support group on Facebook hosted by UKCV-Family
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)Modern patient safety approaches in healthcare highlight the difference between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined). Research in this area has looked at case study examples, but has lacked insights on how results can be embedded within the studied context. This study used Functional Analysis Resonance Method (FRAM) for aligning work-as-imagined with work-as-done. It aimed to show how FRAM can be effectively applied to identify the gap between work prescriptions and practice. It also aimed to show how these findings can be transferred back to and embedded in the daily ward care process of nurses.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)This blog by Tom Geraghty provides a definition of 'work as 'imagined' and how this differs from 'work as done'. He outlines the roots of the concept of difference between how people think work is done and the reality and also describes the concepts of 'work as prescribed' (how we think the work should be done) and 'work as disclosed' (what we say about the work that has been done). He discusses how we can close the gap between work as done and work as imagined through honest conversations, observations and simulations.
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Content ArticleThe incidence of early-onset colorectal cancer has increased significantly over the past decade. Although there has been research on the relationship between outcomes and socioeconomic status in older adults, data on socioeconomic and racial disparities in younger adults is lacking. This US study in Surgery aimed to fill this gap by investigating factors affecting screening, treatment and outcomes for adults under 50 years at the time of diagnosis. The authors found that socioeconomic and racial disparities in early-onset colorectal cancer affect diagnosis, treatment and survival. They call for interventions to boost early diagnosis and access to surgery among minorities and patients living in neighbourhoods with low socioeconomic status.
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Content ArticleThis webinar recording explores the potential benefits of self-referral, its effects on health inequalities and the factors which enable self-referral. The webinar panel includes RCP outpatients clinical lead Theresa Barnes, RCP digital lead Anne Kinderlerer and head of patient partnership at the Patients Association Sarah Tilsed.
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Content ArticleThis document by the Centre for Perioperative Care outlines principles that should be used to design checklists for invasive procedures.
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Content ArticleIn recent years, both of the UK's largest political parties have made explicit commitments to tackle the country's geographic health inequalities. In their starkest form, health inequalities—whether based on race, class, gender, geography and so on—will mean that those at the wrong end have, on average, fewer years to live and worse health when alive. This article in IPPR Progressive Review argues that the reason progress on tackling health inequalities is not being made is the failure of national leaders to identify mechanisms of change.
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Content ArticleJournalist Jessie Hewitson has two children with autism and has first hand experience of the difficulties autistic people face when accessing healthcare. In this inews article, she looks at the shocking statistic that autistic people die between 6 and 16 years earlier than the rest of the population and suggests that many small interactions and obstacles contribute to poorer outcomes. She highlights three key factors that contribute to health inequalities for autistic people: communication difficulties, anxiety about phoning the GP and difficulties with interoception—the ability to know and respond appropriately to your bodies signals.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)This podcast by the National Patient Safety Board asks how healthcare can address the systemic challenges that have prevented progress on patient safety for decades. Hosted by Karen Wolk Feinstein, this episode looks at lessons that can be taken from other industries that have made safety a top priority. Karen talks to guests Professor Nancy Leveson, engineer and systems safety expert, and Dr. Michael Shabot, former healthcare executive and expert in high-reliability healthcare safety and quality.
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Content ArticleThis commentary in JAMA Network Open looks at the increasingly recognised problem of burnout among US healthcare professionals. General Social Survey data suggest that almost one-half of US health care workers experienced symptoms of burnout often or very often in 2022, up from less than one-third in 2018. The article explores research that demonstrates the extent of the issue and highlights studies looking at ways to reduce burnout. The authors conclude that systemic change will be required to tackle the issue.
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Content ArticleThis webpage outlines the role and purpose of the Norwegian Healthcare Investigation Board (NHIB)—or 'Ukom' in Norwegian—an independent government agency set up in 2019. NHIB investigates serious adverse events and other serious concerns involving Norwegian healthcare services, aiming to improve patient and user safety by learning for improvement. Its investigations focus on systems and processes in healthcare, identifying factors that could have led, or could potentially lead, to harm for patients. On this page, you can also access NHIB reports and summary reports that have been translated into English, including: Death at a psychiatric intensive care ward: Risk factors in conjunction with seclusion Early diagnosis and treatment of serious illness in the febrile child Adolescents with mental health issues Investigation following the tragic drowning in Tromsø: What can we learn about integration and refugee health? Maintaining patient safety with new surgical and invasive methods
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Content ArticleIn this Medscape article, Jane Dacre, President of the Medical Protection Society (MPS) looks at the importance of ensuring international medical graduates (IMGs) are given thorough and appropriate induction when they join NHS organisations. She highlights that although many trusts do offer IMGs appropriate induction, others are failing to do this She refers to the results of a recent MPS survey which demonstrate the impact of the issue: Nearly 6 in 10 (58%) IMGs said their induction was not adequate or appropriate for them as an IMG. Nearly half (48%) felt anxious about starting clinical duties because of this. 38% said they did not have sufficient time to shadow other doctors. 45% said their induction did not include training on cultural differences and acceptability in the UK. 61% went on to say they felt fearful of medicolegal issues arising from their work.
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Content ArticleIn this blog, consultant rheumatologist and RCP Digital Health Clinical Lead Anne Kinderlerer looks at how digital solutions could improve patient care and safety in outpatients. She highlights that existing triage systems make it difficult to manage risk across pathways and outlines how digital tools might enable patients to access the right support at the time when they most need it. She also describes why increasing interoperability and sharing of data between primary and secondary care will be vital to improving how the health service predicts and manages risk, reducing health inequalities and preventing patients getting 'lost in the system'.
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Content ArticleThere is currently little research about the clinical management of people recently discharged from inpatient psychiatric care who die by suicide. This study in BJGP Open aimed to improve understanding of how people discharged from inpatient mental health care are supported by primary care during this high-risk transition. The authors carried out a nested case-control study using interlinked primary and secondary care records for people who died in England within a year of discharge between 2001 and 2019. Key findings included: Over 40% of patients who died within two weeks and 80% who died later had at least one primary care consultation. There was infrequent evidence of discharge communication from hospital. Within-practice continuity of care was relatively high. Those who died by suicide were less likely to consult within two weeks of discharge. They were more likely to consult in the week before death, be prescribed multiple types of psychotropic medication, experience readmission and have a diagnosis outside of the ‘Severe Mental Illness’ definition. The authors concluded that healthcare professionals working in primary care have opportunities to intervene and should prioritise patients experiencing transition from inpatient mental health care. Clear communication and liaison between services is essential to provide timely support.
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Content ArticleThe Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the United States. This study in Patient Safety analysed more than 23,970 healthcare association infection (HAI) reports submitted by long term care facilities in Pennsylvania in 2023. The results showed an increase in the number of reports of HAIs submitted. The overall infection rate increased by 11.4%, from 0.88 in 2022 to 0.98 in 2023, and all six regions of the state had an increase in infection rate. The Northeast region had the highest rate, with 1.28 reports per 1,000 resident days, and the Southeast region had the lowest rate, at 0.72. The overall rate increase was driven by rates of urinary tract infection (UTI) and skin and soft tissue infection (SSTI), which increased by 20.1% and 17.4%, respectively. Within the UTI infection type, symptomatic urinary tract infection (SUTI) rates increased by 21.1% and catheter-associated urinary tract infection (CAUTI) rates increased by 11.8%.
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Content ArticleThe Joint British Diabetes Societies (JBDS) for Inpatient Care group was created in 2008. It aims to improve inpatient diabetes care by developing and promoting high quality evidence-based guidelines and creating better inpatient care pathways. The JBDS–IP group was created and supported by Diabetes UK, ABCD and the Diabetes Inpatient Specialist Nurse (DISN) UK group, and works with NHS England, TREND-UK and with other professional organisations. This webpage contains guidance on a wide range of subjects relating to inpatient care for people with diabetes, including: The hospital management of hypoglycaemia in adults with diabetes mellitus The management of diabetic ketoacidosis in adults Management of adults with diabetes undergoing surgery and elective procedures: improving standards Self-Management of diabetes in hospital Glycaemic management during enteral feeding for people with diabetes in hospital The management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes Admissions avoidance and diabetes: guidance for clinical commissioning groups and clinical teams Management of hyperglycaemia and steroid (glucocorticoid) therapy The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients Discharge planning for adult inpatients with diabetes Management of adults with diabetes on dialysis Managing diabetes and hyperglycaemia during labour and bir
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Content Article
There has been an big increase in the use of diabetes technology in the NHS recently, especially in type 1 diabetes. Continuous glucose monitors (CGMs) are now standard care for people with type 1 diabetes, and work has begun to increase access to hybrid closed loop (HCL) systems, which are sometimes referred to as an 'artificial pancreas'. Along with this expansion, it is important to raise awareness of these devices when people with diabetes are admitted to hospital, whether this is directly for their diabetes or not. This information poster, developed by Mayank Patel and the diabetes team at University Hospital Southampton, aims to raise awareness of diabetes tech devices. It also addresses the issue of safe insulin delivery, especially related to pumps.
