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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    People taking methotrexate (for inflammatory conditions such as rheumatoid arthritis) have regular blood tests to check for certain side effects. Researchers have developed a tool to predict the likelihood of them discontinuing methotrexate due to these side effects, which could in future lead to less frequent testing for most people (68%) on methotrexate. The tool uses information routinely collected by GPs. The study found that it could predict people’s risk of discontinuing methotrexate because of side effects. It was accurate for most people across different ages, inflammatory conditions, methotrexate doses and routes of administration. The researchers say the tool could in future be used by GPs to identify people who need more or less frequent blood tests. This article refers to the original research study Risk stratified monitoring for methotrexate toxicity in immune mediated inflammatory diseases: prognostic model development and validation using primary care data from the UK
  2. Event
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    This popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
  3. Content Article
    Connections are critical junctures and points of access along intravenous (IV) lines. Microorganisms may colonise these connections, potentially leading to catheter-related bloodstream infections (CRBSIs). For patients, CRBSIs are a significant cause of morbidity and death, and for healthcare facilities these infectious complications lead to unnecessary costs. Safe connections may help reduce the risk of needlestick injuries for healthcare professionals (HCPs) and the occurrence of CRBSIs for patients. In this webinar recording, Nancy Trick, Registered Nurse and Adjunct Instructor at Perdue Global University in West Lafayette, USA, discusses CRBSIs and presents solutions to help prevent them. After watching this webinar, you should be able to: describe open versus closed infusion systems in VAM. briefly discuss the clinical risks of open infusion systems. discuss clinical practice change. consider how evidence-based standards of practice recommend using closed IV access/needleless connectors.
  4. 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. Benjamin talks about why we need a radical shift in how we view and treat people with chronic pain and how over-investigation and over-treatment compromise patient safety. He also talks about the power of communal singing for people with long-term conditions and what wild swimming has taught him about supporting people living with chronic pain.
  5. Content Article
    Left-handedness was historically considered a disability and a social stigma, and teachers would make efforts to suppress it in their students. Little data are available on the impact of left-handedness on surgical training and this report aimed to review available data on this subject. The review revealed 19 studies on the subject of left-handedness and surgical training. Key findings include: Left-handedness produced anxiety in residents and their trainers. There was a lack of mentoring on laterality. Surgical instruments, both conventional and laparoscopic, are not adapted to left-handed use and require ambilaterality training from the resident. There is significant pressure to change hand laterality during training. Left-handedness might present an advantage in operations involving situs inversus or left lower limb operations.
  6. Content Article
    This report outlines the results of a survey carried out by The Institute of Health Visiting (iHV)—the largest UK survey of frontline health visitors working with families with babies and young children across the UK. Poverty was the cause of greatest concern to health visitors, with 93% reporting an increase in the number of families affected by poverty in the last 12 months. Other key findings included: 89% of health visitors reported an increase in the use of food banks 78% an increase in perinatal mental illness 69% an increase in domestic abuse 63% an increase in homelessness and asylum seekers 50% an increase in families skipping meals as a result of the cost-of-living crisis.
  7. Content Article
    In this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
  8. Content Article
    Boards and leaders of healthcare organisations are legally responsible for the performance of their organisation and must take definitive responsibility for improvements, successful delivery and failures in the quality of care. Board effectiveness relies on the ways in which board members translate their knowledge and information into quality and safety plans with measurable goals, maintain oversight on progress towards these goals and hold the chief executive accountable for these goals. This resource by the Canadian Patient Safety Institute lists tools available to boards and board members to allow them to understand their legislative responsibilities for quality and safety, conduct self-evaluation and understand the competencies needed to lead on quality and patient safety.
  9. Content Article
    Racial and ethnic disparities in health are substantial and persistent in the USA. They occur from the earliest years of life, are perpetuated by societal structures and systems, and profoundly affect children’s health throughout their lives. This series of articles in The Lancet Child & Adolescent Health summarises evidence on racial and ethnic inequities in the quality of paediatric care, outlines priorities for future research to better understand and address these inequities and discusses policy solutions to advance child health equity in the USA. Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence Policy solutions to eliminate racial and ethnic child health disparities in the USA
  10. Content Article
    As part of the Lancet's Child and Adolescent Health Spotlight, the journal called for young people around the world aged 18–25 years to lend their perspectives and lived experiences on the two key spotlight asks: That children must be immediately prioritised in health and social policies; children and young people deserve attention in their own right, and not only because they are an indispensable foundation for a sustainable future. That governments and health providers should prioritise health equity for children and young people, within and between countries. The Lancet received 104 submissions in Chinese, English, Portuguese and Spanish, many of which have been published as essays in Lancet publications. This article in The Lancet Child & Adolescent Health summarises the key themes that were raised in the submissions received, including: the need for honest conversations with trusted adults about less talked-about areas including sex and death. the mental health impacts of attacks on transgender young people. the issues associated with living with a chronic illness as a young person. the importance of non-tokenistic youth engagement in research.
  11. Content Article
    This guide by the Health Foundation can be used to make the case for improvement to policy, executive, operational and front-line audiences, and to initiate and support conversations about the benefits of improvement approaches among key stakeholders. The guide is divided into four broad areas improvement approaches can benefit: the health and care workforce patients, service users and society  organisations and system-level bodies. Specific examples are given for each area, illustrating the diverse and multi-faceted benefits that come from improvement approaches.
  12. Content Article
    This Lancet article is written by two young people aged 19 and 20 years, based in the UK, who both developed Long Covid more than two years ago. They describe their wide-ranging symptoms and highlight the impact the condition has had on their lives, causing them to miss out on key milestones—such as starting university and learning to drive. They go on to look at the specific challenges facing young people with long-term conditions, arguing that many services that are meant to help young people—health services, schools and higher education facilities—are failing those dealing with a chronic illness or disability. This article is free to view, but you will need to sign up for a free Lancet account
  13. Content Article
    Medication shortages can occur for many reasons, including manufacturing and quality problems, delays and discontinuations. This Food and Drug Administration (FDA) database provides information on drugs with a supply issue. Information is provided to the FDA by manufacturers.
  14. Content Article
    Healthcare decision making should be a collaboration between patients and their providers. This eBook produced by Pfizer is for patients, caregivers and care team members. It aims to help empower individuals on their healthcare journey so they can be engaged patients who understand the health information they receive in order to act upon it.
  15. Content Article
    These draft regulations from the Department of Health and Social Care set out how the statutory medical examiner system will operate in the NHS in England from April 2024. Medical examiners will be appointed by NHS bodies to provide independent scrutiny of causes of death and will be a contact for bereaved people who want to ask questions or raise concerns. The draft regulations set out: medical examiners’ terms of appointment, training and payment the procedure for independence additional functions
  16. Content Article
    This study in JAMA Psychiatry aimed to assess whether multivariate machine learning approaches can identify the neural signature of major depressive disorder in individual patients. The study was conducted as a case-control neuroimaging study that included 1801 patients with depression and healthy controls. The results showed that the best machine learning algorithm only achieved a diagnostic classification accuracy of 62% across major neuroimaging modalities. The authors concluded that although multivariate neuroimaging markers increase predictive power compared with univariate analyses, no depression biomarker could be uncovered that is able to identify individual patients.
  17. Content Article
    Undervaccination—receiving fewer than the recommended number of Covid-19 vaccine doses—could be associated with increased risk of severe Covid-19 outcomes including hospitalisation or death compared with full vaccination. This study aimed to determine the factors associated with undervaccination and to investigate the risk of severe Covid-19 outcomes in people who were undervaccinated in each UK nation, and across the UK. The authors found that rates of undervaccination against Covid-19 ranged from 32·8% to 49·8% across the four UK nations in summer 2022. They also concluded that undervaccination was associated with an elevated risk of severe Covid-19 outcomes.
  18. Content Article
    Health care algorithms are used for diagnosis, treatment, prognosis, risk stratification and allocation of resources. However, bias in the development and use of algorithms can lead to worse outcomes for racial and ethnic minoritised groups and other historically marginalised populations such as individuals with lower incomes. This study aimed to provide a conceptual framework and guiding principles for mitigating and preventing bias in health care algorithms, in order to promote health and health care equity. The authors suggested five guiding principles: Promote health and health care equity during all phases of the health care algorithm life cycle Ensure health care algorithms and their use are transparent and explainable Authentically engage patients and communities during all phases of the health care algorithm life cycle and earn trustworthiness Explicitly identify health care algorithmic fairness issues and trade-offs Establish accountability for equity and fairness in outcomes from health care algorithms.
  19. Content Article
    This systematic review conducted for the Agency for Healthcare Research and Quality (AHRQ) aimed to examine the evidence on whether and how healthcare algorithms exacerbate, perpetuate or reduce racial and ethnic disparities in access to healthcare, quality of care and health outcomes. It also examined strategies that mitigate racial and ethnic bias in the development and use of algorithms. The results showed that algorithms potentially perpetuate, exacerbate and sometimes reduce racial and ethnic disparities. Disparities were reduced when race and ethnicity were incorporated into an algorithm to intentionally tackle known racial and ethnic disparities in resource allocation (for example, kidney transplant allocation) or disparities in care (for example, prostate cancer screening that historically led to Black men receiving more low-yield biopsies).
  20. Content Article
    This staffing calculator has been developed by the US Association for Professionals in Infection Control and Epidemiology (APIC). The tool is in beta version and uses input from individual healthcare facilities to provide recommendations to assist with infection prevention staffing decisions. There are three separate calculators: Acute care hospital calculator Long-term care calculator Ambulatory clinic calculator As the tool is currently in development, the data collected from participating organisations will be used to update the calculators and provide the most accurate staffing recommendations.
  21. Content Article
    The aim of this study in the Journal of Patient Safety was to identify quantitative evidence for the efficacy of interprofessional learning (IPL) to improve patient outcomes. The authors conducted a systematic review and meta-analysis of quantitative patient outcomes after IPL in multidisciplinary healthcare teams reported in the Medline, Scopus, PsycInfo, Embase and CINAHL databases. The authors believe that their results are the first to demonstrate significant quantitative evidence for the efficacy of IPL to translate into changes in clinical practice and improved patient outcomes. They reinforce earlier qualitative work on the value of IPL.
  22. Content Article
    The rise of the #TheatreCapChallenge in 2017, which saw participants donning surgical caps labelled with their names and roles, promises to be a seemingly simple intervention aimed at improving operating theatre communication and patient safety. This narrative review strives to expand upon the perceived and studied benefits of this intervention and address potential concerns that have arisen with the use of these name and role-labelled surgical caps.
  23. Content Article
    Error management is a systematic approach aimed at identifying and learning from critical incidents by reporting, documenting and analysing them. However, almost nothing is known about the incidents doctors in outpatient care consider to be critical and how they deal with them. This interview study aimed to to explore outpatient doctors’ views on error management, discover what they regard as critical incidents and find out how error management is put into practice in ambulatory care.
  24. Content Article
    This open letter penned by four senior female NHS doctors outlines the issues caused by ongoing misogyny in the medical profession in Wales. They call for real change to ensure that the trainees and medical students of the future do not experience the same harassment, inappropriate comments and bullying from senior colleagues that each of them can recall during their careers. "The four of us have risen to senior leadership positions in our respective specialties. We work in cancer, general practice, psychiatry and HIV medicine. And every single one of us can think of experiences from our own career that at the time we ignored, brushed off, pretended not to hear or not to see–but we saw, we heard, and we still remember."
  25. Content Article
    There is limited guidance on how to effectively promote safety culture in healthcare settings. This systematic review aimed to identify interventions to promote safety culture specifically in oncology settings. The authors concluded that in spite of a growing evidence base describing interventions to promote safety culture in cancer care, definitive recommendations were difficult to make because of heterogeneity in study designs and outcomes. They highlight that implementation of incident learning systems seems to hold most promise.
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