Patient-Safety-Learning
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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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Content Article
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. -
Content ArticleThis study in the International Journal of Mental Health Nursing presents a qualitative evaluation of staff perspectives of the impact and value of the REsTRAIN Yourself initiative. REsTRAIN Yourself aimed to reduce the use of physical restraint in mental health inpatient wards through training and practice development with whole teams within ward settings. Thirty-six staff participated in semi-structured interviews for this study.
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Content ArticleThis training from the World Health Organization (WHO) is part of WHO's QualityRights Initiative, which aims to change mindsets and practices in a sustainable way to improve the lives of people with psychosocial, intellectual or cognitive disabilities globally. It seeks to empower all stakeholders to promote rights and recovery. These materials can be used to build capacity among mental health practitioners, people with psychosocial, intellectual and cognitive disabilities, people using mental health services, families, care partners and nongovernmental organisations. They offer guidance on how to implement a human rights and recovery approach to mental health in line with the UN Convention on the Rights of Persons with Disabilities, and other international human rights standards.
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Content ArticleThis document by the Restraint Reduction Network offers a framework to support care providers in reducing the use of restrictive practices. Restrictive practices are often a response to behaviours seen by care providers and wider society as ‘behaviours of concern’ or ‘challenging behaviour’. These behaviours can occasionally include wilful acts that have the potential to cause harm, but more often than not, these behaviours are symptoms of distress or frustration and a response to the environment or situation that a person finds themselves in. This document outlines the National Minimum Standards for the content of Restrictive Interventions Reduction Plans in mental health and learning disability settings.
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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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Content Article
Transvaginal mesh timeline (7 December 2017)
Patient-Safety-Learning posted an article in Women's health
This blog sets out a timeline of the major landmarks for transvaginal surgical mesh since its first approval in 1996. -
Content ArticleThis cross-sectional survey in the British Journal of General Practice looks at the availability and use of emergency admission risk stratification (EARS) tools across the UK and aims to identify factors that influence their implementation. The authors identified 39 different EARS tools in use. They found that the most important factors in encouraging general practices to use EARS tools were: promotion by NHS commissioners involvement of clinical leaders engagement of practice managers. High workloads and information governance were significant barriers to their use. The authors highlight the need to align policy and practice with research evidence.
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Content ArticleThis systematic review in The Journal of Advanced Nursing aimed to synthesise current knowledge about the impact of safety briefings on improving patient safety. The authors found that safety briefings achieved beneficial outcomes and can improve safety culture. Beneficial outcomes included: improved risk identification. reduced falls. enhanced relationships. increased incident reporting. ability to voice concerns. reduced length of stay.
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Content ArticleThis Annual Quality Statement provides a summary of the work of Cardiff and Vale University Health Board in 2019-2020, with a particular focus on community mental health.
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Content ArticleThis systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
