Patient-Safety-Learning
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Content ArticleTrauma remains a leading cause of global mortality and morbidity, necessitating effective trauma care. Despite progress, adverse events during trauma resuscitation persist, impacting patient outcomes and the healthcare system. This study in the American Journal of Surgery aimed to investigate adverse events in trauma resuscitation, evaluate contributing factors, and assess methods, such as trauma video review (TVR), to mitigate adverse events. The authors concluded that trauma video review (TVR) shows promise for identifying adverse events. They identified challenges including ensuring reporting consistency and integrating approaches into existing protocols. They call for future research to prioritise linking trauma team performance to patient outcomes and develop sustainable TVR programs to enhance patient safety.
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Community PostPatient-Safety-Learning replied to Patient_Safety_Learning's topic in Medication including labellingYou might be interested in this new interview with Katinka Blackford Newman, founder of the website AntiDepressantrisks.org. Katinka references the issues of PSSD as a risk that patients are not usually told about.
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Content ArticleThis video was produced as a training resource for NHS organisations, to demonstrate the impact the initial response to a patient safety incident and subsequent investigation have on the patient. In this video, Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed. She describes the clear, compassionate communication displayed by the healthcare professionals involved in her care, both immediately after the incident and throughout the subsequent investigation.
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Content Article
Antidepressant medications are taken by millions of people globally. A small percentage of people who take them will experience rare but dangerous adverse reactions. In this interview, Katinka Blackford Newman tells us about her personal experience of antidepressant-induced psychosis and how this led her to campaign for increased awareness about side effects. She highlights a widespread lack of education and awareness about the risks associated with antidepressants and outlines why she is asking suicide prevention charities to ask callers one simple question about their medication. -
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The Patient Safety Management Network (PSMN) started on a Friday afternoon in June 2021 as three people in a Zoom meeting. In this interview, PSMN founder Claire Cox reflects on why the network has grown to have over 1600 members and what it has achieved over the past three years. She outlines how the network has fostered a safe space for staff to raise issues and shares feedback from members about what they love about the PSMN. -
Content ArticleThis article looks at recent efforts to increase awareness of female genital mutilation (FGM) amongst healthcare professionals in the UK. Dr Victoria Kinkaid conducted a UK-wide survey to find out how much medical students knew about FGM. Results from the survey highlighted a gap in medical student education around FGM. Further exploration with the help of focus groups revealed that this knowledge gap also affected other frontline professionals with mandatory reporting duties for FGM, including teachers, midwives and social workers. Working with her MSc supervisor, Dr Heather May Morgan, Victoria launched a four week course entitled 'Female Genital Mutilation (FGM): Health, Law, and Socio-Cultural Sensitivity' in 2022 to try and bridge this gap. This article looks at the impact of the course and how Victoria and Heather's work to increase awareness is expanding.
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Content ArticlePolypharmacy is a term used to describe when a patient is taking a number of medicines at the same time. This study in the British Journal of Clinical Pharmacology aimed to measure how common polypharmacy is and describe the prescribing of selected medications known for overuse in older people with polypharmacy in primary care. It was a multinational retrospective cohort study that used data from patients with a mean age of 75-76 years from six countries: Belgium, France, Germany, Italy, Spain and the UK. The results revealed a high prevalence of polypharmacy with more than half of the older population being prescribed at least five drugs in four of the six countries. Whilst polypharmacy may be appropriate in many patients, the authors found worryingly high usage of PPIs and benzodiazepines. The study's results support current efforts to improve polypharmacy management across Europe.
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Content ArticleMedicines reconciliation is the process of compiling a complete list of a person’s current medicines. When a patient registers at a new primary care setting, medicines reconciliation contributes to patient safety and continuity of care. This article in The Pharmaceutical Journal explores how to optimise the multidisciplinary team and involve pharmacy technicians in the process, using four case scenarios. The article aims to help those working in community pharmacy teams to: identify potential risks and appropriate management strategies for new patients with complex medication needs, including those with chronic conditions and those requiring specialist care. understand the importance of timely referrals, communication with specialists, and adherence to guidelines in ensuring safe and effective medication management. recognise the significance of interdisciplinary collaboration and patient-centred approaches in addressing the diverse healthcare needs of patients, particularly those from other cultural backgrounds. You can access this article by signing up for a free account with The Pharmaceutical Journal.
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Content ArticleA fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.
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Content ArticleOnline reporting tools are a key component of professional accountability programmes as they allow hospital staff to report co-worker unprofessional behaviour. Ethos is a whole-of-hospital professional accountability programme that includes an online messaging system, which has now been implemented across multiple Australian hospitals. This study examined reported unprofessional behaviour that staff indicated created a risk to patient safety. It included 1310 Ethos submissions reporting co-worker unprofessional behaviour between 2017 and 2020 across eight Australian hospitals. The findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organisations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety.
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Content ArticleChildren are at higher risk of medication errors due to the complexity of drug prescribing and administration. Intravenous (IV) paracetamol overdose differs from overdose by ingestion as there is no enteral absorptive buffering. This study outlines the first national UK data focusing on paediatric IV paracetamol poisoning. The data show that unintentional IV paracetamol overdose appears to occur more frequently in young children. A significant proportion of errors were calculation errors, which were often 10-fold errors. While these errors have the potential to cause serious harm, thankfully most cases were asymptomatic. Errors with IV paracetamol might be reduced by electronic prescribing support systems, better communication regarding administration and consideration of whether other routes are more appropriate.
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Content ArticleThe healthcare systems of nearly every country are straining to keep up with the demands placed on them by advances in both treatment and technology. In this article, Timothy Ferris explores ways in which technology can reduce the burden on already under-resourced healthcare workforces. Acknowledging the complexity of healthcare compared to other industries, and the highly professional nature of the workforce, he uses the concept of 'unit cost' to look at how the financial and time burden associated with healthcare interactions can be reduced.
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Content ArticleDiagnostic error is largely discovered and evaluated through self-reporting and manual review, which is costly and not suitable for real-time intervention. AI presents new opportunities to use electronic health record data for automated detection of potential misdiagnosis, executed at scale and generalised across diseases. The authors of this study propose a new, automated approach to identifying diagnostic divergence considering both diagnosis and risk of mortality. The aim of this study was to identify cases of misdiagnosis of infectious disease in the emergency department by measuring the difference between predicted diagnosis and documented diagnosis, weighted by mortality. Two machine learning models were trained for prediction of infectious disease and mortality using the first 24 hours of data. Charts were manually reviewed by clinicians to determine whether there could have been a more correct or timely diagnosis. 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 ArticleSuicide is a leading cause of maternal death during the perinatal period, which includes pregnancy and the year after birth. While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK, the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth. This qualitative study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt. The researchers spoke to women with lived experience of perinatal mental illness. Their results highlighted three key themes: Trauma and Adversities which captures the traumatic events and life adversities with which participants started their pregnancy journeys. Disillusionment with Motherhood which brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. Entrapment and Despair which presents a range of factors that lead to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control. The authors called for further research into these factors which could lead to earlier detection of suicide risk, i
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Content ArticleAlzheimer’s Society estimates that there are currently around 900,000 people living with dementia in the UK. Unlike other major conditions, there is no national clinical pathway for dementia, and despite there being a national target, there is wide variation in dementia diagnosis rates across England. Alzheimer’s Society commissioned The King’s Fund to explore the development of Integrated Care Systems (ICSs) through the lens of dementia diagnosis—to consider what opportunities ICSs present to approach dementia differently and to improve diagnosis rates by doing so. The research team explored enablers and barriers to improving dementia diagnosis through interviews with stakeholders and people affected by dementia in three case study ICSs.
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Content ArticleNurses, midwives and paramedics make up over half of the healthcare workforce in the UK National Health Service and have some of the highest prevalence of mental ill health. This study in BMJ Quality & Safety explored why mental ill health is a growing problem and how we might change this. The authors identified the following key themes: It is difficult to promote staff psychological wellness where there is a blame culture The needs of the system often over-ride staff psychological well-being at work There are unintended personal costs of upholding and implementing values at work Interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors It is challenging to design, identify and implement interventions. They suggest that healthcare organisations need to rebalance the working environment to enable healthcare professionals to recover and thrive. This requires: high standards for patient care to be balanced with high standards for staff mental well-being. professional accountability to be balanced with having a listening, learning culture. reactive responsive interventions to be balanced by having proactive preventative interventions the individual focus balanced by an organisational focus.
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Although healthcare worker violence ranks high among today's top patient safety concerns, healthcare workers continue to be harmed, and healthcare has been identified as the profession with the highest percentage of nonfatal workplace violence injuries. Over the last few years, a Pennsylvania facility found that assaults on nursing in their acute care organisation were more than double the national rate. In the webinar, Loni Francis, MSN, RN, director of Behavioral Health Services, and Erin Marinchak, MSN, RN, senior director of clinical practice, Reading Hospital, Tower Health, will explain how proactive rounding by internal experts an prevent assaults and how behaviour management plans can reduce physical assaults. Register for the webinar This event takes place at 12:00 EDT and 17:00 BST -
Content ArticleIn this opinion piece for The Guardian, Adrian Chiles describes how his father was unnecessarily transferred from a community hospital to an A&E department by a locum GP. This caused his father—who was largely alone, confused and without his hearing aids—great distress, and should have been avoided, as healthcare professionals said the transfer had been unnecessary. Adrian describes his father's rapid deterioration following the incident and his regret that some of his father's last days were spent—avoidably—in distress. He says, "The process, the system, the protocols, the whatever, take hold and the wrong thing happens even though everyone can see it’s wrong but is powerless to put a stop to it."
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Content ArticleBeta-lactamases are enzymes produced by some bacteria that may make them resistant to some antibiotics. Extended Spectrum Beta-Lactamase (ESBL) production is associated with a bacteria usually found in the bowel. ESBL bacteria can be present in the bowel of individuals without their knowledge and may survive there harmlessly until the person becomes ill or requires antibiotic therapy. This information leaflet from the Northern Ireland Public Health Agency explains who is at risk of being infected with an ESBL-producing bacteria, how to reduce transmission and how EBSL infection is treated.
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Content ArticleAlthough diagnostic errors are estimated to affect about 12 million Americans each year in ambulatory care settings alone, the conceptual and pragmatic scientific foundations for their measurement are under-developed. Further progress towards reducing diagnostic errors will rely on our ability to overcome measurement-related challenges. This article in BMJ Quality & Safety outlines a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). The authors describe how Safer DX serves as a conceptual foundation for system-wide safety measurement, monitoring and improvement of diagnostic error. They believe it lays robust groundwork for measurement and monitoring techniques to ensure diagnostic safety. 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 ArticleThis increased implementation of artificial intelligence (AI) in healthcare could be either great or terrible news for the safety of services, depending on how organisations develop and implement it. This blog, written by the Professional Record Standards Body in partnership with the user experience company HD Labs, looks at the safety risks associated with using AI in health and care and outlines how standards can help keep AI safe.
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Content ArticleIn this article, Ashley Milne-Tyte looks at how older people are treated by healthcare professionals and the impact that negative views can have on their care and treatment. She highlights examples of older people being marginalised by healthcare professionals, who sometimes shout at their patients or speak to family members rather than addressing their older patient directly. Emphasising the harm that this can cause, she cites research that shows that medical bias towards older people can accelerate cognitive decline, increase anxiety and depression and shorten lifespans by up to seven-and-a-half years.
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Content ArticleThe Welsh Health Equity Solutions Platform is part of the Welsh Health Equity Status Report initiative (WHESRi), which supports a healthier, more equal and prosperous Wales. The platform is a gateway to data, evidence, health economics and modelling, policies, good practice, innovative tools and practical solutions to help improve population wellbeing and reduce the health equity gap in Wales and beyond. It is structured around an innovative WHO framework of ‘Five Essential Conditions’ for healthy prosperous lives for all. The platform will link with and feed into a WHO health equity gateway, providing an example and inspiration for countries to learn and follow, as well as to contribute and share.
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Content ArticleThis editorial in The Lancet Infectious Diseases reflects on the consequences of the infected blood scandal, in which more than 30,000 people in the UK were infected after receiving contaminated blood products in the 1970s and 1980s. It examines the systems in place for blood donation and transfusion in low and middle income countries (LMICs) and argues that the chance of a blood scandal coming to light in LMICs is much higher. This is because blood donations in many LMICs go against the WHO recommendation of national blood systems being based on blood supply from voluntary donors. Instead, they rely heavily on paid-for donations and family or replacement donations, which are unsafe due to the higher prevalence of bloodborne infections.
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Content ArticleIncreasingly, some nursing leaders say it’s time to move away from the 12-hour nursing shifts used by many hospitals. They say that health systems must develop other scheduling options to accommodate the changing needs of nurses as they progress in their careers. This article by Ron Southwick looks at the arguments for moving away from the 12-hour shift, including the risks that the current system poses to patient safety.
