Patient-Safety-Learning
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Content ArticleIn this long read, inews health correspondent Paul Gallagher looks at the processes now in place to ensure patient safety in blood transfusions and mitigate the risk of another infected blood scandal. He talks to Will Irving, Professor of Virology at the University of Nottingham, who outlines at although the risk is low, there may be transmission risks associated with blood transfusions that we are not yet aware of. The article also describes the work of the Serious Hazards of Transfusion (SHOT) committee, which has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the UK since 1996.
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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. Mark talks to us about his role as a National Patient Safety Partner (PSP). He explains the important role that PSPs play at national, regional and local levels of the healthcare system and identifies key opportunities and challenges they face in bringing the voice of patients and families at a strategic level. He also highlights the challenge of implementing the Patient Safety Incident Response Framework (PSIRF) across a diverse range of providers and the complexities arising where PSIRF interfaces with systems and processes outside of the NHS. -
Content ArticleThis standard, which complements existing health and safety legislation, has been developed by NHS England. NHS employers have a general duty of care to protect staff from threats and violence at work, and the standard delivers a risk-based framework that supports a safe and secure working environment for NHS staff, safeguarding them against abuse, aggression and violence. It employs the Plan, Do Check, Act (PDCA) approach, an iterative four-step management method to validate, control and achieve continuous improvement of processes. It was developed in partnership with the Social Partnership Forum and its subgroups, including trade unions and the Workforce Issues and Violence Reduction Groups.
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Content ArticleThe use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioural health settings since the field’s early infancy. The use of restraints has a harmful impact on both patients and providers alike, working against the therapeutic treatment environment aimed to support the healing journey. In this quality improvement project, the use of mechanical restraints was fully eliminated from a 252-bed inpatient setting in the US. This was achieved using a strategy of leadership, workplace development and data, and performance was sustained over the following year.
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Content ArticleThis study in Surgery aimed to assess the impact of presenting the STOPS framework (stop, talk to your team, obtain help, plan, succeed) on how surgeons cope in the operating room. It also looked at the related outcome of burnout and examined sex differences. The results suggest that there is evidence of efficacy in the STOPS framework—female surgeons who were presented this material reported higher levels of coping in the operating room compared to those who did not receive the framework. In addition, an increase in coping ability was associated with reduced levels of burnout for both genders.
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Content ArticleThis study in Surgery aimed to investigate the accuracy of ChatGPT-4’s surgical decision-making compared with general surgery residents and attending surgeons. Five clinical scenarios were created from actual patient data based on common general surgery diagnoses. Scripts were developed to sequentially provide clinical information and ask decision-making questions. Responses to the prompts were scored based on a standardised rubric for a total of 50 points. Each clinical scenario was run through Chat GPT-4 and sent electronically to all general surgery residents and attendings at a single institution. Scores were compared using Wilcoxon rank sum tests. The results showed that, when faced with surgical patient scenarios, ChatGPT-4 performed superior to junior residents and equivalent to senior residents and attendings. The authors argue that large language models, such as ChatGPT, may have the potential to be an educational resource for junior residents to develop surgical decision-making skills.
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Community PostHi @DKJoker84 You can email [email protected] if you are interested in joining UKCVFamily's support forum for people who have experienced vaccine injury. They may be able to offer some signposting to research regarding your symptoms and services that can offer further support.
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Content ArticleThis paper was presented to the NHS England board at its public session on 16 May 2024. It discusses the effect the pandemic has had on NHS productivity with details of NHS England’s estimates for the drivers of the loss of productivity observed. It also discusses the emerging plan to improve productivity in the coming years.
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Content ArticleThese action cards developed by Mark Rigby, Head of Theatre Services at Warrington and Halton Teaching Hospitals NHS Foundation Trust, contain a checklist of actions to be taken in the event of: incorrect swab count incorrect instrument count incorrect missing sutures or small metal items count
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Content ArticleThis audit tool developed by Mark Rigby, Head of Theatre Services at Warrington and Halton Teaching Hospitals NHS Foundation Trust, is designed to assess theatre compliance with the five steps to safer surgery, which includes the World Health Organization (WHO) Surgical Safety Checklist. The checks included in the five steps are designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and by verifying and checking essential care interventions. The tool features a monthly observation audit and documentation audit and presents recorded data in a results tab which tracks progress by month, providing more timely data locally than the clinical scorecard.
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Content ArticleIn Birmingham, eight out of 10 Somali children live in ‘poor’ households with low levels of economic activity and high rates of mental health issues, such as PTSD. In the UK, six in 10 (59%) people in the Somali community live in overcrowded accommodation, compared to fewer than one in 10 (8%) of the overall population. Meanwhile, studies show that many Somali people find it difficult to access health and social care services, due to language and socio-economic barriers. Suad Duale is a community activist, clinician, mother and researcher who grew up as a Somali refugee in Birmingham. In this blog for The King's Fund, she describes how unfair treatment of the Somali community leads to a collective lack of trust in professionals, particularly in the health system. She describes the issues contributing to the disparities faced by the community, including a lack of people from the Somali community in leadership roles who are able to advocate for the needs of the community. She describes the work of Dream Chaser Youth Club in Birmingham, where she volunteers by acting as a link to help people from the Somali community connect with health and care services.
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Content ArticleThis article by Saoirse Mallorie, Senior Policy Analyst at The King's Fund, looks at the detail behind the results of the 2023 NHS Staff Survey. She highlights that although it looks as though there has been improvement in some areas, staff satisfaction is not where it should be. The article also looks at variation between staff groups in terms of work-related stress, autonomy, belonging and workload, representing these differences visually in graphical form.
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Content ArticleMedicines waste is a significant problem in the NHS, with an estimated £300m wasted annually on unused or partially used medicines. In hospitals, this waste is added to when patients do not take their medicines home or when their medicines are not transferred with them as they change wards. In this blog for The Pharmaceutical Journal, Claire Williams, deputy clinical pharmacy manager at Hampshire Hospitals NHS Foundation Trust describes how her Trust reduced its medicines waste by moving patients’ medication with them and returning unused medication to the pharmacy in a timely manner. The Trust was participating in the Centre for Sustainable Healthcare ‘Green Team’ competition, and Claire and her colleagues saw it as an opportunity to showcase the impact that pharmacy can have in supporting the green agenda. This article is free to read but you will need to sign up for a Pharmaceutical Journal account to access it.
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Content ArticleThis report commissioned by the US Agency for Healthcare Research and Quality aims to identify major themes related to the current state of diagnostic safety and highlight key gaps in knowledge. Through a rapid narrative review methodology to evaluate multiple resources in the literature and interviews with experts, it presents several findings that have implications for future resource investments to reduce harm from diagnostic errors. The report looks at the following key themes: Incidence and Contributing Factors Measurement: Data and Methods Cognitive Processes Culture, Workflow, and Work System Issues Disparities Health Information Technology Patients and Families Testing Interventions Implementation
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Content ArticleLarge language models (LLMs) are a form of artificial intelligence that can generate human-like text and functions as a form of an input–output machine. They bring great potential to help the healthcare industry centre care around patients’ needs by improving communication, access and engagement. However, LLMs also present significant challenges associated with privacy and bias that also must be considered. This blog looks at three major patient-care advantages of LLMs, as well as the potential risks associated with using them in healthcare.
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Content ArticleFebriDx® is a single-use, analyser-free, point-of-care test with markers for bacterial and viral infection, measured on a finger-prick blood sample. As part of a larger feasibility study, this study explored the views of healthcare professionals (HCPs) and patients on the use of FebriDx® to safely reduce antibiotic prescriptions for lower respiratory tract infections (LRTI) in primary care. The authors concluded that the tool was perceived as a useful in guiding antibiotic prescribing and supporting shared decision making. Initial practical problems with testing and communicating results are potential barriers to use. Training and practice on using the test and effective communication are likely to be important elements in ensuring patient understanding and satisfaction and successful adoption.
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Content ArticleThis BMJ long-read article argues that health is going in the wrong direction in the UK, and reversing the trend requires political and societal commitment to deal with the underlying causes. It proposes evidence-based solutions to the worsening health and widening inequalities in the UK through action on the social determinants of health.
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Telemetry monitors are patient-worn devices that allow the patient's heart rate, heart rhythm, and other physiologic conditions to be assessed without restricting the patient to a bed. These devices allow cardiac patients to move around the facility while still being monitored. Monitors are designed to transmit an alarm signal to nursing staff if the patient develops a concerning heart rhythm or other condition that requires attention. The safety and effectiveness of a telemetry monitoring program depends heavily on the organization's alarm management strategy. Any failure to recognize or delay in responding to a potentially life-threatening change in the patient's condition could lead to severe harm. As with any physiologic monitoring system, healthcare organizations must scrutinize all aspects of how telemetry alarms are initiated, how they are communicated, and how staff respond. The use of inappropriate alarm settings or notification processes can prevent staff from learning about a change in the patient's condition or may lead to frequent false alarms or nuisance alarms that overwhelm, distract, or desensitize staff—a phenomenon known as alarm fatigue. Either situation can result in valid alarm conditions being missed by staff, and thus a patient's deterioration going unnoticed. Improvements in the way that telemetry systems are implemented and managed can help combat alarm fatigue and reduce the risk of alarm-related adverse events. During this lab webcast, we will discuss: Alarm fatigue: what it is, why it is a concern, and how telemetry implementation decisions can contribute to this hazard Criteria for selecting patients for telemetry monitoring Policies and procedures for setting and disabling alarms Alarm escalation processes and secondary alarm notification systems Strategies to optimize the monitor watching function Register for the webcast The webcast will take place at 12:00 ET, 17:00 BST -
Content ArticleThe Safe Learning Environment Charter supports the development of positive safety cultures and continuous learning across all learning environments in the NHS. It is underpinned by principles of equality, diversity and inclusion. It has been developed by over 2482 learners, educators and key stakeholders in health education. The Charter was created by NHS England in response to healthcare learners’ feedback on their clinical experiences in maternity services, set out in the Kirkup (2015 and 2022) and Ockenden (2020 and 2022) reports. The Charter is designed for learners and those responsible for supporting placement learning across all learning environments and all professions within them. It is aligned to the NHS People Promise in recognition that learners are vital to the workforce and are included in the promises NHS staff and leaders must all make to each other, to improve everyone’s experience of working in the NHS. The Charter sets out the supportive learning environment required to allow learners to become well-rounded professionals with the right skills and knowledge to provide safe and compassionate care of the highest quality.
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Content ArticleIn this blog, Miqdad Asaria, Assistant Professor at the Department of Health Policy at LSE, argues that AI could lead to a paradigm-shift in healthcare systems likes the NHS. He outlines how AI could help personalise medical treatments, enhance research and development of new drugs and help with the administrative burden currently undermining the productivity and efficiency of healthcare providers.
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Content ArticleThis is the second ‘saving babies’ lives’ progress report from the Joint Policy Unit. When the first report was published in May 2023, the Unit committed to reassessing progress each year. Through this process it aims to hold government and decisionmakers to account, helping to ensure that saving babies’ lives and tackling inequalities in pregnancy and baby loss are the political priorities they deserve to be. This years report highlights that maternity services need a much more transformative approach from government, that matches the scale and impact of the issue. Maternity services are not on course to meet government ambitions to reduce rates of stillbirth, neonatal death or preterm birth, and there continue to be stark and persistent inequalities in rates of pregnancy and baby loss by ethnicity and deprivation. View a summary version of the report
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Content ArticleKerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in two months. In March 2021 she complained of having per vaginal bleeding for six weeks and she was referred for an ultrasound. Due to her underlying ill health, she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. There were a number of missed appointmen
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Content ArticleThis report from Public Policy Projects (PPP) calls for changes in the use of approved medicines to improve diabetes care in the UK. It is the first in a series looking at specific areas of diabetes care in the UK.
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Content ArticleDespite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic quality, and many diagnostic safety events are not recognised. Without methods to identify, measure, investigate and analyse events, healthcare organisations cannot understand causes of diagnostic errors, identify contributing factors or create solutions. One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error.
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Content ArticleThe National Diabetes Foot Care Audit (NDFA) has published a State of the Nation report for 2018 to 2023. Based on data from England and Wales from 1 Apr 2018 to 31 Mar 2023, it details the findings and recommendations relating to the assessment, outcomes and participation in the NDFA for this period. Ulceration of the foot in people living with diabetes presents significant challenges, including emotional, physical and financial costs, and is associated with increased risk of both amputation and death. It affects between 1 and 2% of all people with diabetes each year and its management accounts for approximately 1% of the total NHS budget. The overall aim of the NDFA is to measure factors associated with increased risk of ulcer onset and adverse ulcer outcomes, and to share information relating to best clinical practice. This report contains three key findings: The time to first expert assessment (FEA) is key to achieving the positive outcomes of being alive and ulcer free (AAUF) at 12 weeks There is a marked variation between foot care services both in terms of assessment and outcomes There are wide ranging differences between regions, integrated care boards and services in ulcer registration rates, and also the percentage of those registered that are classified as severe.
