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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Event
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    The theme for this year's The Private Healthcare Information Network (PHIN) forum underscores the pivotal role that advancements in AI, robotics, and data play in shaping the future of healthcare for the benefit of patients and everyone involved in the sector. The event is free to attend, but you need to book to guarantee your place. Register for the event
  2. Content Article
    This cohort study in JAMA Network Open aimed to assess whether therapist burnout is associated with reduced effectiveness of guideline-recommended psychotherapies for posttraumatic stress disorder (PTSD). The findings suggest that interventions to reduce therapist burnout might also result in more patients experiencing clinically meaningful improvement in PTSD symptoms from evidence-based psychotherapies.
  3. Content Article
    This report contains the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel formed under Section 103 of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA). Reporting to the US Federal Aviation Administration (FAA) and Congressional committees of jurisdiction, the Expert Panel reviewed the safety management processes and their effectiveness for each holder of an ODA for the design and production of transport aeroplanes.
  4. Content Article
    In this blog, Siva Anandaciva, Chief Policy Analyst at The King's Fund, examines NHS productivity—a top political priority. He highlights the difficulties in understanding the reasons for low productivity in the NHS after the Covid-19 pandemic and outlines the need to distinguish between productivity and delivery in order to really understand the issues.
  5. Content Article
    How we talk about health is important, and even those with the best intentions don't always do it well. Krista Lamb is an author and science communicator in Toronto. For years she has helped scientists, physicians, advocates and others share their healthcare stories effectively. Along the way, some of them have taught her how we can and should talk about health in ways that are empathetic, understandable and accurate. In this podcast she asks those people to share their tips and tricks to help everyone communicate better.
  6. Content Article
    The Health Services Safety Investigations Body (HSSIB) came into operation on 1 October 2023. One of the organisation's key priorities is to develop a new strategy, outlining the long-term goals and themes that underpin its objectives. This consultation is an opportunity to engage and shape HSSIB's strategy and investigation criteria for the future. The organisation is inviting comments and suggestions for improvement from all stakeholders. Comments can be submitted via this online survey. The deadline for submissions to the consultation is 16 May 2024.
  7. Content Article
    The Nuffield Trust's Health and International Relations Monitor project, supported by the Health Foundation, tracks issues that are important for the delivery of health and care in the UK. It aims to understand how our changing relationship with Europe is changing the picture for the NHS and health more generally, and what the prospects are for the future. This latest report shows that global medicine shortages are being felt particularly acutely in the UK, and the country's reliance on migration as a source of health and social care staff is intensifying.
  8. Content Article
    This research letter in JAMA Internal Medicine describes a multicentre retrospective cohort study that investigated associations between stigmatising language, errors in the diagnostic process and demographics for hospitalised patients. The study found that stigmatising language in patient documentation was associated with diagnostic error and multiple diagnostic process errors. The prevalence of stigmatising language was higher in documentation relating to Black patients and patients with housing instability. The authors argue that this may be indicative of clinician biases that interfere with data gathering, communication and clinical reasoning. They call for further research to explore the mechanisms behind this and to understand how clinician use of stigmatising language can be reduced.
  9. Content Article
    This systematic review and meta-analysis in JAMA Internal Medicine aimed to assess the rates of complications from central venous catheter (CVC) use. The authors found that rates of complications varied substantially across studies, but on average, the rate of serious complications (arterial cannulation, pneumothorax, infection or deep vein thrombosis) from a CVC placed for three days was estimated to be 30 events per 1000 catheters placed (3%). Use of ultrasonography was associated with lower rates of immediate insertion-related complications.
  10. Content Article
    This French cohort study in JAMA Internal Medicine aimed to find out whether spending a night in the emergency department (ED) associated with increased in-hospital mortality and morbidity among older patients. The results showed that older patients who spent a night in the ED showed a higher in-hospital mortality rate and increased risk of adverse events compared with patients admitted to a ward before midnight. This finding was particularly notable among patients with limited autonomy.
  11. Content Article
    Incident reports of medication errors are valuable learning resources for improving patient safety. However, key information is often contained within unstructured free text, which prevents automated analysis and limits the usefulness of these data. Natural language processing can be used to structure this free text automatically and retrieve relevant past incidents and learning materials, but this requires a large, fully annotated and validated set of incident reports. This study in Nature used a set of 58,658 machine-annotated incident reports of medication errors to test a natural language processing model. The authors provide access to the validation datasets and machine annotator for labelling future incident reports of medication errors.
  12. Content Article
    Surgical Site Infections (SSIs) can have subtle, early signs that are not readily identifiable. This study aimed to develop a machine learning algorithm that could identify early SSIs based on thermal images. Images were taken of surgical incisions on 193 patients who underwent a variety of surgical procedures, but only five of these patients developed SSIs, which limited testing of the models developed. However, the authors were able to generate two models to successfully segment wounds. This proof-of-concept demonstrates that computer vision has the potential to support future surgical applications.
  13. Event
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    Social innovation labs are innovative spaces that encourage creative thinking and experimentation. A recent evidence review undertaken by the Innovation Unit explores how labs can achieve greater impact. This session, jointly delivered by Q and Innovation, is an opportunity to hear more about the evidence review, hear from leading practitioners in the field and connect with others with an interest in social innovation. Register for the webinar
  14. Content Article
    As the NHS’s digital transformation journey enters a new phase, there are opportunities to improve the quality and productivity of the healthcare system. This phase is not just about advancing the maturity of electronic health records (EHRs) but also about embracing the vast potential of generative artificial intelligence tools. In this HSJ article, Robert Wachter and Harpreet Sood explore the reasons why EHRs have not yet delivered promised productivity improvements and look at how GenAI offers opportunities for the NHS to realise productivity benefits faster, cheaper and at a greater scale.
  15. Content Article
    In this report for Stat, technology correspondent Casey Ross looks at the dangers involved in using AI to predict patient outcomes, especially in life-or-death situations such as suspected sepsis. He looks at the recent case of US electronic health record provider Epic who were force to rewrite the algorithm being used by tens of thousands of US clinicians to predict sepsis.
  16. Content Article
    Despite widespread efforts to combat the opioid epidemic, post-operative opioid overprescribing by doctors remains an ongoing contributor to opioid misuse. This US study aimed to evaluate the impact of a low-cost, reproducible “just in time” intervention on opioid prescribing in dialysis access operations. Standardised opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. The results showed a decrease in patients discharged with opioids following the intervention, from 58% to 36%. For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents.
  17. Content Article
    This Medscape article tells the story of Josephine Vest, who was diagnosed with endometriosis aged 19. Now 30, she describes how her symptoms were dismissed and belittled by GPs and gynaecologists before she received a diagnosis a year after her symptoms began. With an average diagnostic delay approaching nine years across the UK, Josephine counts herself fortunate to have been diagnosed in this time frame. She goes on to describe the obstacles she faced in getting effective treatment and the suspicious attitudes healthcare staff displayed towards her.
  18. Content Article
    Consumer perspectives enable a broader understanding of how harm occurs. This webpage by Te Tāhū Hauora, the Health Quality & Safety Commission of New Zealand, contains guidance on engaging patients and consumers who have experienced harm and wish to be involved in learning and improvement in the healthcare system. It describes how patients and family will be supported to work in partnership with health care workers.
  19. Content Article
    Throughout 2023, the Arthritis and Musculoskeletal Alliance (ARMA) carried out the first ever national inquiry into musculoskeletal (MSK) health inequalities. The inquiry found that the prevalence and impact of musculoskeletal conditions are not experienced equally across the population. Musculoskeletal conditions are linked to deprivation and age, are more prevalent in women and disproportionately affect some ethnic groups. Deprivation is a significant driver of inequalities in MSK health. People in deprived areas experience more chronic pain, are more likely to have a long term MSK condition and experience worse clinical outcomes and quality of life. These inequalities are avoidable through changes in the design and delivery of MSK services, and actions to address wider determinants of health and prevention. The report makes recommendations to reduce health inequalities in MSK care, treatment and outcomes.
  20. Content Article
    In this blog, Peter Provonost MD, Chief Quality and Transformation Officer at University Hospitals Cleveland Medical Center, offers advice about what patients and their families can do to prevent health risks associated with hospital stays. He looks ways to mitigate against medication errors, surgical errors, infections, blood clots and other medical complications.
  21. Content Article
    This study aimed to assess perceptions of Covid-19 vaccines amongst pregnant or recently pregnant women in the US over two different time periods between November 2021 and February 2023. The results highlighted decreasing confidence in Covid-19 vaccine safety in a large, diverse pregnant and recently pregnant insured population, and the authors see this as a public health concern.
  22. Content Article
    This National Paediatric Diabetes Audit (NPDA) report on care and outcomes 2022/23 found that the prevalence of children and young people cared for in Paediatric Diabetes Units (PDUs) in England and Wales has increased from 33,251 in 2021/22 to 34,371 in 2022/23, despite a fall in the incidence of new cases. It also found that the percentages of children and young people with Type 1 and Type 2 diabetes receiving all six key annual healthcare checks have increased, but there remains much variability between PDUs (and completion rates for those with Type 2 remain lower than for those with Type 1). Other findings include: Percentages of young people with early signs of micro and macrovascular complications for both Type 1 and Type 2 diabetes show very little change in 2022/23 compared to the previous audit year Use of diabetes related technology has increased in 2022/23, with around half of children and young people with Type 1 diabetes using insulin pumps and half using a real time continuous glucose monitor (rtCGM) Around a quarter of all new cases of Type 1 diabetes had diabetic ketoacidosis (DKA) at diagnosis, compared to 25.6% in 2021/22. The report also states that, despite improvements in outcomes and use of technologies across different ethnicities and areas of deprivation, inequalities remain evident. In terms of rtCGM use, the inequality gap by deprivation has reduced, however the difference in use between Black and White children with Type 1 diabetes has widened from 8.6% in 2021/22 to 14% in 2022/23.
  23. Content Article
    Currently, surgical site infection surveillance relies on labour-intensive manual chart review. Recently suggested solutions involve machine learning to identify surgical site infections directly from the medical record. Deep learning is a form of machine learning that has historically performed better than traditional methods, while being harder to interpret. This study proposed a deep learning model—an explainable long short-term memory network—for the identification of surgical site infection from the medical record. The study found that the model had greater sensitivity when compared to traditional machine learning methods.
  24. Event
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    The Patients Association is running a webinar to support Future Health’s campaign, The Forgotten Majority. This campaign aims to raise awareness among policy representatives from Government and other political parties, as well as other key stakeholders, about the real life every day challenges faced by people with long-term health conditions and advocate for meaningful policy change as we approach the General Election. This webinar will provide patient experience to bring to life policies and initiatives aimed at addressing gaps in care for people with long-term health conditions. We hope this will raise awareness among policymakers and key stakeholders about the challenges faced by the ‘forgotten majority’ and the urgency of addressing their treatment and care. Rachel Power, Chief Executive of the Patients Association, will be chairing this webinar. The panel will share their insights on the importance of addressing the needs of people with long-term health conditions, and will advocate for improved care and support services. Hopefully this will increase awareness and understanding among policymakers and key stakeholders about the challenges faced by individuals with long-term health conditions, and drive systemic change. Register for the webinar
  25. Content Article
    This cohort study in JAMA Network Open explored whether the empathy displayed by doctors has an impact on the outcomes of patients with chronic pain. 1470 adults with chronic low back pain were included in the study, in which empathy was more strongly associated with favourable outcomes than nonpharmacological treatments, opioid therapy and lumbar spine surgery. The findings suggest that empathy is an important aspect of the patient-doctor relationship and is associated with better outcomes among patients with chronic pain.
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