Patient-Safety-Learning
PSL ModeratorsContent Type
Communities
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleDuring the Covid-19 pandemic, global stocks, supply logistics and suitability of Personal Protective Equipment (PPE) to protect healthcare workers were recurrent challenges. The “Personal Respirator – Southampton” (PeRSo) was developed by a team of healthcare professionals at University Hospital Southampton NHS Foundation Trust during the first wave of the pandemic. It delivers High-Efficiency Particulate Air (HEPA) filtered air from a battery powered fan-filter assembly into a lightweight hood with a clear visor that can be comfortably worn for several hours. This study looks the development of PeRSo and highlights feedback from doctors and nurses that the PeRSo prototype was preferred to standard FFP2 and FFP3 masks, being more comfortable and reducing the time and risk of recurrently changing PPE. Patients also reported better communication and reassurance as the entire face is visible.
-
Content ArticleThis article in JAMA Health Forum looks at the US Government's track record of investment in domestic public health and international global health. It highlights the unknown consequences for the US and global health of the Trump administration's disengagement from the World Health Organization (WHO) and points to an undermining of the US as leaders in global health.
-
Content ArticleNominations are now open for the Patient Safety Hero Award—one of five main award categories in the Healthcare Quality Improvement Partnership's (HQIP's) 2025 Clinical Audit Heroes Awards. This award recognises clinical audits and quality improvement projects supporting improved patient safety. To enter, complete the nomination form by Sunday 27th April 2025. What are the judges looking for? Excellence in clinical audit and/or quality improvement, supporting real and impactful improvements in patient safety, should be demonstrated. More specifically, submissions will be judged on the following criteria: Clear project design involving robust clinical audit(s) or similar evidence/data-informed quality improvement Evidence of improvements in patient safety made as a result of the project, preferably providing data Wider impact on patient outcomes and experience, or on healthcare service provision. The following additional criteria will also be taken into consideration: Consideration of sustainability and/or longevity Innovative approach.
-
Content ArticleIntegrated care systems (ICSs) have a key role in tackling health inequalities—this goal is set out as one of the four core principles of ICSs, alongside improving population health, enhancing value for money and making a wider social and economic contribution to society. Tackling health inequalities and their causes are at the centre of ICS strategies and joint forward plans, but system leaders need support to do this. This framework was developed by the Care Quality Commission's (CQC's) partnership with National Voices and the Point of Care Foundation and aims to support a whole-system approach to embedding meaningful engagement and reducing health inequalities. It helps ICSs identify marginalised groups and assess their current engagement strategies. Where gaps are identified, the framework encourages collaboration with external networks that have stronger ties to these communities, all aimed at tackling health inequalities.
-
Content Article
Black maternal mortality remains disproportionately high
Patient-Safety-Learning posted an article in Maternity
This article by Samantha Anderer looks at the results of a US National Center for Health Statistics report into maternal deaths. The results show that the US maternal mortality rate was more than three times higher for Black women than for those of any other racial or ethnic group in 2023. Although the overall maternal mortality rate in the US has declined every year since 2021, it remained substantially higher than in other high-income nations, with research suggesting that many such deaths are preventable. -
Content ArticleThis US cohort study aimed to explore how antimicrobial resistance (AMR) has changed between 2012 and 2022. The findings showed that overall resistant cases per 10,000 hospitalizations declined between 2012 to 2016. However, progress varied across pathogens and was inconsistent before the Covid-19 pandemic. The pandemic was associated with notable increases in hospital-onset cases of AMR.
-
Content ArticleThe catastrophic wildfires that devastated Los Angeles County in January 2025 were caused by an unprecedented combination of extreme weather conditions and urban vulnerability. Within a span of hours, the Palisades and Eaton fires, propelled by record-breaking Santa Ana winds reaching 150 miles per hour, consumed more than 37,000 acres, destroyed more than 16,000 structures and claimed 29 lives. The increasing frequency and severity of wildfires present new challenges to healthcare systems, particularly in regions prone to these disasters. Staffing shortages, burnout and disaster fatigue are all major issues. This analysis in JAMA examines important aspects of health care system response during wildfire emergencies, offering evidence-based recommendations for institutional preparedness and adaptation.
-
EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore MNSI's findings following a systematic literature review analysing the research regarding cord management during neonatal transition and resuscitation. Register for the webinar
-
EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore factors affecting the delivery of safe care in midwifery units following the analysis of 92 randomly selected cases where care had been given at some time during labour on a birth centre. Register for the webinar
-
EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore MNSI’s Health Equity Warning Score (HEWS) and the Health Equity Assessment and Resource Toolkit (HEART). MNSI's health equity, diversity and inclusion leads developed this assessment tool to systematically identify, acknowledge, investigate and analyse factors affecting health equity which impact care and perinatal outcomes. Join this webinar to find out how you can put this tool into practice in your trust. Register for the webinar
-
EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. MNSI made recommendations to trusts 33 times between September 2018 and December 2023 in relation to birthing outside of guidance. These were reviewed by a team of maternity investigators and clinical advisors who identified this as a learning theme. In this webinar we will explore how healthcare professionals are able to support women / birthing people who birth outside of guidance so we can improve the outcomes and the experience of mothers, birthing people and babies. Register for the webinar
-
EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. For every 1000 babies born, 1-2 need assistance (2-10% of these need intubation). In this webinar we will explore learnings following a review of hypoxic ischaemic injuries (HIE) or early neonatal deaths (ENND). Register for the webinar
-
EventuntilThis conference is being run by the Local Government Association (LGA) in partnership with the Association of Directors and Public Health (ADPH). This key annual conference in public health will offer delegates the opportunity to hear from leading expert speakers on the very latest thinking on health inequalities, as well as gaining insights from those delivering on the ground. It will provide a much-needed opportunity for the public health community to come together, share learning, take stock and plan for the future. This year’s virtual conference will focus on addressing health inequalities, with a keen eye on local government and system-wide perspectives. It will provide practical insights and strategic discussions to inform and address the changing needs of our communities. Over three days, delegates will be able to put their questions and comments to a line up of speakers and will have the opportunity to participate in sessions sharing good practice from local areas and to discuss issues that matter to them. The afternoon will also feature a virtual Innovation Zone, kindly sponsored by NIHR, providing an opportunity for councils, partners and stakeholders to showcase their public health practice and innovations. Confirmed speakers Professor Sir Michael Marmot, Director UCL Institute of Health Equity Anne Longfield, Founder and Chair, Centre for Young Lives Alice Wiseman, Vice President, ADPH Sarah Muckle, Director of Public Health, Essex County Council and ADPH Policy Lead for Children and Young People Alison Hadley OBE, Director Teenage Pregnancy Knowledge Exchange, University of Bedfordshire James Woolgar, Sexual & Reproductive Health & HIV Commissioning Lead, Liverpool City Council and Chair, English HIV & Sexual Health Commissioners Group (EHSHCG) Carol Harris, Teenage Pregnancy Operational Lead, Walsall Healthcare NHS Trust Christopher Rocks, Lead Economist and Head of Secretariat, The Health Foundation Sally Cartwright, Director of Public Health Cambridgeshire Council Glenn Halliday, Strategic People Lead – Work and Health Integration Ruth Tennant, DPH Solihull and ADPH Board Member Katherine Merrifield, Assistant Director of Healthy Lives, The Health Foundation Dr Mubasshir Ajaz, Head of Health and Communities, West Midlands Combined Authority David Buck, Senior Fellow, Public Health and Inequalities, Kings Fund Vicky Head, DPH Milton Keynes Natalie Turner, Deputy Director for Localities, Centre for Ageing Better Greg Fell, President, ADPH This is a virtual event run on the Zoom platform. Register for the conference
-
Content Article
In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Peter and Helen speak to Bernie Rochford MBE, who spoke up while working as a clinical commissioner at a primary care trust. Bernie found serious issues and inaccuracies in records that posed a risk to patient safety—vital information about Continuing Healthcare patients (patients with significant ongoing care needs in the community) was missing from the system, and there were financial anomalies and serious governance issues. After raising her concerns and getting no response from her managers, Bernie found herself classed as a whistleblower and was isolated at work, eventually losing her job and going to employment tribunal. Bernie describes the serious impact this had on her health and talks about how she is now using her own traumatic experience to work for positive change for others who speak up. She discusses the complexities of regulating managers with Peter and Helen, and argues that we need to look at how people relate, rather than looking to technology, to provide a safer future for healthcare. Now a Principal Freedom to Speak Up Guardian, Bernie currently has a Churchill Fellowship award and is researching different global approaches to speaking up. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series Can you help? As part of Bernie’s Churchill Fellowship award she will be looking at speaking up and whistleblowing good practice and alternative approaches from around the world. She will be particularly focusing on approaches in Japan, South Korea, the USA and the Philippines. While her research is predominantly patient safety and healthcare focused, Bernie's interest in learning and sharing best practice goes beyond these areas, as we can learn from other industries and cultures as well. If you have any suggestions, ideas, best practice or experience that you can share with her, from anywhere in the world, please email Bernie. She will be very grateful to hear from you! How whistleblowers are passed around the system In the interview, Bernie talks about how she was passed from one person and organisation to another as she tried to raise her concerns. This diagram, which was included in the report of the Freedom to Speak Up review carried out in 2015 by Sir Robert Francis QC, shows the 54 people, teams and organisations Bernie approached to speak up about the patient safety issues she saw. -
Content Article
When someone needs a joint replacement, there are many factors that affect how well they will respond, how quickly they will recover from the procedure and the potential risks of surgery. Patient complexity is the term used to describe these factors and includes other health conditions, sometimes called co-morbidities, as well as local risk factors related to the specific joint needing to be replaced. In this interview, consultant orthopaedic surgeon Sunny Deo and engineer and founder of TCC-Casemix Matthew Bacon, discuss how new technology is allowing surgeons to more accurately predict the surgical risk and outcomes for patients having knee replacement surgery. They describe how a new approach to data modelling is allowing the orthopaedic team at Great Western Hospital NHS Foundation Trust to more accurately assess complexity for individual patients. This has benefits for patient care and outcomes, theatre productivity and the development of pathways that are more patient-centred. They also highlight some patient safety issues associated with elective surgical hubs, which were set up to deal with high volume low complexity patients, including the deprioritising of more complex patients who may be at greatest need of surgery. Finally, they discuss the applicability of this approach to other specialties and areas of healthcare. Read more about clinical complexity in joint replacement surgery in this presentation by Sunny Presentation - Overview of clinical complexity by Sunny Deo.pdf -
Content ArticleThe Australian Commission on Safety and Quality in Health Care released a set of national standards which became a mandatory part of accreditation in 2013. Standard 9 focuses on the identification and treatment of deteriorating patients. The objective of the study was to identify changes in the characteristics and perceptions of rapid response systems (RRS) since the implementation of Standard 9. The authors concluded that implementing a national safety and quality standard for deteriorating patients can change processes to deliver safer care, while raising the profile of safety issues. Despite limited dedicated funding and staffing, respondents reported that Standard 9 had a positive impact on the care for deteriorating patients in their hospitals.
-
Content ArticleFor people living with type 2 diabetes, achieving the best health outcomes requires good self-management and sticking to agreed treatment. While some studies suggest an association between poor medication adherence and lower levels of health literacy, the evidence for this association remains inconclusive. This systematic review aimed to examine the evidence on the association between health literacy and medication adherence among adults from ethnic minority backgrounds living with type 2 diabetes.
-
Content ArticleThe US Department of Justice (DOJ) has sued both CVS and Walgreens, along with dozens of their state subsidiaries, for allegedly aiding and abetting the US opioid epidemic. The country’s two largest pharmacy chains collectively operate more than 17,000 stores. The civil lawsuits by the DOJ rest on the allegation that the pharmacy chains violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA). The CSA states that narcotics can only be used for “a useful and legitimate medical purpose.” By filling prescriptions that were invalid, the pharmacies “made choices that caused these millions of violations of federal law,” the DOJ alleged in the Walgreens lawsuit. The FCA states that entities cannot knowingly present a “false or fraudulent claim” for government payment—either due to “deliberate ignorance” or “reckless disregard” of the claim’s falsehood. The DOJ alleged that by requesting reimbursement from Medicare and Medicaid for illegitimate prescriptions, the pharmacies broke the law. They unlawfully dispensed “massive quantities of opioids and other controlled substances to fuel its own profits at the expense of public health and safety,” the lawsuit against CVS stated.
-
Content ArticleQuantitative studies of public opinion on healthcare often distinguish between support for the system and satisfaction with its services. The relationship between these two dimensions can appear contradictory: in UK surveys, strong support for the NHS co-exists with rising dissatisfaction with care quality. This study aimed to investigate this apparent contradiction by analysing 169 critical reviews of emergency care visits in the UK submitted to the Care Opinion platform between 2015 and 2023. While reviews all describe instances of poor care, the authors identify the ‘justificatory repertoires’ through which reviewers express continued support for the NHS. This may reveal how societal attitudes towards public healthcare provision are in a recursive relationship with actual experiences of healthcare, and that the articulation of those experiences is deeply shaped by awareness of the broader political context.
-
Content ArticleThe phenomenon of a 'weekend effect' refers to a higher potential for adverse outcomes in patients receiving care over the weekend. Few prior studies have comprehensively investigated the effects of postoperative weekend care on surgical outcomes in a generalisable cohort. The aim of this study was to examine differences in short-term and long-term postoperative outcomes of patients undergoing surgical procedures immediately before vs after the weekend. In a cohort study involving 429 691 patients undergoing 25 common surgical procedures in Ontario, Canada, those who underwent surgery immediately before the weekend experienced a statistically significant increase in the composite outcome of death, complications, and readmissions at 30 days, 90 days, and 1 year compared with those treated after the weekend. These findings suggest that patients treated before the weekend are at increased risk of complications, emphasising the need for further investigation into processes of surgical care to ensure consistent high-quality care and patient outcomes. It is important for healthcare systems to assess how this phenomenon may impact their practices to ensure that patients receive excellent care irrespective of the day.
-
Content ArticleSince 2022, general practice has shifted from responding to the challenges of Covid-19 to restoring full services using a hybrid of remote, digital and in-person care. This BJGP study aimed to examine how quality domains are addressed in contemporary UK general practice. The authors found that: quality efforts in UK general practice occur in the context of combined impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that is unfit for purpose and physically distant and asynchronous ways of working. providing the human elements of traditional general practice, such as relationship-based care, compassion and support, is difficult and sometimes even impossible. systems designed to increase efficiency have introduced new forms of inefficiency and have compromised other quality domains such as accessibility, patient-centredness, and equity. long-term condition management varies in quality. measures to mitigate digital exclusion such as digital navigators are welcome but do not compensate for extremes of structural disadvantage. many staff are stressed and demoralised.
-
Content ArticleResearch suggests that insights from patient narratives—stories about care experiences in patients' own words—contain information that can be used to improve care. However, assessments of narratives reported by clinical personnel have been mixed. This US study aimed to systematically measure how useful staff in primary care perceive patient narratives to be. The authors surveyed 276 clinical and administrative personnel in nine primary care clinics in a large health system in the USA. We found that perceived usefulness of patient narratives is generally high, but varies by individual characteristics such as level of burnout and professional role, and with organisational characteristics such as a clinic's learning orientation and history of using patient feedback to improve quality. These findings imply that narratives can be useful for improving primary care and that their perceived usefulness is greater when organisational practices facilitate learning from patients' narrative feedback.
-
Content ArticleThis systematic review aimed explore the association between triclosan-containing sutures and the risk of surgical site infections. The results show that use of triclosan-containing sutures was associated with significantly fewer surgical site infections compared with sutures without triclosan.
-
Content ArticleThis study in BMJ Quality and Safety aimed to retrospectively estimate the prevalence of harmful diagnostic errors in a randomly selected sample of 675 patients receiving general medical care in a US hospital between July 2019 and September 2021. The researchers developed and validated a structured case review process to enable clinicians to interrogate the electronic health record (EHR) to evaluate the diagnostic process for hospital patients, assess the likelihood of a diagnostic error and characterise the impact and severity of harm. Their findings estimate that harmful diagnostic errors may be occurring in as many as 1 in every 14 (7%) hospital patients. Read a easy-read press release about the research
-
Content ArticleOne way pharmaceutical companies try to prolong revenue streams from their expensive brand-name drugs is by using various strategies collectively referred to as “product hopping.” Product hopping involves creating new formulations of existing drugs using the same active ingredients and then switching patients to the new product, often as generic competition is set to emerge. Product-hopping strategies include switching from a tablet to a capsule, switching from a short- to a long-acting form or incorporating new inactive ingredients. Some may offer incremental benefits, but all lead to greater spending by patients and the health care system. A new form of product hopping—drug versioning—may have crossed a line at which the desire to maximise profits led to patient harm. Drug versioning is when a manufacturer delays a new version of an existing product to maximise profits from an older one. In this JAMA article, S. Sean Tu and Timothy Bonis describe at a recent California lawsuit against the pharma company Gilead, which is accused of delaying the release of a safer medication to treat HIV in order to maximise the profits from its existing licensed product. They look at the benefits of preventing unethical, negligent drug versioning, which include avoiding unnecessary patient deaths and enabling timely access to affordable generic medicines.
