Patient-Safety-Learning
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Content ArticleThis Office for National Statistics (ONS) report provides in-depth analysis of Winter Coronavirus Infection Study (Winter CIS) data looking at trends in self-reported symptoms of Covid-19 including ongoing symptoms and associated risk factors. Winter CIS was a joint study with the UK Health Security Agency (UKHSA), carried out between November 2023 and March 2024 for England and Scotland. The study was structured as a longitudinal panel survey, with each participant sent a questionnaire and asked to take a lateral flow device test every four weeks for the detection of Covid-19.
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Content ArticleSheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF) aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. This video was produced by SHSCFT to help staff, service users and their families understand the importance of sharing information around their ethnicity and protected characteristics.
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Content ArticleThese patient safety professional standards aim to support pharmacists when responding to patient safety incidents. They describe good practice and provide a broad framework for continually improving services, shaping future services and roles and delivering high-quality care across all settings and sectors. They have been developed by the Royal Pharmaceutical Society (RPS), Association of Pharmacy Technicians UK and Pharmacy Forum NI, with the support of an expert steering group and public consultation. Pharmacists, pharmacist prescribers, pharmacy technicians and the wider pharmacy team across the United Kingdom will find these standards useful. They may also be of interest to the public, to people who use pharmacy and healthcare services, other healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
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The future of health and care lies at the intersection of prevention and precision. It’s a paradigm shift that requires vision, leadership, change management and the critical need to be radical. At Radical Health Festival Helsinki 2024, we’re not just thinking about the future of healthcare; we’re redefining it. Imagine a world where health is a lifelong journey, where risks are identified before they turn into crises, and care is personalised for every citizen. Is this just a pipe dream? No, it’s the radical shift we need now more than ever! This year, we deep dive into the intersection of prevention and precision. It’s a bold move and a paradigm shift requiring bold leadership. But it´s the only way forward. The 2024 programme explores the three pillars and key questions that will enable this deployment at scale: PEOPLE: Can we shift our focus from technology to people and place humans at the heart of digital transformation efforts? INNOVATION: Can we re-think innovation frameworks to accelerate the adoption and integration of cutting-edge technologies in clinical pathways? DATA: How do we turn data into insights for prevention, precision, and equity? We may not have all the answers. But Radical Health Festival Helsinki is where radical ideas take flight. Find out more about the festival -
Content ArticleClive Treacey, who had a learning disability, epilepsy and complex mental health needs, died in 2017 aged 47, having spent his adult life in residential social care and inpatient settings. In 1993, he was placed by Staffordshire County Council into the David Lewis Centre in the borough of Cheshire East, where it is alleged he was sexually abused by a member of staff. Cheshire East Safeguarding Adults Board (CESAB) and Staffordshire and Stoke-on-Trent Adults Safeguarding Partnership Board (SSASPB) jointly commissioned a Discretionary Safeguarding Adults Review (D-SAR) to look at Clive's case. Authored by Professor Michael Preston-Shoot, the review relates to historical incidents of abuse and examines what is now in place to protect adults at risk since adult safeguarding became a statutory duty under the Care Act in 2014. The SAR makes 14 recommendations to the boards.
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Content ArticleThis toolkit is a practical guide for system leaders that will help to inform future spending on health inequalities and support implementation of high-impact changes within integrated care boards (ICBs) to address health inequalities. It aims to build system leaders’ confidence in their ability to tackle inequalities in their organisations and is accompanied by a research report that looks at the approaches systems took to spending health inequalities money. It is structured in line with the four main stages of quality improvement methods: Culture, leadership and governance Understanding the problem Developing the best solution Evaluating success
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Content ArticleThis report is a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001). It finds that diagnosis, and in particular the occurrence of diagnostic errors, has been largely unappreciated in efforts to improve the quality and safety of healthcare. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, healthcare organisations, patients and their families, researchers and policy makers. The report's recommendations contribute to the growing momentum for change in this crucial area of healthcare quality and safety.
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Content ArticleComputerised provider order entry (CPOE) prompts can provide patient-specific risk estimates for multidrug-resistant organisms (MDROs). This JAMA Network study aimed to find out whether CPOE prompts could reduce empiric extended-spectrum antibiotic use in patients admitted with pneumonia. The authors found that prompts promoting standard-spectrum antibiotics for patients at low risk of infection with MDROs reduced extended-spectrum antibiotic use by 28.4%, without increasing intensive care unit transfers or length of stay for patients with pneumonia.
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This virtual launch event celebrates the ARMA report Act Now: MSK Health inequalities and deprivation. • Hear about the findings of the report and what they mean for health services and healthcare professionals. • How does deprivation relate to MSK health? • What are the 5 steps to addressing health inequalities and what do they look like in practice? • What are the particular issues for children and young people? • What can you do to create change if you act now? Join the discussion with the panel: • Anthony Gilbert, Postdoctoral Clinical Research Physiotherapist, Royal National Orthopaedic Hospital NHS Trust • Shabir Aziz, Lived Experience Partner • Lesley Kay, National Clinical Director for MSK, NHS England • Jacqui Clinch, Consultant Paediatric Rheumatologist Register for the event -
Content ArticleThe Patient and Carer Race Equality Framework (PCREF) was a recommendation following the national Mental Health Act Review in 2018. This video by South London and Maudsley NHS Foundation Trust (SLAM) explains PCREF and how it is being applied at the Trust.
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Good health should be shared with all. It should not be damaged by social or economic disadvantage. Shared Health Foundation is inviting any GP or clinical lead who is working in the deep end of medicine to join its annual Doctors in Deprivation Training Day. The day aims to inspire, challenge, encourage and most importantly help participants find their tribe of other clinicians working in areas of deprivation. The training day will explore the challenges faced by those working in areas of deprivation and disadvantaged communities and share the hopeful work organisations in Greater Manchester and beyond are doing to reduce health inequalities and the impact of poverty on health. Attendees will: get to grips with the health inequalities that many people face, and how they can help put things right. learn about the causes and effects of health inequalities find out about the ways in which GPs and healthcare staff can do their bit to make a difference. Tickets to the training day are free of charge. Sign up for the training day -
Content ArticlePublic confidence in the NHS is at an all time low and even when people can access the service, national surveys tell us that their experiences of NHS services are deteriorating. The authors of this blog—Patients Association Trustee Alf Collins and Health Consultant Richard Sloggett—make a simple plea: that all aspects of patient experience is taken seriously. They argue that the care backlogs and levels of unmet need require a radical re-orientation of the relationship between the Government, the health system and the public, and that this needs to involve a complete step-change in how patients are engaged in their care.
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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 -
Content ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleIn 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.
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Content ArticleHow 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.
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Content ArticleThe 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.
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Content ArticleThe 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.
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Content ArticleThis 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. 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 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.
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Content ArticleThis 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.
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Content ArticleIncident 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.
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Content ArticleLots of helpful information about health and medical science is available on the internet, often found via search engines and social media. However, some online health information is false and misleading—this is called health misinformation. Health misinformation can be harmful and can be hard to recognise, as the information may appear to come from an official or safe source. This article by US-based doctor Kelly Johnson-Arbor provides advice on how to recognise health misinformation, where misinformation comes from and why it can be harmful. The author goes on to explain ways to look for reliable health information.
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Content ArticleSurgical 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.
