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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Achieving shared interpersonal understanding between healthcare professionals, patients and families is a core patient safety challenge around the world. The SACCIA model promotes safe communication practice amongst healthcare teams and between providers patients. It was developed by Professor Annagret Hannawa, Director of the Center for the Advancement of Healthcare Quality & Safety in Switzerland. The interpersonal processes that are captured in the SACCIA acronym are considered 'safe' because they lead to a shared understanding between all care participants: Sufficiency Accuracy Clarity Contextualization Interpersonal Adaptation The five SACCIA competencies emerged from a communication science analysis of hundreds of critical healthcare incidents. They were identified as common deficient interpersonal processes that often cause and contribute to preventable patient harm and insufficient care. They therefore represent an evidence-based set of core competencies for safe communication, which constitute the vehicle to patient care that is safe, efficient, timely, effective and patient-centred.
  2. Content Article
    This Newsnight report looks at the case of Rebecca Wight, an advanced nurse practitioner who raised concerns about a colleague at at Manchester’s Christie cancer hospital and felt her treatment by Trust management as a whistleblower was poor. She is now taking The Christie to an employment tribunal for constructive dismissal. The video also features an interview with Helené Donnelly, a nurse who tried to raise the alarm more than 100 times at Mid Staffs and went on to be a key witness in the subsequent Francis inquiry. She calls for failing NHS managers to be struck off, highlighting that a decade on from one of the worst failings in NHS history, those raising concerns were still not being listened to.
  3. Content Article
    A recent report found that a third of female surgeons have been sexually harassed at work. In this opinion piece, Dr Liz O’Riordan speaks out about the abuse she suffered from male colleagues while working for the NHS. She describes her experiences, highlighting that incidents of sexual harassment are common amongst female surgical trainees who fear speaking out as it may affect their careers. She also draws attention to the fact that it is not just an issue amongst surgeons, but that many other healthcare professionals experience inappropriate sexual comments and behaviour while at work.
  4. Content Article
    The Acute Frailty Network (AFN) was a scheme run in England by NHS Elect, using an approach called Quality Improvement Collaboratives (QICs), to help trusts implement principles of Comprehensive Geriatric Assessment (CGA) as part of their acute pathway. In July 2023, Street et al published a paper in BMJ Quality and Safety analysing the impact of the AFN which concluded that there was no difference in length of hospital stay, in-hospital mortality, institutionalisation and hospital readmission between organisations that took part in AFN and those that did not. This article outlines the position of the British Geriatrics Society (BGS) on the paper, addressing why it thinks that focusing on older people’s healthcare is more important than ever. It highlights the importance of ensuring that the paper's findings are not used as a reason to abandon efforts to improve acute frailty care. Rather, they should be seen as a call to redouble efforts to identify and overcome the barriers to delivering CGA in acute settings.
  5. Content Article
    As awareness of the importance of psychological safety in the workplace increases, there is a corresponding increase in the number of psychometric tools, applications and services that attempt to measure psychological safety. This post on the blog Psychological Safety outlines some helpful principles for organisations to apply when choosing a psychometric tool. It lays out the following key principles, stating that in choosing a psychometric tool, we should ensure that we understand the methods and algorithms the tool uses. it’s usable and accessible for everyone. it’s secure. people retain ownership of their own data. the questions and statements actually correlate with psychological safety. it doesn’t make assumptions based upon majority culture. the tool doesn’t create perverse incentives.
  6. Content Article
    In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
  7. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm.
  8. Content Article
    For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviours may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications. This article in JAMA Surgery aimed to assess whether patients of surgeons with a higher number of coworker reports about unprofessional behaviour experience a higher rate of postoperative complications than patients whose surgeons have no such reports. The authors found that  patients whose surgeons had a higher number of coworker reports had a significantly increased risk of surgical and medical complications. These findings suggest that organisations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behaviour toward other medical professionals may increase patients’ risk for adverse outcomes.
  9. Content Article
    The nurse-to-patient ratio represents the number of patients a registered nurse cares for during a shift. Most hospitals have guidelines to ensure safe staffing ratios, but staffing shortages have led to heavier nursing workloads. This article outlines which US states have laws and regulations in place for safe staffing ratios.
  10. Content Article
    How we treat each other at work has an enormous impact on how teams perform—with potentially fatal consequences if you work in healthcare. Chris Turner, consultant in emergency medicine and founder of Civility Saves Lives, reveals the shocking impact of rudeness in the workplace. He highlights the importance of understanding the complex realities of practice and communication between healthcare professionals in different team environments, if we are to learn from patient safety incidents.
  11. Content Article
    The Patient Safety Network (PSNet) produces primers which provide guidance on  key topics in patient safety through context, epidemiology and relevant PSNet content. This primer focuses on nurse-related medication administration errors and highlights that despite error reduction efforts through implementing new technologies and streamlining processes, medication administration errors remain prevalent. It covers the background to the issue, low-tech and high-tech prevention strategies and the current context.
  12. Content Article
    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. James talks to us about the value of patient feedback in boosting morale and enabling organisations to make real patient safety improvements. He also describes the power of the unique perspective patients have on safety, and asks how we can use this insight to shift culture and provide safer care.
  13. Content Article
    Most US healthcare organisations use staffing guidelines to decide a nurse's patient load on a given shift, but current staffing shortages are pushing nurse-to-patient ratios to the limit. In this article for Nurse Journal, registered nurse Alexa Davidson asks whether laws and regulations could prevent nursing workloads from getting out of control. She argues that mandated staffing ratios are a proven way to ensure patient safety. She describes the situation in Massachusetts and California, the two US states where laws have been passed mandating nurse-to-patient ratios, and outlines the implications of introducing ratios for nurses and patients.
  14. Content Article
    In this consultation, the Department of Health and Social Care (DHSC) is seeking views on the possible introduction of regulations mandating the disclosure of industry payments to the healthcare sector. The consultation concerns the possible introduction of new secondary legislation that would place a duty on manufacturers and commercial suppliers of medicines, devices and borderline substances to report details of the payments and other benefits they provide to healthcare professionals and organisations. This consultation aims to address the second part of recommendation 8 in the Independent Medicines and Medical Devices Safety (IMMDS) Review, regarding real and perceived conflicts of interest in the health system. The proposals will enable respondents to share views on: the information they would need to provide recipients in scope payments that would potentially need to be reported the timing and content of reporting alternatives to regulation. The consultation closes at 11:59pm on 16 October 2023.
  15. Content Article
    The Aviation Safety Reporting System (ASRS) is an important part of the continuing effort by the US government, industry and individuals to maintain and improve aviation safety. The ASRS collects voluntarily submitted aviation safety incident/situation reports from pilots, controllers and others. it analyses and responds to these incident reports to reduce the likelihood of aviation accidents. ASRS data are used to: identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities. support policy formulation, planning for and improvements to the NAS. strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally recognised that over two-thirds of all aviation accidents and incidents have their roots in human performance errors. The ASRS website outlines the purpose and aims of the system, provides details on how to submit reports and lists related research studies and resources.
  16. Content Article
    There is widespread variation in the instance and quality of meaningful patient involvement across the 42 Integrated Care Systems (ICSs) of NHS England. This is seen throughout the structures, policies and processes of the ICSs, from the omission of patient representatives on decision-making bodies—such as Integrated Care Boards (ICBs)—to the neglect of clear consultation when decisions are made concerning a patient’s care. This report present the results of research and analysis conducted by the Medical Technology Group (MTG). It shows that where a patient lives is the biggest determinant to whether they are involved in their care meaningfully, or at all. It makes recommendations for the Government, NHS England and ICS's on the approach that should be taken to ensure meaningful patient engagement.
  17. Content Article
    Patients and families are key partners in diagnosis, but there are few methods to routinely engage them in diagnostic safety. Policy mandating patient access to electronic health information presents new opportunities, and in this study, researchers tested a new online tool—OurDX—that was codesigned with patients and families. The study aimed to determine the types and frequencies of potential safety issues identified by patients with chronic health conditions and their families and whether their contributions were integrated into the visit note. The results showed that probable Diagnostic Safety Opportunities (DSOs) were identified by 7.5% of paediatric and adult patients with underlying health conditions or their families. Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. The most common types of DSOs were patients or families not feeling heard, problems or delays with tests or referrals and problems or delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. The researchers concluded that OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients and families identified DSOs and most of their OurDX contributions were included in the visit note.
  18. Content Article
    The Trade Unions Congress (TUC) is proposing a new care workforce strategy for England, developed with trade unions and informed by the voice and experiences of care workers. This strategy document sets out the critical building blocks to ensure care workers are valued and supported, as a key means of addressing the current staffing crisis and improving access to and quality of social and childcare services.
  19. Content Article
    Leadership within the NHS has never been more critical. The need to support staff, remain resilient to the ongoing operational challenges create space to develop services which are locally responsive and inclusive are all pre-requisites for organisational success. However, for every leader there is also the need to know when it is time to move on, and the system can make that easier (or harder) to recognise and to act on. In this blog for BMJ Leader, Aqua’s Chief Executive Sue Holden looks at the issues facing senior NHS leaders who are having to function in ever-changing structures and a shifting culture. She asks whether innovative approaches to roles and contracts would allow the NHS to retain their skills and experience, while allowing new leaders to come through to senior positions.
  20. Content Article
    This is one of a series of 'Learning from safety incidents' resources published by the Care Quality Commission (CQC). Each one briefly describes a critical issue—what happened, what the CQC and the provider have done about it, and the steps you can take to avoid it happening in your service. This edition is about ensuring the safety of people using wheelchairs in health and social care. The CQC recently prosecuted a care home provider for exposing someone using their service to a significant risk of avoidable harm, which resulted in a life-changing injury.
  21. Content Article
    Learn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. The resources have been designed, together with people who have experienced patient safety incidents and investigations, to provide the information and support patients might need following a patient safety incident. Information is provided in a range of formats including downloadable guides, videos and infographics. The site also provides information and resources for engagement leads. Learn Together is a partnership between Sheffield Hallam University, the University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford District Care NHS Foundation Trust, Leeds and York Partnership NHS Foundation Trust and York and Scarborough Teaching Hospitals NHS Foundation Trust, and is funded by the National Institute for Health and Care Research (NIHR).
  22. Content Article
    In this article for Health Services Insight, NHS consultant David Oliver examines why most comments on articles in the Health Services Journal (HSJ) are posted anonymously. He highlights that this tendency towards anonymity from commenters who are clearly in influential, senior NHS posts, indicates that the culture in the NHS management community, from NHS England down, is one that makes most people fearful of saying anything in their own name in case of reprisal. He also points out that a culture where people are afraid to make comments and criticisms in their own name is in conflict with the Nolan Principles of 'selflessness', 'integrity', 'objectivity', 'accountability', 'openness', 'honesty' and 'leadership' that senior NHS managers and officials are supposed to be guided by.
  23. Content Article
    In the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals. NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.” But will they? In this BMJ opinion piece Alison Leary, professor of Healthcare and Workforce Modelling at London South Bank University, looks at why the NHS has failed to learn lessons from patient safety tragedies spanning the last fifty years. She highlights that unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work. This includes a failure to see the value in retaining experienced staff and a hierarchical approach to the value of work. She also outlines that more focus should be placed on management listening, rather than on staff having to find the courage to speak up when they have concerns: "When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture."
  24. Content Article
    In 2011, the government acknowledged a large treatment gap for people with mental health conditions and sought to establish ‘parity of esteem’ between mental and physical health services. From 2016, the Department of Health & Social Care (DHSC) and NHS England made specific commitments to improve and expand NHS-funded mental health services. NHSE, working with the Department and other national health bodies, set up and led a national improvement programme to deliver these commitments. This report by the House of Commons Public Accounts Committee assesses progress made in delivering these commitments. The report acknowledges that NHS England has made progress in improving and expanding mental health services, but says this was "from a low base."
  25. Content Article
    In this interview for Times Radio, Sir Robert Francis KC, who led the 2010 inquiry into failures in care at Mid Staffordshire NHS Foundation Trust, discusses the benefits and disadvantages of statutory and non-statutory inquiries. In light of Lucy Letby's conviction for the murder of seven babies under her care while she worked as a NICU nurse, he also talks about how poor organisational culture can lead to staff covering up patient safety concerns.
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