Patient-Safety-Learning
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Everything posted by Patient-Safety-Learning
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Content ArticleThis is the second in a series of investigations exploring why medications intended to be provided to patients were not provided. Patients who need medications can suffer harm if these are not provided. This investigation explored the systems and processes in place to support staff when a patient who is usually taking an anticoagulant undergoes a procedure. An anticoagulant is a medication that reduces the ability of a patient’s blood to clot. The investigation also explored the role played by electronic prescribing and medication administration (ePMA) systems and electronic patient record (EPR) systems in supporting care in this area.
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Content ArticleSublingual nitroglycerin (Nitrostat) is a nitrate vasodilator used to treat episodes of chest pain in patients who have coronary artery disease. The tablets are supplied in small, amber bottles that are tightly capped to keep out light, moisture, and air. The loss of potency from environmental exposure often prevents repackaging of the tablets from a multidose bottle into single doses. Therefore, without single doses pre-packaged ahead of time and proper safeguards to warn against the multidose bottle, an overdose of up to 25 times the intended dose can occur. This study examines reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing unintended dispensing and administration of whole bottle contents. These incidents have resulted in patients needing to be resuscitated and transfer to a higher level of care.
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Content ArticleSara Riggare has had Parkinson's disease for nearly forty years. In this BMJ blog, she highlights the importance of trust and dialogue when making treatment decisions. Sara describes a recent interaction with a doctor to illustrate why listening to patients' concerns and answering their questions is vital to building mutual trust.
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Content ArticleThe Patient Experience Agency is an Australian consultancy that aims to change the approach of healthcare providers towards delivering exceptional patient experiences. They want to see a healthcare sector in Australia that works in partnership with its patients, embraces a team-based, data-driven approach, constantly monitors experiences and outcomes and uses patient insights to continuously improve.
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Content ArticleIn this BMJ Leader article, Stephen Swensen outlines the concept of 'The Kind Organisation'—an organisation that prioritises the workforce’s mental, physical, social and spiritual wellbeing. He argues that when organisations help their people do better, patients get better experience and outcomes, and the organisation's financial results improve. The article describes how an integrated systems approach that cultivates staff agency, coherence, belonging and positivity is needed for the best work environment. It outlines nine validated actions that improve staff well-being are presented.
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Content ArticleThis study investigated burnout and sources of stress related to the Covid-19 pandemic among a group of healthcare risk managers and patient safety practitioners. An online survey asked the open question, "Since the start of the Covid-19 pandemic, what work or non-work-related issues have been causing you the most stress?" The results showed that burnout and pandemic-related stress were very common in the healthcare risk management and patient safety workforce. Stressors included: the impacts of social distancing. changing duties and workload. real and potential impacts of the virus (for example, fear of infection for self or others). financial concerns (personal and organisational). untrustworthy and constantly changing guidance. feeling abused by persons in power. positive comments about the experience of working during the pandemic.
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Content ArticlePatient-reported measures provide a comprehensive, real-life understanding of patients’ care, essentially “telling the story” that data sources often miss. While conventional metrics offer only snapshots of safety events, patient-reported experiences (PREs) and patient-reported outcome (PROs) capture the lived experience of patients, shedding light on patterns and opportunities for improvement that might otherwise go unnoticed. This blog looks at an innovative project which aims to redefine how patient feedback shapes patient safety and diagnostic excellence. Project PIVOT is organised by Patients for Patient Safety US, an emerging coalition of patients, patient groups and other key stakeholders committed to safer care.
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Content ArticleIn this BMJ article, Mala Rao, director at the Ethnicity and Health Unit and Imperial College London, and Victor Adebowale, Chair of NHS Confederation, share their perspectives on whether racism has improved in the NHS and UK medicine since 2020.
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Content ArticleASSIST ME is a model for staff support following patient safety incidents in healthcare, developed by the National Open Disclosure Programme of the Irish Health Services Executive. This booklet aims to provide practical information and guidance for health and social care managers and staff about: understanding the potential impact of patient safety incidents on staff. recognising and managing the associated signs and symptoms. supporting staff following patient safety incidents. providing information on the support services available to staff.
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Content ArticleIn this Health Services Journal article, Alastair McLellan looks at the financial planning challenges facing Daniel Elkeles as he takes up the position of Chair of NHS England. The article suggest that NHS Providers should prioritise making the challenges facing trusts clear to the Government and NHS England. It also suggests the need for a patient approach to ensure that all parties understand the implications of financial agreements that are made.
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Content ArticleThis guidance sheet developed by Alberta Health Services in Canada offers advice for people supporting healthcare staff who have been involved in serious adverse events. It also describes the impact these incidents can have on 'second victims'—staff involved in errors and patient safety incidents who may develop serious mental health impacts as a result of the experience.
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Content ArticleThe immediate release of test results to patients via patient portals is required. However, pathology reports contain complex medical terminology, are not written for patients and are often read by patients before discussion with a healthcare professional. Whether patients can extract relevant diagnostic knowledge from these reports is unclear. To address this challenge, US researchers have designed patient-centred pathology report (PCPR) formats, which present the most important clinical data from the pathology report in plain language. Pathologists can generate PCPRs as a supplement to their standard report using a template in a few minutes. However, no previous study has directly compared PCPRs with standard report formats in current use. This study compared diagnosis knowledge and worry among adults presented with different formats of prostate biopsy reports.
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Content ArticleThis blog tells the story of Sarah,* whose baby was stillborn due to negligent maternity care. Sarah also suffered from severe, permanent injuries in labour which led to her decision to leave the UK. Sarah was admitted to a leading London maternity unit, but staff failed to recognise that she was in active labour. Lack of appropriate care and monitoring led to her baby dying in the womb. Once her baby's death had been confirmed, Sarah was then left to deliver without support for seven hours, which left her with permanent injuries. The article describes the findings of the trust's internal investigation and the negligence claim Sarah and her partner are pursuing. *not her real name
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Content ArticleThe use of digital health portals, including websites, apps and online consultations, has expanded. The pandemic and increasing public acceptance of digital tools has driven this change. However, this has also led to inconsistency in definitions, language and terminologies used within them, and there is also a significant variation in their functionality. This research by the Professional Record Standards Body (PSRB) and the Patient Information Forum (PIF) aimed to understand the current use of portals and the barriers to increasing engagement for people with long-term conditions to manage their own care better using existing tools and new innovations in the future.
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Content ArticleGovernments worldwide have sought to reform the delivery of public services by mimicking private sector governance models that grant top directors greater autonomy, give them responsibility for meeting key government targets and reward performance with respect to these targets. This paper examines a central plank of this approach–that directors can impact the organisations they run–in the context of English public hospitals, complex organisations with multi-million turnover. The authors find little evidence of top directors’ impact on hospital performance, though estimated differences in pay suggest that the directors are perceived to be differentiated by the market. The results question the effectiveness of blindly mimicking the private sector to bring about improvements in public sector performance.
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Content ArticleIn this blog, Sarah Clark, Research Communications Manager at THIS Institute, looks at the ongoing challenge of trying to improve access to GP services for patients. She reflects on analysis by THIS Institute and the Health Foundation which identified what we called a “zombie solution”—where some options are revisited time and time again even though they never seem to make a real difference for patients. She looks at the issue and how to move beyond this pattern.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)There are many definitions of therapeutic empathy, which sometimes contradict each other. This leads to variation in how the concept is practiced, taught, and researched. This study analysed therapeutic empathy definitions, finding six common components: exploring understanding shared understanding feeling therapeutic action maintaining boundaries.
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Content ArticleDoctors in the US report fear of liability risk and the need to practice “defensive medicine.” In 2024, the American Law Institute revised the legal standard for assessing medical negligence. Understanding the implications of this change is crucial for balancing patient safety, doctor autonomy and the legal system’s role in health care. This JAMA article examines the new standard of care, seeing it as a shift away from strict reliance on medical custom as it invites courts to incorporate evidence-based medicine into malpractice law. Although states may adopt the recommendations from the American Law Institute at different times and to varying degrees, the restatement offers healthcare professionals and the organisations in which they practice an opportunity to reconsider how medical negligence will be assessed, and to focus more directly on promoting patient safety and improving care delivery. Nonetheless, doctors should recognise that, at least for now, many courts will continue to rely significantly on prevailing practice in assessing medical liability.
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Content ArticlePatient-Reported Indicator Surveys initiative (PaRIS) was set up by the Organisation for Economic Co-operation and Development (OECD) to allow countries to work together on developing, standardising and implementing a new generation of indicators that measure the outcomes and experiences of healthcare that matter most to people. The PaRIS survey aims to fill a critical gap in primary healthcare by asking about aspects like quality of life, physical functioning, psychological well-being and experiences of healthcare. This website explains how PaRIS works and provides access to research outputs.
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Content ArticleThe Self-Care Forum and Imperial College London's Self-Care Academic Research Unit (SCARU) collaborated on a major research project to study people’s perspectives on self-care. The ‘Living Self-Care Survey’ collected data from 3,255 UK residents including 227 health & care professionals. This infographic shows five key messages from the research.
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The University of Manchester's Christabel Pankhurst Institute, supported by ARC-GM, is running a programme of work around digital health inequities. As part of this, it is hosting a seminar series about the topic with speakers from different disciplines who have done exemplary research on understanding, identifying, or addressing digital health inequities. This seminar in the Digital Health Inequities Seminar Series is “Cross-pollinating Knowledge on Digital Health Equity: Lessons from Two Countries” with Ibukun Abejirinde from Canada and Nicole Goedhart from the Netherlands. The webinar will start with a conversation between Ibukun and Nicole on their research programs and collaborative projects in digital health equity, followed by a 20-minute presentation delivered by Nicole on her project “Doing eHealth Right”. This will be followed by an open discussion including attendees around bridging the digital divide in healthcare and how strong collaborative networks can chart a way forward. Register for the webinar -
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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 consultant endocrinologist Gordon Caldwell, who retired early from the NHS after speaking up about patient safety concerns in his hospital. Gordon shares his experience of raising concerns about unsafe staffing levels while working as a clinical lead and how this led to extreme stress and the decision to retire years before he had planned to. They discuss the importance of transparency, team work and clear record-keeping processes to ensure patients are kept safe and Gordon outlines how lack of accessible patient health records hinders decision-making and can lead to avoidable harm. They also look at how target-led approaches and financial incentives have led to cultural changes in healthcare organisations over the past few decades. 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 -
Content ArticleThis study aimed to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. The authors developed a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.
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Content ArticleUnderstanding the effects of Covid-19 infection and vaccination during pregnancy can help inform clinical guidance and overcome concerns about vaccine safety. This study examined relationships between Covid-19 infection during pregnancy, Covid-19 vaccination during pregnancy and early child developmental concerns in children aged 13–15 months in Scotland. The study found that Covid-19 infections during pregnancy do not appear to be linked to early childhood developmental concerns and vaccinations during pregnancy appear to be safe from the perspective of early childhood developmental concerns. As some developmental concerns do not become apparent until children are older than 13–15 months, the authors recommended that future research continue to monitor outcomes as children grow and develop. You will need to sign up for a free Lancet account to view this article.
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Content ArticleThis report was produced by retired judge Sir Anthony Hooper, who was invited to carry out an independent review of how the General Medical Council (GMC) engages with whistleblowers who have raised concerns in the public interest. The report examines: Patient safety, the duty to raise concerns and the duty of candour Reprisals against those who raise concerns Legal framework of the GMC Recommendations on the handling of referrals in circumstances where the doctor has raised concerns The handling of cases involving those who have reported concerns to the GMC
