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Content ArticleThis article in USA Today looks at how the Covid-19 pandemic has caused setbacks in hospitals' patient safety progress. It looks at data from a report by the US non-profit health care watchdog organisation, Leapfrog, which show increases in hospital-acquired infections, including urinary tract and drug-resistant staph infections, as well as infections in central lines. These infections spiked during the pandemic and remain at a five-year high. The article also looks at the case study of St Bernard Hospital in Chicago, which was rated poorly by Leapfrog on handwashing, medication safety, falls prevention and infection prevention, but then made huge progress in improving safety. It describes the different approaches and interventions taken by St Bernard.
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Content ArticleDuring the first waves of the Covid-19 pandemic, the UK shielding policy was introduced with the intention to protect people at the highest risk of harm from Covid-19 infection. This study in the journal Public Health aimed to describe intervention effects in Wales at one year. The authors retrospectively compared linked demographic and clinical data for cohorts of people identified for shielding from 23 March to 21 May 2020 with the rest of the population. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). The study found that: Deaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders, but lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.
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Content ArticleThe Relatives and Residents Association (R&RA) is conducting a survey which aims to gather evidence on the impact of the Covid-19 pandemic on access to healthcare services for those living in care homes. R&RA is seeking responses from people who were living in care homes at any point during the pandemic, or from their relatives and friends. Our analysis of the responses will be shared with the UK Covid-19 Inquiry, including anonymised examples. The survey should take around 10-15 mins to complete.
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Content ArticleWhen something goes wrong in health or care, patients need to understand their rights to complain and seek resolution. The Equality Advisory Support Service Helpline (EASS) supports individuals who wish to achieve an informal resolution when they feel they have experienced discrimination or want to understand their human rights. This article, written by the EASS for The Patients Association, explains an individual's rights under the Equality Act 2010 and what to do if you believe they’ve been violated.
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EventuntilGlobal healthcare sectors contribute significantly to climate change. Healthcare makes up more than 4% net global climate emissions. If it were a country, it would be the fifth-largest climate polluter on the planet. Most health sector emissions, up to 70% are embedded in the supply chain, including pharmaceuticals and medical devices. In globalised supply chain contexts, it would not be wise for any single nation to set standards that few others intend to follow. Now that the UK is a single market in a global marketplace, it is more important than ever that the UK’s leaders find consensus among their peers before ushering in new supplier rules and regulations. Without international alignment, the UK risks multinational corporations retreating from the NHS while start-ups and small to medium enterprises become internationally uncompetitive. This session will explore how the decarbonisation of the NHS supply chain is going from NHS and industries perspectives. Speakers will include: Ian Milimo, Project Manager, United Nations Development Programme Lisa Dittmar, Net Zero and Sustainable Supply Chain Lead at NHS England Sign up for the webinar
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EventuntilWhat does it take to successfully implement an award-winning virtual ward? This webinar from GovConnect looks at Leicester Glenfield’s AF virtual ward for cardiovascular disease monitoring and uncovers how the ward was built, assesses the patient recruitment process and explores the meaningful relationships made along the way. Stella Vig will speak to the pioneering clinicians behind the award-winning virtual ward to discuss how they created a secure clinical pathway centred around patients to deliver ground-breaking virtual care. The webinar will increase understanding of the benefits and insights of patient engagement in integrated care and how it can lead to effective digital transformation. It will also explore how medical data was gathered using transformative tech-enabled devices, the challenges and results of a multidisciplinary approach, and the technologies available to support remote patient monitoring. In the webinar you will learn about: How to implement a successful, secure, and scalable virtual ward The challenges and results of a multidisciplinary approach The technology available to support patients from the comfort of their home Register for the webinar
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Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist -
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. Beverley talks to us about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. -
Content ArticleSignificant Event Audit (SEA) ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided. This guidance from the Royal College of General Practitioners (RCGP) aims to enable primary care teams to conduct an effective SEA with the aim of improving care for all patients.
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Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content ArticleIn 2002, a dedicated group from Pennsylvania passed the Medical Care Availability and Reduction of Error (MCARE) Act, the most robust state-level legislation of its kind. Its legacy remains 21 years later. In this interview with the journal Patient Safety, Pennsylvania's Patient Safety Authority chair, Dr Nirmal Joshi, discusses ways care has improved, what challenges persist, and how to achieve the unachievable—true culture change.
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Content ArticleThis briefing by the NHS Confederation provides overview and analysis of the health and care bill.
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Content ArticleMedical equipment, supplies, and devices (ESD) serve a critical function in healthcare delivery and how they function can have an impact on patient safety. ESD-related safety issues include malfunctions, physically missing ESDs, sterilisation and usability. Describing ESD-related safety issues from a human factors perspective that focuses on user interactions with ESDs can provide additional insights to address these issues. This article in the journal Patient Safety reviewed ESD patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System to identify ESD-related safety issues.
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Content ArticleThis book published by the US Food and Drug Administration (FDA) looks at risk communication—the communication approach used for situations when people need good information to make sound choices. It is distinguished from public affairs (or public relations) communication by its commitment to accuracy and its avoidance of spin. Effective risk communication between healthcare professionals and patients is important to ensure patient safety, and in various chapters of the book, the authors look at how to maximise effective communication in healthcare scenarios.
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Content ArticleTargets have been applied to a wide range of public services over the past 40 years. This report analyses whether targets improve the performance of public services and the reasons for this, making recommendations on when and how government should set targets. It focuses on national targets and examines what evidence there is for how they have affected how efficiently public money is turned into outcomes for the public.
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Content ArticleThe CVDPREVENT Audit has published its third annual audit report covering the audit period up to March 2022. The report provides insight into the impact of the Covid-19 pandemic on primary care services, when diagnosis and management of hypertension were significantly disrupted. It also compares the national position against key ambitions identified as milestones for the prevention of cardiovascular disease (CVD) and the detection and management of atrial fibrillation, blood pressure and cholesterol. It also includes findings relating to diagnoses of chronic kidney disease and diabetes, lifestyle and health inequalities, as well as a number of recommendations to support the prevention of cardiovascular disease.
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Content ArticleChairs and non-executives are an important NHS leadership group. As independent board members, they hold the executive to account and in doing so build patient, public and stakeholder confidence in the NHS. This report by the Independent Taskforce on Improving Non-Executive Director Diversity in the NHS explores the steps needed to strengthen the diversity of NHS boards in England. Read a shorter summary of the report
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Content ArticleThis engagement document is focused on the role of integrated care partnerships (ICPs) within statutory arrangements for integrated care systems (ICSs). It has been jointly developed by the Department of Health and Social Care, NHS England and NHS Improvement and the Local Government Association (LGA). This document focuses on the role of ICPs within systems. ICPs are a critical part of ICSs and the journey towards better health and care outcomes for the people they serve. The ICP will provide a forum for NHS leaders and local authorities to come together, as equal partners, with important stakeholders from across the system and community. Together, the ICP will generate an integrated care strategy to improve health and care outcomes and experiences for their populations, for which all partners will be accountable.
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Content ArticleIn this article, Professor Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), outlines an NES research project which aimed to critically review the safety-related content, language and assumptions of a small but diverse range of health and care safety learning reports, policies, databases and curricula.
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Content ArticleIn this blog, interdisciplinary humanistic, systems and design practitioner Dr Stephen Shorrock explores the dangers of project leaders relying on assumptions about work-as-imagined, detached from the reality of contextualised work-as-done. He describes his experience working on a project in which he discovered that operational staff felt anxious and unprepared for the major changes to come. This was unacknowledged by management, and he ascribes their lack of awareness to a failure to physically and empathetically engage with the workers in the reality of the processes and systems management had designed. He highlights the importance of empathy and asks the question, "In your worlds, how connected are managers and other non-operational specialists with operational staff and the operational environment, where changes ultimately end up? Those who wish to support operational staff through change must take the role of pupil, or apprentice – not master."
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Content ArticleAlarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment or intervention. They play a critical safety role in high-risk industries such as healthcare, which relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. The automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. This study in the journal Patient Safety aimed to assess whether these guidelines may provide insights for advancing patient safety in healthcare.
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EventuntilThis online session will explore the purpose of clinical audit and then compare and contrast this with the key principles of a quality improvement approach. With this foundation we’ll then discuss how these approaches are complementary as part of a holistic approach to improving quality of health and care. Some NHS organisations are already on a journey to a more integrated approach to clinical audit and quality improvement, and we hear about the journey underway at Sherwood Forest Hospitals NHS Foundation Trust. It would be great to hear about your journeys with clinical audit and quality improvement too. This session will be presented by Nikki Davey, from Quality Improvement Clinic Ltd, and Craig Short, from Sherwood Forest Hospitals NHS Foundation Trust. Register for the webinar
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Content ArticleThis report by the National Paediatric Diabetes Audit (NPDA) is based on data from 33,251 children and young people receiving care from a paediatric diabetes unit (PDU) in 2021/22 in England and Wales. It found that the increase in incidence of Type 1 diabetes observed in the first year of the Covid-19 pandemic was followed by a continuing increase in the numbers of children newly diagnosed with the condition in 2021/22. Other key findings include: Almost all of those with Type 2 diabetes were overweight or obese, and almost half had a diastolic or systolic blood pressure in the hypertensive range. Despite reductions in the percentages recorded as requiring additional support between 2020/21 and 2021/22, over a third of children and young people were assessed as requiring additional psychological support outside of multidisciplinary meetings. Inequalities persist in terms of the use of diabetes related technologies in relation to ethnicity and deprivation.
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Content ArticleThis report is the Falls and Fragility Fractures Audit Programme's (FFFAP's) State of the Nation Report 2022 for Wales. It examines how the care of inpatient falls and fragility fractures has changed since 2020, highlighting what the audit reveals about the quality of patient care and the impact of the Covid-19 pandemic. The report used three sources of data and concludes with a number of recommendations around the care of people with hip fracture, preventing inpatient falls, and preventing future fractures.
