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Content ArticleUnpaid carers play a substantial and vital role in meeting social care needs. The care they provide has enormous value, both for the people they care for and for wider society. Many carers experience great satisfaction from their role, and through the help and support they provide to friends and family members they may also reduce the costs of formal social care provision. At the same time, caring responsibilities can come at a high personal and financial cost, despite the 2014 Care Act giving carers the right to receive support. 1 in 5 carers report feeling socially isolated and 4 in 10 report financial difficulties because of their caring role. This report by The Health Foundation aims to explore national data on the number of unpaid carers and trends over time, as well as which groups are more likely to have caring responsibilities and who they provide care for. It gives an overview of the types of support available to carers, and what we know–and don’t know–about how many carers are accessing support.
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Content ArticleThis report is the National Confidential Inquiry into Suicide and Safety in Mental Health's (NCISH) annual report on UK patient and general population data for 2010-2020. It includes findings relating to people aged 10 and above who died by suicide between 2010 and 2020 across all UK countries as well as people under mental health care who have been convicted of homicide, and those in the general population.
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Content ArticleBased on data from January 2019 to December 2021, this report by the Paediatric Intensive Care Audit Network (PICANet) catalogues comprehensive information on referral, transport and admission events. This enables the monitoring of delivery and quality of care in relation to agreed standards, and the evaluation of clinical outcomes to inform national policy in paediatric critical care. It reports on five key metrics relevant to Paediatric Intensive Care services: case ascertainment including timeliness of data submission retrieval mobilisation times emergency readmissions within 48 hours of discharge unplanned extubation in PICU mortality in PICU
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Content ArticleThe Operating Room Black Box (OR Black Box) is a system that collects, stores and analyses a large amount of data from the operating room beyond just surgical video, such as video and audio of the operating room and patient physiology data. In this episode of the Behind the Knife podcast, Dr. Teodor Grantcharov, one of the creators of the OR Black Box, talks about how the technology can be used to enhance surgical training. Using the system for feedback through self-directed review, coaching and integrated AI analysis has changed the way we can learn and teach in surgery, and may have implications for the future of evaluation and assessing credentials.
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Content ArticleEach year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs.
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Content ArticleIn this webinar, Jane O'Hara, Professor of Healthcare Quality and Safety at the University of Leeds, outlines how understanding of the role of patients and families in supporting patient safety has developed over the past few years. She highlights the work of the Yorkshire Quality and Safety Research Group (YQSR) and looks at research demonstrating the role patients and families can play in improving the safety of healthcare systems.
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Content ArticleThe Global Taskforce on WASH in healthcare facilities aims to provide global strategic direction and coordination to the World Health Organization (WHO) and UNICEF and to allow for information exchange and dialogue. The latest World Health Organization (WHO) data show that there are major global gaps in water, sanitation and hygiene (WASH) services in health care facilities: half of health care facilities do not have basic hand hygiene services one in five facilities have no water services one in ten have no sanitation services. WHO and UNICEF convened a series of stakeholder ‘think-tanks’ to discuss barriers to progress, coinciding with the launch of the Global Report on WASH in health care facilities. The Global Taskforce on WASH evolved from these think-tanks, and this webpage includes a link to a synthesis of their work in 2022-23. The purpose of the task force is to: encourage and hold accountable national governments to achieve the objectives established by WHA 72/7 and SDG 3 and SDG 6 reinforce calls for strong health leadership (e.g. mobilising political leaders at global events including G7, G20, UNGA) work at country level to increase demand, financing and integration of WASH in health programming and reporting support greater collaboration with other initiatives (e.g. UHC, Child/maternal health, AMR, climate smart health systems, Hand Hygiene for All).
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Content ArticleThis report by the World Health Organization (WHO) identifies major global gaps in water, sanitation and hygiene (WASH) services. It outlines that: one third of health care facilities do not have what is needed to clean hands where care is provided one in four facilities have no water services 10% have no sanitation services. This means that 1.8 billion people use facilities that lack basic water services and 800 million use facilities with no toilets. Across the world’s 47 least-developed countries, the problem is even greater, with half of health care facilities lacking basic water services. In addition, the extent of the problem remains hidden because major gaps in data persist, especially on environmental cleaning. The report describes the global and national responses to the 2019 World Health Assembly resolution on WASH in health care facilities. More than 70% of countries have conducted related situation analyses, 86% have updated and are implementing standards and 60% are working to incrementally improve infrastructure and operation and maintenance of WASH services. Case studies from 30 countries demonstrate that progress is being propelled by strong national leadership and coordination, use of data to direct resources and action, and the mutual benefits of empowering health workers and communities to develop solutions together. The report includes four recommendations to all countries and partners to accelerate investments and improvements in WASH services in health care facilities: Implement costed national roadmaps with appropriate financing. Monitor and regularly review progress in improving WASH services, practices and the enabling environment. Develop capacities of the health workforce to sustain WASH services and promote and practice good hygiene. Integrate WASH into regular health sector planning, budgeting and programming to deliver quality services, including Covid-19 response and recovery efforts.
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The Hand Hygiene Acceleration Framework Tool (HHAFT) tracks the process that a government has undergone to develop and implement a plan of action for hand hygiene improvement, and assesses the quality of that plan. It helps identify barriers, opportunities and priority actions for accelerating progress towards hand hygiene and drive investment to these plans. This webpage includes a dashboard that captures data from different countries. Use of this common framework allows for cross-country learning and exchange, and helps direct and coordinate global action. -
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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. This week is World Immunisation Week so our Content and Engagement Manager, Lotty, has picked nine resources full of practical advice about vaccination in a range of settings. -
Content ArticleIn this blog, Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson look at the long-term consequences of inadequate regulation and approval of pelvic mesh devices. They argue that regulators and health systems around the world failed to heed the early warnings, which lead to thousands of women being irreversibly harmed. They highlight that as early as 1999, a study of 34 women who had ProteGen mesh implants showed that 50% of mesh devices had eroded through the vaginal wall. Boston Scientific voluntarily recalled 20,000 devices as a result. In spite of this, the FDA continued to approve vaginal mesh devices, citing ProteGen as their predicate device.
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Content Article
A ‘Just Culture’ aims to improve patient safety by looking at the organisational and individual factors that contribute to incidents. It encourages people to speak up about their errors and mistakes so that action can be taken to prevent those errors from being repeated. Adam Tasker and Julia Jones are graduate medical students at Warwick Medical School. They wanted to explore doctors’ perceptions of culture and identify ways to foster a Just Culture, so they conducted a qualitative research study at one of the hospitals where they were doing their medical training. We asked them about why Just Culture is important in the health and care system, and what they discovered from their research. -
Content ArticleSimulation is traditionally used to reduce errors and their negative consequences. But according to modern safety theories, this focus overlooks the learning potential of the positive performance, which is much more common than errors. The authors of this article describe the learning from success (LFS) approach to simulation and debriefing. Drawing on several theoretical frameworks, they suggest supplementing the widespread deficit-oriented, corrective approach to simulation with an approach that focuses on systematically understanding how good performance is produced in frequent simulation scenarios.
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Content ArticleBefore she got Covid-19 in October 2021, Professor Kerstin Sailer, who is 46 and from London, had a busy life as an academic and a mum of two daughters. This article tells Kerstin's story of living with Long Covid and its debilitating symptoms, including fatigue, heart palpitations and chest pain. She describes the 'boom and bust' nature of her symptoms and the impact that this has had on her work and personal life. She also talks about the support she received from a Long Covid clinic and how this has helped deal with some of her symptoms.
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Content ArticleSocial movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organisations that, as voluntary and intrinsically motivated change agents, mobilise around a common cause to improve outcomes through knowledge uptake and sustainability. This article in the International Journal of Nursing Sciences shares a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in healthcare. The authors concluded that social movement action can provide a lens through which to view implementation science. Collective action and collective identity–concepts less frequently canvassed in implementation science literature–can lend insight into grassroots approaches to uptake and sustainability. The concept analysis resulted in the development of the Social Movement Action Framework.
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Content ArticleHindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.
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Content ArticleThis article for Forbes looks at new data suggesting that for almost 70% of people, their manager has more impact on their mental health than their therapist or their doctor—and it’s equal to the impact of their partner. It outlines leadership approaches to improve employees' mental health, including self-management, impact recognition, fostering connection, offering choice and providing challenge.
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Content ArticleThe African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality rate twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. This aim of this study in The British Journal of Anaesthesia was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was developed using data from 8799 patients in 168 African hospitals. It includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The authors concluded that the ASOS Surgical Risk Calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.
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Content ArticleWound care is rarely considered a strategic objective within health and care, but it has considerable impact on patients and on health service resources. In this blog, Ameneh Saatchi, Senior Partnerships and Policy Manager at Public Policy Projects looks at the growing burden of wound care on the health service and what can be done to tackle the problem.
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Content ArticleThe Diabetes Record Information Standard defines the information needed to support a person’s diabetes management. It includes information that could be recorded by health and care professionals or the person themselves that is relevant to the diabetes care of the person and should be shared between different care providers. It was commissioned by NHS England and developed in partnership with the Professional Record Standards Body (PRSB). The Diabetes Self-Management Information Standard defines the information that could be recorded by the person themselves (or their carer) at home (either using digital apps or medical technology, for example, continuous glucose monitors or insulin pumps) and shared with health and care professionals.
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Content ArticlePatient Participation Groups (PPGs) are generally made up of a group of volunteer patients, the practice manager and one or more of the GPs from a practice. PPGs meet on a regular basis to discuss the services on offer, and how improvements can be made for the benefit of patients and the practice. The Patients Association has produced this set of videos and resources for PPGs, including: information on why GP practices and Primary Care Networks need patient groups step-by-step guide to establishing a GP patient group reasons to have a patient group and what’s in it for the GP practice and patients effectively working together in partnership recruitment, increasing diversity and communicating with the wider patient population.
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Content ArticleThe ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
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Content ArticleTo thrive and deliver the best healthcare, healthcare professionals depend on their ability to self-reflect and adapt their working behaviours. This skill is developed through self-awareness, an openness to alternative perspectives, proactively seeking feedback and a willingness to change behaviours as a result of reflecting. Transformative reflection is a type of reflective practice that can transform a person's sense of work-based identity, sense of purpose and how they work, ultimately influencing the collective wellbeing. This guide explains what transformative reflection is, how to create an environment in which it can take place and suggests formats and resources to aid organisations in encouraging transformative reflection.
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Content ArticleBetween 2000 and 2010, multi-year funding increases and a series of reforms resulted in major improvements in NHS performance. However, performance has declined since 2010 as a result of much lower funding increases, limited funds for capital investment and neglect of workforce planning. Constraints on social care spending have also resulted in fewer people receiving publicly funded social care and a repeated cycle of governments promising to reform social care but failing to do so. As a result, the health and social care sector now finds itself facing unprecedented challenges, from increasing demand and growing waiting lists, to a workforce in crisis. This report by Chris Ham, former Chief Executive of The King’s Fund, analyses how a major public service that is highly valued by the public was allowed to deteriorate. It focuses on the period since 2010 and the factors that contributed to the decline of the NHS after the progress that had been made in the previous decade. While the current situation can feel overwhelming, the improvements that occurred between 2000 and 2010 show that change is possible where the political will exists. The paper concludes by setting out what now needs to be done to sustain and reform the NHS, with a focus on spending decisions, moderating demand and sharing responsibility with patients and the public, alongside a long-term perspective.
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Content ArticleSamuel Howes was 17 when he died by suicide in September 2020. Samuel had ongoing mental health issues including anxiety and depression. This led to his use of drugs and dependency on alcohol, which in turn further worsened his mental health. This blog by his mother Suzanne details her experience of the final day of the inquest into her son's death, which found multiple failings on the part of Child and Adolescent Mental Health Services (CAMHS), social services and the police.
