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Content ArticleFatigue refers to the issues that arise from excessive working time or poorly designed shift patterns. It is generally considered to be a decline in mental and/or physical performance that results from prolonged exertion, sleep loss and/or disruption of the internal clock. Fatigue results in slower reactions, reduced ability to process information, memory lapses, absent-mindedness, decreased awareness, lack of attention and underestimation of risk. It can lead to errors and accidents, ill-health and injury, and reduced productivity and is often a root cause of major accidents. This guidance from the Health and Safety Executive (HSE) outlines key information about fatigue and signposts to further resources about managing fatigue at work.
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Content ArticleThis report was produced by NHS Digital to investigate activity in the NHS in England surrounding patients who have had a procedure for the treatment of urogynaecological prolapse or stress urinary incontinence, including those where mesh, tape or their equivalents have been used. The report uses Hospital Episode Statistics (HES) data and was undertaken to help the NHS and others establish a clearer national picture of patients who have had these procedures. NHS Digital notes that these statistics are classified as experimental and should be used with caution. Experimental statistics are new official statistics undergoing evaluation.
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Content Article
‘Human factors’ is the science of improving performance by understanding individual or team behaviour and cognitive biases. This can allow a redesign of clinical systems and environments to improve patient safety. This course aims to help healthcare professionals understand human factors in complex healthcare setting and can be delivered as a full day, half day or a conference talk. It was developed by Professor Robert Galloway, Emergency Medicine Consultant at University Hospitals Sussex NHS Trust. The course covers: the principles of ‘human factors’–why errors occur. human cognitive biases (in memory, reasoning, decision-making). practical skills and tools to improve individual/team performance and patient safety. You can email Rob Galloway for more information on booking this course. -
Content ArticleThese prompt cards were developed by a team at University Hospitals Sussex NHS Foundation Trust to assist emergency department teams in dealing with: medical emergencies trauma transfers and briefings anaesthetics and resuscitation procedures medications clinical scores.
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Content ArticleThis video and written summary from the Institute of Health and Social Care Management (IHSCM) look at the principles of running virtual wards, where patients are monitored and cared for in their own homes with the help of remote treatment options and supported by technology. Hosted by health policy analyst Roy Lilley, speakers include: Professor Alison Leary Elaine Strachan-Hall Steph Lawrence Alexandra Evans Dr Elaine Maxwell
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Content ArticleThis study in the British Journal of Nursing aimed to explore whether fatigue, workload, burnout and the work environment can predict the perceptions of patient safety among critical care nurses in Oman. A cross-sectional predictive design was used on a sample of 270 critical care nurses from the two main hospitals in the country's capital, with a response rate of 90%. The authors found a negative correlation between fatigue and patient safety culture (r= -0.240), which indicates that fatigue has a detrimental effect on nurses' perceptions of safety. There was also a significant relationship between work environment, emotional exhaustion, depersonalisation, personal accomplishment and organisational patient safety culture. Regression analysis showed that fatigue, work environment, emotional exhaustion, depersonalisation and personal accomplishment were predictors for overall patient safety among critical care nurses.
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Content ArticleThis systematic review in the Western Journal of Nursing Research examined the relationship between hospital nurse fatigue and outcomes. The authors found that fatigue was consistently associated with mental health problems, decreased nursing performance and sickness absence. Many studies confirmed that nurse fatigue is negatively associated with nurse, patient-safety and organisational outcomes. The review also highlighted gaps in current knowledge and the need for future research using a longitudinal design and measuring additional outcomes to better understand the consequences of nurse fatigue.
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Content ArticleIn this video, Leah Coufal’s mother, Lenore Alexander, recounts the tragic story of her 12-year-old daughter’s preventable death in hospital in December 2002. Leah died from opioid-induced respiratory depression due to a lack of continuous postoperative monitoring which could have saved her life. Lenore now campaigns for the legal requirement to monitor patients on opioids after surgery.
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Content ArticleThis poster produced by researchers at Warwick Medical School summarises a qualitative research project that examined attitudes and behaviours related to patient safety culture at a single West Midlands Trust. The study's objective was to gain an understanding of staff’s views regarding the culture within the Trust and of their attitudes and behaviours when reviewing clinical incidents and mortality and morbidity. The poster was a winner at the HSJ Patient Safety Congress 2022 in the category 'A just culture for learning and change'. Read the full research paper.
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Content ArticleThis article in BMJ Open Quality aimed to improve patient safety by examining the organisational and individual factors that contribute to adverse events, enabling corrective action so that errors are not repeated. Using interviews and observations of Trust meetings at a single Hospital Trust in the Midlands, England, this qualitative study: analysed whether the attitudes and behaviours of clinicians and managers are aligned with a Just Culture. identified barriers and enablers to an organisation adopting a Just Culture. The study found evidence of a fair incident management process within the Trust; however, there was no agreed vision of a Just Culture and the majority of the staff were unfamiliar with the term. Negative perspectives relating to clinical incidents and their management persist among staff with many having concerns about being the subject of an investigation and doubts about whether they drive improvement.
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Content ArticleWhen healthcare workers are fatigued, the safety of both patients and staff is compromised. This short article in the American Journal of Nursing reports on a recent webinar in which the Joint Commission distilled current research on fatigue, discussing its causes and symptoms and the various means of addressing the issue. Ann Scott Blouin, a nurse and Executive Vice President of Customer Relations at the Joint Commission, led the discussion and highlighted that factors contributing to staff fatigue fall into three categories: organisation and management issues, the nature of the work and personal challenges. Fatigue has emotional, physical, and behavioural consequences, including lapses in attention, diminished reaction time, and reduced motivation.
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Content ArticleWhen Covid-19 first struck the UK, the disease was described as 'a great leveller'. But it soon became clear that Covid's impacts were not evenly distributed—we may have been in the same storm, but we were in different boats. In this episode of All in it together, guests Charlotte Augst, Halima Begum, Beth Kamunge-Kpodo, Professor Sir Michael Marmot and Pastor Mick Fleming discuss unequal outcomes during the Covid-19 pandemic.
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Content ArticleThis video shows CCTV footage of Bob being treated for a cardiac arrest on his way to watch a football match at the AMEX stadium in Brighton. The video could be used as a training tool to show how to start cardiopulmonary resuscitation (CPR) and how to use an automated external defibrillator (AED). The video highlights what the AED is analysing and then shocking, showing what happened to the electrical rhythm as it converts ventricular fibrillation (VF) to sinus rhythm. It also features the voice prompts from the cardiac arrest. Bob survived with a completely normal quality of life and was the seventh person (out of seven) at the AMEX stadium to have a cardiac arrest and survive with a normal quality of life. The video shows great team work and human factors interactions between the St John Ambulance volunteers who saved Bob's life, the stewarding team and paramedics.
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Content ArticleThis study by a team at the University of Derby in the British Journal of Anaesthesia used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. The authors found that errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays, a finding that was replicated for correct responses for error-absent trays. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.
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Content ArticleOn 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
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Content ArticleThis article in The Times explains why the Times Health Commission was set up, what it aims to achieve and how it will do this. The year-long commission aims to address the most urgent challenges facing health and social care including the growing pressure on budgets, the A&E crisis, rising waiting lists, health inequalities, obesity and the ageing population. Commissioners will draw up recommendations in ten areas to identify problems and find solutions. The Commission will publish its final report in January 2024.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin. The reference event for this investigation was the case of baby Elliana, who was born at 32 weeks and 1 day via a forceps delivery and then transferred to the Trust’s special care baby unit (SCBU). Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby and a routine blood sample was taken from around two hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team. The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon. Another blood sample was taken when Elliana was two days old and was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon. Over the next two days, Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well. When Elliana was five days old, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken which showed she had a high level of bilirubin in her blood and treatment was started accordingly. Elliana’s bilirubin levels returned to within acceptable levels over the next three days and she was subsequently discharged home.
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Content ArticleThis recording is of the launch of the Health Equity Network (HEN) on 24 January 2023. The HEN aims to roll out practical solutions to reduce health inequalities, and will help organisations and individuals across the public, private and third sectors to connect and collaborate with those working towards similar health equity goals. It will offer opportunities to share work and knowledge and for members to engage with others across the country. Speakers at the event included: Dr. Jessica Allen, Deputy Director of The Institute for Health Equity Dr. Henry Kippin, Managing Director of the North of Tyne Combined Authority Pete Gladwell, Group Social Impact and Investment Director, Legal & General Capital Alan Higgins, Health Equity Network Lead Professor Sir Michael Marmot, Director of the Institute of Health Equity Sign up to join the Health Equity Network online community
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Community Post
Pain during IUD fitting
Patient-Safety-Learning replied to PatientSafetyLearning Team's topic in Women's health
Hi Jenn, I would recommend you go and see your doctor to get your symptoms checked out if you are still experiencing pain. I do hope you can find some relief and answers soon.- Posted
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Content ArticleIt is difficult to monitor compliance to surgical checklists, which is associated with improved patient outcomes. This research study in The Annals of Surgery reported for the first time on the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality. The authors took a retrospective review of prospectively collected ORBB data and measures of checklist compliance, engagement and quality were assessed. ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. This technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.
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Content ArticleIn this article for the Byline Times, Consultant David Oliver analyses claims by media and political commentators about spending, waste and inefficiency in healthcare and proposes a ten point plan to restore services to their 2010 level.
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EventuntilHybrid Event: You can participate In-person at Dubai, UAE or virtually from your home or work. If you're interested in presenting your research work, case studies, experience or thesis, you can submit abstracts through an online submission portal. Program Objectives Highlight programs of research with strong relevance to nursing practice. How nurse educators can reinvigorate/revitalize/reignite their profession to strengthen our communities through inclusion, equality, and mental health support. Explore ways in which practice informs clinical nursing research. Describe examples of nursing research findings that have been meaningfully and successfully translated into practice. To provide opportunities to develop knowledge in nursing field Define the issue of providing nursing/case management services across state lines To foster and enhance collaborations and partnerships with educational, research and clinical institutes. 494977355_Nursing2023Brochure (1).pdf
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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. Angela and Caroline spoke to us about how they are helping healthcare organisations consider sustainability a core part of their work. They reflect on the responsibility of both patients and healthcare professionals to ensure patient safety for future generations. -
Content ArticleIn this interview for The Guardian, Pat Cullen, General Secretary of Royal College of Nursing (RCN), talks about how RCN members are being forced to use food banks, her frustration with the government and how she learned to be a tough negotiator. She discusses the issues that led to nurses balloting to strike—violence, sexual assault, unsafe staffing levels and pay that has not kept up with inflation—and outlines the difficult realities of being a nurse in the NHS. She also describes the negotiations with the Government, who according to Cullen, refused to discuss nurses' pay.
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Content ArticleThis video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.
