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Content ArticleIntegrated care systems are now legally responsible for leading a localised approach that brings multiple aspects of the healthcare system closer together, and for working better with social care and other public services. However, this is not a new aspiration, so why should it be any different this time? The Nuffield Trust hosted a series of roundtables to discuss concerns with stakeholders and experts to try and understand how to ensure the aims are achieved. This report summarises these findings and offers ways forward as the new era gets underway.
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Content ArticleThis primer article by the Agency for Healthcare Quality and Research (AHQR) looks at the impact of fatigue and sleep deprivation on patient safety. Fatigue is the feeling of tiredness and decreased energy that results from inadequate sleep time or poor quality of sleep. Fatigue can also result from increased work intensity or long work hours. The article outlines the current context for discussions in the US around mitigating the potential risks of sleep deprivation among healthcare workers, highlighting measures that can be put in place by healthcare organisations including employing optimal practices for scheduling, planned napping and ensuring appropriate spaces are available for rest breaks.
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Content ArticleFatigue in anaesthesia practice is often ignored or accepted as the norm due to persistent, high-intensity work demands and expectations. This document produced by the American Association of Nurse Anesthesiology (AANA) aims to provide guidance to healthcare professionals, healthcare facilities and nurse anaesthesia programs regarding sleep deprivation and fatigue. It provides evidence-based information that promotes fatigue management and work-life balance.
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Content ArticleThis systematic review in BMJ Open synthesised evidence on the impacts of insufficient sleep and fatigue on health and performance of physicians in independent practice, as well as on patient safety. The authors also assessed the effectiveness of interventions targeting insufficient sleep and fatigue. The authors found that fatigue and insufficient sleep may be associated with negative physician health outcomes, but concluded that current evidence is inadequate to inform practice recommendations.
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Content ArticleHours of work and other conditions of service are matters for agreement between employers and staff, but it is vital that working patterns are designed to reduce risks from fatigue as much as is practical. This resource from the Office of Rail and Road outlines why the rail industry needs to take staff fatigue seriously, and provides links to key guidance.
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Content ArticleCardiovascular disease (CVD) causes 1 in 4 deaths in England, and is a leading cause of morbidity, disability and health inequalities. The Covid-19 pandemic has added to the urgency of tackling CVD because CVD significantly increases the risk of severe disease and death from Covid-19. This report by The King's Fund looks at published data, literature, policy and evidence on CVD. The writers also carried out interviews and a workshop with key stakeholders working in health and care to inform their research.
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Content ArticleIn 2022, the Co-Production Collective worked with several partners and hundreds of co-producers to try to answer the question, "What is the value of co-production?" The aim of this project was to make the case for the value of co-production for individuals, organisations and society. This webpage contains information about the project and resources about co-production that it has generated, including videos, reports and stories relating to these stages: Survey Rapid critical review Community reporting Pilot projects
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Content ArticleIn this blog, Sarah Douglas explains the impact that working night shifts can have on the body; there is growing evidence that night work contributes to a number of serious health conditions—from heart disease, diabetes and cancer to mental health issues. Sarah shares the vision behind Night Club, an award winning wellbeing programme that brings workers and employers together with sleep scientists to improve the health, wellbeing and engagement of night shift workers. She describes how the programme is helping staff improve their sleep health.
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Content ArticleHealthcare relies on high levels of human performance; however, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. This narrative review in the journal Anaesthesia aims to describe what is known about human factors in anaesthesia to date.
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Content ArticleThis consensus document by The Association of Anaesthetists of Great Britain & Ireland aims to improve patient safety. It is intended to act as a reference document for individuals and departments when considering the effects of hours of work and type of work undertaken in anaesthesia on clinician’s performance and wellbeing.
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EventuntilJoin us to learn how welfare rights advice services are being integrated with healthcare nationwide to tackle poverty and health inequality. This event will be of interest to people working in Integrated Care Systems and public health policy and practice. Taking action on poverty and health inequality is ever more important for the NHS, as the current cost of living crisis increases hardship among communities. The consequences for health and wellbeing will be felt most keenly among low income and vulnerable patient groups. Health justice partnerships are targeted interventions that support patients with social and economic circumstances that are root causes of health inequality. They are partnerships between health services and organisations specialising in welfare rights. Advice on welfare rights issues is integrated with patient care, helping people resolve problems relating to benefits, debt, housing, employment and immigration, among others. This can support those in the hardest circumstances to maximise their health and wellbeing. This one-day in-person workshop is an opportunity to learn about health justice partnerships and how they are being implemented across the country in a range of NHS settings. We will be joined by speakers who are engaged in service delivery, policy and research, who will provide examples and insights from their work. Speakers will include: Professor Dame Hazel Genn, Director of the Centre for Access to Justice, UCL Cedi Frederick, Chair of the NHS Kent and Medway Integrated Care Board Natalie Davis, Head of Legal Support Policy, Ministry of Justice Catherine McClennan, Director of the Women’s Health and Maternity Programme, Cheshire and Merseyside Health & Care Partnership Paul Sweeting, Insight and Performance Partner, Macmillan Cancer Support Refreshments are provided and there will be opportunities for discussion and networking. Outline of the day (provisional timings) 09.15: Registration and refreshments 10.15: Plenary session 1 - Introducing Health Justice Partnerships 11.45: Plenary session 2 - Health Justice Partnership case studies 13.00: Lunch provided 14.00: Plenary session 3 - Implementing Health Justice Partnerships 15.15: Group discussion session 4 - Where next for you? 16.30: Refreshments and networking Please see our website for further information on Health Justice Partnerships. Register for a place This event is supported by The Legal Education Foundation.
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Content ArticleThis chapter in Patient Safety and Quality: An Evidence-Based Handbook for Nurses outlines how fatigue and sleepiness impact on the performance of nurses and consequently on patient safety. It highlights safety practices that can be implemented to counter the effects of fatigue, including restrictions on working hours, napping, use of bright lights and exercise.
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Content ArticleThis brief paper reviews the available published literature on shiftwork and safety that allows the estimation of the relative risk of “accidents” or injuries associated with specific features of shift systems. It discusses three main trends in risk: Risk is higher on the night shift, and to a lesser extent the afternoon shift, than on the morning shift Risk increases over a span of shifts, especially so if they are night shifts Risk increases with increasing shift length over eight hours The authors discuss the fact that some of these trends are not entirely consistent with predictions made based on considerations of the circadian variations in sleep propensity or rated sleepiness, and consider factors relating to sleep that may underlie the observed trends in risk. They also discuss the practical implications of the trends in risk for the design of safer shift systems.
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Content ArticleThis study in the journal Acta Neuropathologica Communications examined neuropathological findings of patients who died following hospitalisation in an intensive care unit with Covid-19. The researchers conducted brain autopsy on 20 people who had died, followed by ex-vivo imaging and dissection. They found that acute tissue injuries and microglial activation were the most common abnormalities discovered in Covid-19 brains. They also found evidence of encephalitis-like changes despite the lack of detectable virus. The majority of older subjects showed age-related brain conditions even in the absence of known neurologic disease. The findings of this study suggest that acute brain injury alongside common pre-existing brain disease may put older subjects at higher risk of post-Covid neurological issues.
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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.
