Patient-Safety-Learning
PSL Moderators
-
Joined
-
Last visited
Everything posted by Patient-Safety-Learning
-
Event
until
The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore the findings from MNSI's investigations into first trimester deaths in England from venous thromboembolism associated with hyperemesis. Speakers: Dr Charlotte Frise Dr Louise Page Chandrima Biswas Kirsty MacLennan Register for the webinar -
Event
until
The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore a thematic analysis of safety investigations into Sudden Unexplained Death in Epilepsy (SUDEP). Speakers: Dr Charlotte Frise Dr Louise Page Joanna Girling Emily Barrow Register for the webinar -
Event
until
The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore learnings following maternal deaths secondary to HLH and consider learning points for future clinicians and investigators. Speakers: Dr Charlotte Frise Dr Bethan Goulden Dr Louise Page Clare Luby Register for the webinar -
Content ArticlePeople working in healthcare will sometimes see things at work that cause them concern, such as a situation or action that is causing or could cause harm to a patient, member of staff or the public. If you work in health and social care and have concerns that you would like to raise, here are some helpful sources of advice and information about speaking up. If you would like to add an organisation or resource to this page, please contact us.
-
Community PostOur 'Speaking up for patient safety' interview series highlights some of the issues that healthcare staff who raise concerns about patient safety face. If you have spoken up about unsafe care, have been a whistleblower, or have been put off raising concerns, we would like to invite you to share your reflections. What encouraged or discouraged you from raising your concerns? What support did you receive from your employer or elsewhere, and how helpful was it? How can organisations make it safer for staff to speak up when they see something that worries them? What changes need to be made to the legal system and other national systems to improve the situation for staff who speak up? Read information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub.
-
Content Article
Patient Safety Learning and retired urology consultant Peter Duffy have launched a new interview series, ‘Speaking up for patient safety’. Peter is an NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK. The series looks at how people who speak up in healthcare are treated by organisations, leaders and regulators, and how this acts as a barrier to staff raising patient safety concerns. In each interview, Peter and Patient Safety Learning’s Chief Executive Helen Hughes talk to someone who has spoken up about patient safety in healthcare, or who works to help staff raise concerns. In this blog, Peter and Helen explain the concepts of speaking up and whistleblowing and outline why creating a safe environment for speaking up is vital for patient safety. They share why they decided to produce the interview series and outline the impact they hope giving people who have spoken up a platform to share their experiences and insights will have. You can follow the interview series on the hub and by subscribing to the series YouTube podcast. -
Content Article
In this 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 interview, Peter and Helen speak to Helené Donnelly OBE, who spoke up about unsafe care she witnessed while working as a nurse at Mid Staffordshire NHS Foundation Trust. Helené contributed as a witness to the inquiry led by Sir Robert Francis KC into failings at the trust and was also an advisor in the Freedom to Speak up Review in 2015, where she called for the creation of Freedom to Speak Up Guardians in the NHS. Helené explains why she decided to raise concerns about the quality of nursing care at Stafford Hospital A&E and describes the bullying and threats she received from other staff as a result. She discusses with Peter and Helen the barriers that still prevent staff speaking up today and what can be done to create a more open and responsive culture in teams and organisations. Helené highlights the need to reform how human resources departments respond to staff raising concerns and the vital role of embedding speaking up and organisational culture in the curriculum of all healthcare professional training courses. Subscribe to our YouTube podcas -
Content ArticleDespite medication being the most common healthcare intervention and medication-related incidents being common in hospitals, many rural and remote hospitals in Australia lack onsite pharmacy services due to resource constraints. This study examined the outcomes of a Virtual Clinical Pharmacy Service (VCPS) staffed by two senior, rural generalist hospital pharmacists assigned to four hospitals each that was implemented in rural and remote facilities. It aimed to determine whether the VCPS increased adherence to National Safety and Quality Health Service Standards (NSQHS). The study demonstrated that the VCPS: improved compliance with national standards for medication safety had high patient acceptability resulted in the detection of clinically relevant medication-related issues in rural and remote settings. The authors recommend that the possibilities of virtual pharmacy should be explored in further rural and remote locations, in addition to other settings such as urban locations with no onsite clinical pharmacists.
-
Content ArticleIn this interview, Dana Edelson, an expert in cardiac resuscitation at the University of Chicago, discusses how hospitals can best use early warning score tools to risk stratify patients—without adding to clinicians’ alarm fatigue. Dana recently co-authored a study which compared six different early warning scores designed to recognise clinical deterioration in hospitalised patients, including three proprietary AI tools.
-
- AI
- Decision making
- Deterioration
- Diagnosis
-
Tagged with:
-
Content ArticleThe early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study in the Journal of Patient Safety aimed to improve the proportion of patients receiving antibiotics within one hour of triage and compliance with sepsis bundles. A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 2018 to December 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. After this initial stage, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared and showed that: the proportion of patients receiving antibiotics within one hour of triage improved from 44% to 84%. intravenous crystalloid administration within three hours improved from 62% to 94%. serum lactic acid measurement within three hours improved from 62% to 94%. vasopressor initiation within six hours improved from 76% to 94%. mortality rates decreased from 32% to 21% between the 2 study periods.
-
Content ArticleThe Covid-19 pandemic, which rapidly escalated into a global crisis that impacted millions of lives and disrupted economies around the world, was a wake-up call for the management of infectious disease outbreaks. Dr Stella Chungong and Dr Landry Ndriko Mayigane work for the Health Security Preparedness Department in the World Health Organization’s Health Emergencies Programme. In this article, they encourage countries to implement early action reviews (EARs) of disease outbreaks. EARs help countries assess their vigilance, planning and responsiveness, and could help countries be better prepared during outbreaks.
-
Content ArticleThis open access book explores epistemic justice in mental healthcare, bringing together perspectives from psychologists, psychiatrists, philosophers, activists and lived experience researchers. Through eight chapters, authors identify threats to the agency of people who hear voices, experience depression, have psychotic symptoms, live with dementia, are diagnosed with personality disorders, and face serious mental health issues while receiving palliative care. Considering the power asymmetries in clinical interactions, where patients are vulnerable and healthcare professionals are uniquely placed to offer support, this book reaffirms the importance of recognizing patients as agents and collaborators. Topics covered include trust in the therapeutic relationship, dignity at the end of life, the social dimension of health, stigma in an acute ward, the harm caused by biases and stereotypes, the role of clinical communication and the promise of digital health.
-
Content ArticleThe impact of a patient safety incident (PSI) on nurses and doctors in hospital settings has been studied in depth. However, the impact of a PSI on general practitioners and how those health care professionals can be supported are less clear. This Belgian study investigated the prevalence of GPs (in training) being personally involved in a PSI, as well as the impact, the support needed and open disclosure in the aftermath of these PSIs.
-
Content ArticleThis article in JAMA Health Forum examines how the growing use of clinical algorithms exacerbates health disparities through perpetuating discrimination. Anirban Basu discusses five critical issues that should be considered when developing and using clinical algorithms to minimise algorithmic discrimination: Should race belong in a clinical algorithm? Do we then have to develop two separate algorithms for decision-making invoking compensation vs reward? What happens if there is differential mismeasurement of race? What happens when there are differential measurement errors in other predictors, including biological variables? What happens when differential measurement errors exist in the clinical outcomes for which the algorithm is being developed?
-
Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)Over the past three decades, more advanced pre-hospital systems have increasingly integrated doctors into targeted roles, forming interprofessional teams. These teams focus on providing early senior decision-making and advanced interventions while also ensuring rapid transport to hospitals based on individual patient needs. This study aimed to evaluate the benefits of an inter-professional care model compared to a model where care is delivered solely by paramedics. The results suggest that the targeted deployment of interprofessional teams led by doctors in the pre-hospital care of critically ill or injured patients improves patient outcomes.
-
Content ArticleThe knowledge gained during the Covid-19 pandemic and other health emergencies could prove invaluable for planning responses to future health crises. In this blog, Dr Landry Ndriko Mayigane and Dr Stella Chungong from the Health Security Preparedness Department of the World Health Organization’s Health Emergency Programme describe how they devised the open-source ‘Nuggets’ of Knowledge (NoK) platform to facilitate effective knowledge management and continuity during health emergencies. The NoK platform collates vital knowledge collected by first responders during past and present health crises to inform the planning of interventions and actions during future emergencies.
-
Content ArticleIn this LinkedIn blog, Judy Walker outlines four ways that After Action Reviews (AARs) differ from more informal 'Lessons Learned' events, and how AARs can result in more effective learning. She also highlights four topics that organisations affected by recent cyberattacks can explore in AARs: Leadership and co-ordination - Large cyber-attacks demand that robust command and control structures are switched on, to respond to the initial chaos that inevitably ensues when disasters strike. Large incidents also involve a multitude of agencies, each of which must direct its own resources and co-ordinate with each other. Communications. Systems of command, control, and coordination are predicated on being able to communicate efficiently and requires that people are willing to share information with each other. Planning - Gaps in emergency plans cause serious problems when disaster strikes and weaknesses in plans often go unnoticed because actual plans are not trained fully or exercised realistically. Resilience – AARs should always address what supportive behaviours, processes and structures enabled efficient and effective response and recovery so that these can be repeated and strengthened as required.
-
Content ArticleLearning from clinical data on the subject of safety in dentistry is still in its early stages and current evidence does not provide epidemiological estimates on adverse events (AEs) associated with dental care. The aim of this dental practice study was to quantify and describe the nature and severity of harm experienced in association with dental care, and to assess for disparities in the prevalence of AEs.
-
Content ArticleNew Hospital Harm data shows that 1 in every 17 hospital stays in Canada involved patient harm in 2023-2024, highlighting the ongoing need to make healthcare safer for everyone. Reported by the Canadian Institute for Health Information (CIHI), the rate of hospital harm has held steady at 6% for the past four years after increasing in 2020. In this article, Denise McCuaig, Executive Director for Healthcare Transformation & Capacity Building at Healthcare Excellence Canada looks at how effective communication and engaging patients and their caregivers can improve the safety and quality of healthcare. She outlines four ways to prioritise safety through patient engagement: Create an engaging environment. Engagement-capable environments value the wisdom and experiences of patients and their essential care partners, fostering a culture of patient- and family-centred care that helps improve quality, safety and equitable outcomes. Foster inclusive communication. Inclusive communication is a key skill for healthcare providers, helping reduce misunderstandings, bridge communication gaps and make all patients feel valued. Recognise different forms of harm. Safety extends beyond the physical; psychological, social and spiritual wellbeing are also important. Engaging diverse individuals with lived experiences and providing trauma-informed care can help reduce harm, no matter what form. Learn to prevent harm. Taking a proactive approach to patient saf
-
Content ArticleThis cross-sectional analysis aimed to find out how state restrictions affected the number of excess Covid-19 pandemic deaths across 50 US states plus the District of Columbia. It found that if all states had imposed Covid-19 restrictions similar to those used in the 10 most (least) restrictive states, excess deaths would have been an estimated 10% to 21% lower (13%-17% higher) than the 1.18 million that actually occurred during the two-year period analysed. Behaviour changes were associated with 49% to 79% of this overall difference.
-
Content ArticleIn most developed countries, people don’t have to worry about sifting through a dozen different health plans—and they don’t live in fear of losing their health care after losing a job. They receive more affordable, higher-quality care than Americans do. The paradox of the world’s wealthiest nation having one of the weakest health systems among developed nations has long been a vexing policy problem—without an easy solution. In this article, Vox Senior Correspondent Dylan Scott looks at how the insurance-based healthcare system in the US developed from the 1920s onwards, and why it is so complex and compartmentalised compared to systems in other developed countries.
-
Content ArticleOver 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures. This scoping review in the Journal of Patient Safety aimed to identify, summarise and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process. This is the first step in a larger study to co-design a patient-facing question prompt list for patients to use throughout the diagnostic process.
-
Content ArticleIn this Substack post, journalist Rory Cellan-Jones looks at a privately-funded project that aimed to give patients a better idea of how safe different hospitals were—the Good Hospital Guide. He speaks to Alex Kafetz, who worked on the Good Hospital Guide over a decade ago and was also a witness at the Mid Staffs inquiry in 2013. The project spotted and alerted Stafford Hospital to its high adjusted mortality rate ahead of the scandal, but the hospital rejected its data and findings. The Good Hospital Guide project was discontinued after its parent company was taken over, and nothing like it has been developed since, in spite of its success in identifying data patterns that indicated patient safety issues. Rory also highlights the lack of accessible data about hospital performance and mortality rates available to patients and highlights the need for making its data more accessible and transparent.
-
Content ArticleOne in 20 outpatients in the United States experiences a diagnostic error each year, but there are no validated methods for collecting feedback from patients on diagnostic safety. This mixed-methods study in the Journal of Patient Safety examined patient experience surveys to determine whether patients’ free text comments indicated diagnostic breakdowns. The study aimed to evaluate associations between patient-perceived diagnostic breakdowns reported in free text comments and patients’ responses to structured survey questions. The authors concluded that patient feedback in routinely collected patient experience surveys is a valuable and actionable information source on diagnostic breakdowns in the ambulatory setting. The more easily monitored structured survey data provide a screening method to identify encounters that may have included a patient-perceived diagnostic breakdown and therefore require further examination.
-
Content ArticleWe all communicate multiple times a day but could we be getting better results? From a simple text or phone call, to a job interview or big presentation, the way we express ourselves and get our point across can really matter. On the Communicating podcast, Ros Atkins and his guests reveal the best ways to communicate and how simple changes in the way we make our point can be really effective. In this episode, Ros speaks to Dr Rob Elias, a kidney consultant at King's College Hospital in South London. Ros and Dr Elias discuss the role of empathy in communication, the need to calculate how much information someone is able to digest, and the need to make effective communication a priority.
