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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.
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Content ArticleThis video published by the Irish Health Service Executive (HSE) tells the story of Pat, whose bowel cancer diagnosis was missed, resulting in his premature death. His daughter Patricia talks about the two investigations that took place into her father's death and how the hospital's internal investigation failed to acknowledge that a staff member had raised concerns about Pat's initial colonoscopy on five occasions, but this had not been followed up. She describes the impact of these events on her father and the rest of the family and calls on medical professionals to "trust us (families) more and fear solicitors less."
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Content ArticleThis blog by Brita Lundberg of Lundberg Health Advocates looks at how healthcare providers can sometimes blame the patient for their condition, errors in treatment and communication issues. She looks at the role that language used in medical settings and historical views of the medical profession have on the tendency to blame patients, and highlights how the issue is also present in wider society. She offers three potential steps to help tackle patient-blaming: Recognise the problem, as it is difficult if not impossible to solve a problem until one recognises that it exists. Families, friends and clinicians should start with the assumption that the patient is correct and question others, particularly any in authority. All of us can be much too quick to dismiss patients’ concerns and to reassure them. It’s a bad habit. Instead–it is prudent never to eliminate any diagnosis, particularly one suggested by the patient, until all the supporting and contradictory evidence for each is carefully considered. Listen–that terribly overused and so little practiced—word. Listening instead of interrupting right away not only helps preserve the flow of the narrative but also gives us time to think about what is being said, and time to formulate a more considered response.
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Content ArticleIn this interview with the publisher Bloomsbury, freelance health journalist and founder of the Hysterical Women blog Sarah Graham talks about her book, Rebel Bodies: A guide to the gender health gap revolution. She discusses the recurrent themes she came across in her work as a health journalist which inspired her to set up her blog: women's experiences of gaslighting, dismissal and disbelief by the medical system. Sarah talks about how her book aims to bring together all the stories and ideas she has worked on for the last five or so years and highlight how closely they’re linked. The book also celebrates the resilience, determination, sisterhood and solidarity Sarah has witnessed from patient advocates and campaigners across the sphere of women’s health and trans health. Read Sarah's 2020 blog, Gender bias: A threat to women’s health, on the hub.
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Content ArticleHealthcare professionals are encouraged to use feedback from their patients to inform service and quality improvement. This study in the journal Sociology of Health and Illness aimed to understand how three NHS Trusts in England were interacting with patient feedback through online channels. The authors found that organisations demonstrated varying levels of ‘preparedness to perform’ online, from invisibility through to engaging in public conversation with patients within a wider mission for transparency. Engagement varied between the Trusts; one organisation employed restrictive ‘cast lists’ of staff able to respond to patients, while another devolved responding responsibility amongst a wide array of multidisciplinary staff.
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Content ArticleIn this blog, Judy Walker, an After Action Review (AAR) expert, looks at how effective learning from disasters and incidents can restore hope and trust, offering long-term improvements to systems that have failed. She talks about how public inquiries, although they can seem frustratingly slow, benefit society when the relevant authorities ensure that learning is understood and implemented. She compares this to the impact of AARs, highlighting that people’s trust in the process is linked to their perception of the changes that happen as a result of the AAR. She outlines three steps that NHS providers should take to ensure the AAR process is effective in restoring hope: Highlight to all staff on a regular basis, the benefits that are being delivered due to AARs Ensure patients and family members are provided with specific information about how AARs prevent future harms Support the people who lead AARs to do so skilfully, so that quality is assured and staff can trust in the safety and value of the process.
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Content ArticleThis multinational research study in the journal Diabetes Research and Clinical Practice aimed to investigate perceived to people with diabetes adopting and maintaining open-source automated insulin delivery (AID) systems. 129 participants with type 1 diabetes from 31 countries were recruited online to elicit their perceived barriers towards the building and maintaining of an open-source AID system. The study identified a range of structural and individual-level barriers to the uptake of open-source AID, including: sourcing the necessary components lack of confidence in one's own technology knowledge and skills perceived time and energy required to build a system fear of losing healthcare provider support Some of these individual-level barriers may be overcome over time through the peer-support of the DIY online community as well as greater acceptance of open-source innovation among healthcare professionals. The findings have important implications for understanding the possible wider use of open-source diabetes technology solutions in the future. Further reading How safe are closed loop artificial pancreas systems?
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Content ArticleIn this post, Amber Clour, author of the Diabetes Daily Grind blog, talks about her experience of managing her type 1 diabetes while attending the emergency room for suspected appendicitis. She describes the steps she took to make sure her blood sugar levels were managed safely and with her consent, including communicating clearly with all healthcare professionals, ensuring her continuous glucose monitor (CGM) was not removed and bringing her own supply of glucose tablets to manage hypoglycaemia. Further reading Blog - “I felt lucky to get out alive”: why we must improve hospital safety for people with diabetes
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Content ArticleIn this blog, Paul E Sax, Contributing Editor at NEJM Journal Watch looks at a recent study into the effectiveness of medical masks compared to N95 respirators for preventing Covid-19 infection among healthcare workers. The author aims to help readers understand how to appraise research studies and decide how and whether to apply their findings. He defines some of the complex terminology used in the study and looks at its methods and findings from both a critical and supportive viewpoint.
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Content ArticleThis blog published by the Irish Health Service Executive (HSE) tells the story of Mark, who was diagnosed with schizophrenia 15 years ago, aged 15. It describes the issues he and his mother faced in getting him the care he needed, including being treated inappropriately and without dignity during emergency department visits, problems accessing ongoing community support and a reluctance to assist him with reducing his medication dosage. It also highlights how his family were not included in care plans and treatment decisions, and their needs as carers were rarely considered.
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Content ArticleSafety-II is moving beyond the conceptual, with practical applications emerging from the fog of models and theory. But critics still point to a lack of evidence and limited real-world proof that the promise is justified. This blog reports on a webinar by Mark Sujan and Simon Gill that looked at how to implement Safety-II thinking in real world settings. The blog outlines different elements of the webinar including: a case study of anticipatory practice being used to reduce serious harm from falls in an emergency department a discussion on how to move towards a non-hierarchical clinical leadership challenges to adopting Safety-II principles evaluation of Safety-II: how do you measure a non-event?
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Content ArticleThis webinar was organised by the Chartered Institute of Ergonomics & Human Factors (CIEHF) in partnership with the Israel Human Factors and Ergonomics Association (IHFEA). It looks at the impact of human factors in the design and use of a range of medical devices. Experts from Israel, the Netherlands and the UK share their insights about the challenges involved and how they were overcome. In her talk, Avital Zik shares examples from her experience in leading the human factors work of the Medtronic Lung Navigation system. Lung cancer care is currently invasive, ineffective, inefficient, difficult for users and often comes too late. Avital's team is on a mission is to transform the future of lung care.
