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Content ArticleThis case study describes the project that won the 'Future-proofing Healthcare 2022' category in the Healthcare Quality Improvement Partnership's (HQIP's) Clinical Audit Heroes Awards. The Sustainable Respiratory Care Audit team at Newcastle Hospitals NHS Foundation Trust was recognised for its work improving care for individual patients while also reducing the environmental impacts of healthcare. Their nomination detailed how the project provided a structure for the audit of patients’ techniques, preferences and knowledge about inhalers, and the need for a clinical review—interventions that can reduce the carbon footprint of healthcare while improving the quality of care.
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Content ArticleThis report by the Harmed Patients Alliance (HPA) explores the needs of injured patients and their loved ones for independent advocacy, advice and information when they have been involved in patient safety incidents that are believed to have led to harm. It examines the extent to which this is available or resourced, and aims to stimulate and inform a national discussion about this issue in England among key stakeholders. It looks at the historical context and the moral and economic arguments and implications of resourcing these kinds of services.
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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. Sharon talks to us about why manual handling needs to be more than tick-box training, and describes its significance for patient safety. -
Content ArticleThe King’s Fund and Engage Britain commissioned Bill Morgan, a former Conservative special adviser, to explore what can get in the way of ministers taking meaningful, long-term action to address NHS workforce shortages. In this report, he focuses on the role of politicians in workforce planning and delivery. The report sets out the scale of the workforce crisis and the impact that it has. It also considers the political reasons around why it has been so hard to fix and considers three factors that could contribute to tackling the current shortages: Transparency in workforce forecasts The establishment of an independent workforce-planning organisation Accepting the NHS’s historical reliance on recruitment from outside the UK as explicit future policy and planning accordingly
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SHOT: Transfusing wisely webinar
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Content ArticleThis is a summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey to discuss the Patient Safety Incident Response Framework (PSIRF) to the law firm Browne Jacobsen. The session covered key elements of PSIRF, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust,
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Content ArticleThis report by LCP Health Analytics, looks at how inequalities across the medicine life cycle impact patients and populations. It paints a vision of what success could look like, and proposes specific, feasible calls to action across industry, health technology assessment (HTA) bodies and players that could transform the role of the life science sector in reducing inequalities and fostering healthy populations. The report identifies two key challenges in addressing health inequalities that are tractable, and where the life science sector is most likely to make commitments and contributions: Multimorbidity is increasing and embedding inequalities in health Financial incentives across health systems are not aligned with patient and population health
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Content ArticleThis study in the Annals of Surgery aimed to characterise errors, events and distractions in the operating theatre, and measure the technical skills of surgeons in minimally invasive surgery practice. The authors of the study implemented the use of an operating room (OR) Black Box, a multiport data capture system that identifies intraoperative errors, events and distractions. The study found that the OR Black Box identified frequent intraoperative errors and events, variation in surgeons’ technical skills and a high number of environmental distractions during elective laparoscopic operations.
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Content ArticleHuman factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system. This article explores how HFE can be used to improve patient safety, in particular using the Systems Engineering Initiative for Patient Safety (SEIPS) model, which depicts key characteristics and interactions between three core components: work system process outcomes
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Content ArticleThis blog is part of a series in which Steven Shorrock, an interdisciplinary humanistic, systems and design practitioner, outlines seven ‘archetypes of human work’. This blog looks specifically at 'The Messy Reality' archetype, which is characterised by adjustments, adaptations, variations, trade-offs, compromises and workarounds that are hard to prescribe and hard to identify, but that can become accepted and unremarkable for insiders. Steven examines what 'The Messy Reality' is, why it exists and highlights some examples from the aviation and healthcare industries.
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Content ArticleThis study in the journal Health and Social Care Delivery Research aimed to assess the scale, scope and impact of changing the type and number of different healthcare practitioners in general practice in England. The authors undertook an analysis of employment trends, looked at motivations behind employment decisions, examined staff and patient experiences, and assessed how skill mix changes are associated with outcome measures and costs. They found that: employing clinicians who are not GPs did not reduce GPs’ workload or improve their job satisfaction. patients appreciated the longer appointments they had with other clinicians. patients wanted better information about what other practitioners can do, and how to use new booking systems.
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Content ArticleThis cross-sectional study in BMJ Evidence-Based Medicine aimed to understand the relationship between financial conflicts of interest and recommendations for atrial fibrillation (AF) screening in the UK. The authors looked at whether the UK media recommend for or against screening for AF and the financial conflicts of interests of AF screening commentators. The authors found that the vast majority of UK media promotes screening for AF, in contrast to the position of the independent UK National Screening Committee, which recommends against screening. Most commentators, internal NHS organisations and UK charities promoting screening had a direct or indirect financial conflict of interest. Independent information was rare and the reasons for this are unknown. They recommend readers consider the potential impact of financial conflicts on recommendations to screen.
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Content ArticleHealthcare sector strikes are a relatively recent phenomenon, becoming notable only in the last half of the twentieth century. In this article, Spanish medical ethics expert Gonzalo Herranz, from the Bioethics Department at the University of Navarra, examines the ethical issues and legal implications associated with healthcare worker strikes, as well as looking at the moral duty to try and prevent strikes.
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Content ArticleThis systematic review in the International Journal of Health Planning and Management aimed to examine and analyse the existing literature that examines the impact of strike action on patient morbidity—all patient outcomes apart from death. 15 studies were included in the review. and articles included a variety of outcomes from hypertension control to rates of chlamydia. Strikes ranged from 13 to 118 days, with a mean strike length of 56 days. The authors found that the majority of studies reported that strike action had a neutral or mixed impact on patient morbidity. One study reported positive outcomes and three studies reported negative outcomes, however in both cases, the impact that the strike had was marginal.
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Content ArticleIn this blog, journalist David Hencke shares his views on the ruling of Judge Anne Martin in the case of NHS whistleblower Dr Chris Day. He argues that Judge Martin was determined to find in favour of Lewisham and Greenwich NHS Trust, glossing over the disclosure of the deliberate destruction of 90,000 emails and the use of false evidence by the Trust. She discredited the evidence of Dr Day’s witnesses, including the present Chancellor of the Exchequer, Jeremy Hunt and two senior medical experts, on the basis that they were biased.
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Content ArticleDeaths from Covid-19 are rare in children and young people, and the high rates of asymptomatic and mild infections complicate assessment of cause of death in this group. This study assessed the cause of death in all children and young people with a positive Covid-19 test since the start of the pandemic in England. The authors concluded that:Covid-19 deaths remain extremely rare in CYP, with most fatalities occurring within 30 days of infection and in children with specific underlying conditions.Covid-19 was responsible for 1.2% of all deaths in <20 year-olds in this period.
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Content ArticleThe Health Equity Network will launch in January 2023 and aims to build momentum for health equity across the UK. It will provide an opportunity for public and private sector organisations, community and voluntary groups and individuals to share their work on health equity and to engage across the country with others with the same interests. This article describes how the Network will work and offers the opportunity to register interest in joining.
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Content ArticleThis article from Reuters highlights the results of a survey of 1,002 people which was conducted in October 2022 by market research company Censuswide on behalf of recruitment website Indeed. The survey showed that more than three quarters of British people who have suffered persistent ill health following a Covid-19 infection have had to cut back or change the work they do.
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Content ArticleA culture of patient safety is essential for the continual improvement of service and reducing errors. This study in Risk Management and Healthcare Policy aimed to examine how the scores of patient safety culture items impact accreditation compliance percentages in primary care settings in Kuwait.
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Content ArticleThis blog by a UK-based dentist, who blogs under the name Fang Farrier, highlights the dangers of popular media presenting rumour about dentistry services as fact. She refers to an incident where a presenter on the TV show Good Morning Britain said that NHS doctors were no longer trained to be able to perform tooth extractions, describing it as a "categorical fact [presented] by a private dentist." The blog highlights four related issues concerning public perception of dentists, dentistry training and the impact of fear of complaints and litigation on NHS dentistry services: We need to be more mindful about how we talk about dentistry, particularly other dentists Our new graduates seem to be graduating with less experience and less confidence in most procedures, most notably extractions and root canal Fear of failure and taking risks The NHS question… will it stay or will it go?
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Content ArticleThis webinar hosted by the National Orthopaedic Alliance (NOA) gives a brief overview of human factors and ergonomics, its relevance and role in improving patient safety, how it has been embedded in one organisation and the impact it has had. Fran Ives, Human Factors Specialist and part of the Human Factors team at the Robert Jones and Agnes Hunt Hospital (RJAH) speaks about her experience of applying Human Factors both within a large NHS Trust and an Academic Health Science Network, including the successes and challenges of setting up and developing a service, and what difference such a service can make.
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Content ArticleAdam Tasker spent over a decade in the Royal Navy before starting medical training at the University of Warwick. In this article for BMJ Leader, he reflects on a near miss incident that he was involved in while working as a Helicopter Warfare Officer, examining his attitudes and those of his colleagues, and the practices and behaviours of the squadron’s leaders. He compares his experience in the Royal Navy to that of his experience as a medical student, and identifies lessons that are relevant to medical training, professional expectations and the management of clinical incidents. These lessons aim to support the implementation of a Just Culture within the NHS.
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Content ArticleWhen medical errors result in adverse patient outcomes, many healthcare professionals are concerned about malpractice litigation. Fear of malpractice has been associated with excessive health care use through defensive medicine, which involves doctors ordering additional testing or making extra referrals to protect themselves from malpractice accusations. The authors of this study in JAMA Network Open aimed to examine the perspectives of doctors on patient harm and malpractice litigation. They conducted an online survey targeting all emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals across Massachusetts from January to September 2020. The results showed that although clinicians feared legal action, they feared harming patients to a greater degree regardless of specialty, experience or sex.
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Content ArticleIn this article, Kamran Abbasi, editor in chief of the BMJ outlines the need for reform to the General Medical Council (GMC), which is responsible for regulating doctors in the United Kingdom. He talks about how the GMC received a significant backlash from doctors after its handling of the case of Manjula Arora, a GP who was disciplined for a word she used when asking her employer for a laptop. However, he highlights that the GMC's issues started long before this case, with racial bias, discrimination and an adversarial culture present over the last 30 years. Kamran also outlines measures that should be taken to ensure organisational change and accountability for the GMC.
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Content ArticleMoral injury is a specific kind of trauma that can happen when when people face situations that deeply violate their conscience or threaten their core values. This blog for Scientific American looks at the experience of ER doctor Torree McGowan when the Delta wave of Covid-19 hit the central Oregon region where she works. It examines the impact that moral injury has had on her mental health and her relationship with patients. The author looks at how Covid-19 hugely increased the incidence of moral injury as people in frontline roles faced ethically wrenching dilemmas every day. The growing realisation that moral injury is a separate diagnosis to other conditions such as PTSD and depression is resulting in a wider range of treatments and trauma therapies. Many of these treatments encourage people to face moral conflicts head-on rather than blotting them out or explaining them away, and they emphasize the importance of community support in long-term recovery.
