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Content ArticlePeripherally inserted central catheters (PICCs) are medical devices often used for medium-to-long-term intravenous therapy, but they are often associated with morbid and potentially lethal complications. This multi-centre study in the journal Plos One aimed to identify barriers and facilitators to implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. The authors found that structured quality improvement (QI) efforts led to sustained PICC appropriateness and improved patient safety. These interventions included a multidisciplinary vascular access committee, clear targets, local champions and support from an online education toolkit.
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Content ArticleThis blog by Dr Anna Bayes from Altera Digital Health looks at the benefits of closed-loop medication administration (CLMA) in preventing avoidable medication errors. CLMA provides an extra validation at the point of drug administration by using barcode technology to positively identify the patient and validate their prescribed medications against the physical medication product (for example, pills, infusions or creams) at the point of care. Anna also considers CLMA's role in advancing digital maturity.
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Content ArticleIn this BMJ opinion piece, Iona Heath reviews a new book by Penelope Campling, who worked as an NHS psychiatrist and psychotherapist for 40 years. Don't Turn Away tells the story of "an increasingly brutal turning away from the most abused and damaged people who struggle to survive within our complacent society." The article argues that over the past few decades, our society has failed to listen to and support the most vulnerable people, with mental health systems focusing on exclusion criteria and keeping people out of the system.
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Content ArticleIn July 2022, HSIB launched a national investigation into the safety risk of clinical investigation booking systems failures. Specifically, the investigation explores the use of paper or hybrid booking systems and the production of appointment letters. This interim bulletin highlights a safety risk identified by the investigation and presents a safety observation for the attention of NHS care providers. Some vital NHS services still use paper-based or hybrid systems, which may have been developed over time and could leave unintended gaps where patients can be lost in the system. The reference case for this investigation is the experience of a patient whose magnetic resonance imaging (MRI) scan was not rescheduled following a cancellation, leading to a delay in the diagnosis of cancer. Hybrid systems were in use, which did not assist staff to keep track of patients. Additionally, the hybrid systems in use did not allow appointment letters in non-English languages to be produced.
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Content ArticleAfter the US Food and Drug Administration (FDA) first warned in 2008 of serious complications associated with transvaginal mesh, thousands of lawsuits have been filed, most of which were compiled into seven federal multidistrict litigation cases against the major manufacturers. This blog by Meghann Cuniff for Forbes Advisor provides an update on the progress of these law suits. It also advises on how to file a vaginal mesh lawsuit and joining a class action lawsuit.
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Content ArticleThis article for Vogue explores the experience of a midwife working in an overstretched maternity unit in England. Melissa Newman, who has been a midwife for nearly six years, highlights the impact of staff shortages on midwives—she describes how she does not have time to eat, avoids drinking because she will not have time to go to the toilet, and sometimes works fifteen hours without any break. She calls on the Government for more funding to fix the crisis facing NHS maternity services, and the NHS more widely.
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Content ArticleThis Canadian study in the Journal of Patient Safety describes an initiative that introduced system-wide changes to practice and patient safety culture in a rapid time frame. it looks at the implementation of a 'zero harm' approach to eliminate preventable harm across a wide variety of clinical areas. In less than a year, the intervention increased patient safety incident reporting by 37% while decreasing falls with injury by 39%, pressure injury rates by 37% and central line–associated blood stream infections by 34%.
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Content ArticleThis letter from Dr Robert Farley, President of the Institute of Physics and Engineering in Medicine (IPEM) to Karen Reid, the Chief Executive Officer of NHS Education for Scotland (NES) highlights that lack of funding for Clinical Scientist training places is putting patient safety in Scotland at risk. Dr Farley says, "We understand NHS Education for Scotland are proposing funding that equates to less than a single training post in medical physics and clinical engineering in 2023. ‘This is despite the Scottish Government's Chief Healthcare Science Officer’s public acknowledgement of the importance of training. "Scotland currently has a 10 per cent Clinical Scientist vacancy rate across the medical physics specialisms. This equates to seven vacancies in radiotherapy, three in nuclear medicine, four in diagnostic radiology and radiation protection. These posts are critical to supporting diagnostics and cancer treatments."
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Content ArticleThe Patient Safety Database (PSD), previously called the Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. This year, PSD has also been involved in the development of the SafeTeam Academy, an e-learning training platform associated with the Patient Safety Database, which offers video immersive courses using the power of cinema to train healthcare professionals. This is the latest newsletter from PSD, featuring a wide range of content by safety experts across Europe.
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Content ArticleCore20PLUS5 is NHS England's approach to reducing health inequalities at both national and system level. The approach defines a target population cohort and identifies five focus clinical areas that require accelerated improvement. This infographic outlines the specific Core20PLUS5 approach to reducing health inequalities for children and young people.
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Content ArticleIn this blog, Judy Walker, Senior Business Consultant at iTS Leadership, describes an After Action Review (AAR) that took place at a large London hospital following the first wave of Covid-19. As part of the AAR, Emergency Department porter Aaron described his experience of the first Covid 19 surge—wheeling large numbers of patients who had died through an empty hospital. Judy describes the value of staff listening to different perspectives as a way to reflect on their own experiences and understand the impact events have on different individuals. She highlights the importance of listening to the process of learning for individuals and teams.
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Content ArticleThis article in Computer Weekly outlines the tribunal proceedings and judgement in high-profile case brought by whistleblower Chris Day. Dr Day claimed that Lewisham and Greenwich NHS Foundation Trust had concealed evidence when a director deleted up to 90,000 emails before he was due to testify at an earlier tribunal, concerning allegedly false and detrimental public statements about Dr Day made by the Trust. Dr Day’s lengthy legal battle first began when he was a junior doctor working at Queen Elizabeth Hospital Woolwich’s intensive care unit in 2013, where he spoke up about under-staffing at the ICU.
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Content ArticleThe Industrial Injuries Advisory Council (IIAC) is an independent scientific advisory body that looks at industrial injuries benefit and how it is administered. Since the start of the Covid-19 pandemic in 2020, the IIAC has been reviewing and assessing the increasing scientific evidence on the occupational risks of Covid-19. This report builds on an IIAC interim Position Paper published in February 2021 and considers more recent data on the occupational impacts of Covid-19, particularly around the longer term health problems and disability caused by the virus. IIAC found the most convincing and consistent evidence was for health and social care workers in certain occupational settings, who present with five serious pathological complications following Covid-19 that have been shown to cause persistent impairment and loss of function in some workers.
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Content ArticleThis report by NHS Wales summarises the ways in which the cost of living crisis can impact on health and well-being. It takes a public health lens to identify actions for policy makers and decision-makers to protect and promote the health and well-being of people in Wales in their response to the cost of living crisis, outlining what a public health approach to the crisis could look like in the short and longer-term.
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Content ArticlePatient safety remains a global challenge for society today; in high income countries, it is estimated that one patient in ten is subject to adverse events while receiving hospital care. This article by Laís Junqueira, Quality, Patient Safety and Innovation Manager at Elsevier, in The Journal of mHealth looks at how enabling safer healthcare decision-making could reduce the burden of avoidable harm. Junqueira highlights the need to recognise that non-analytic and implicit decisions occur in healthcare systems, and that these have an impact on patient safety. He argues that as healthcare systems evolve, there must be an increased focus on the importance of an environment that fosters safe decision-making.
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Content ArticleIn this press release, The Health Foundation responds to the Autumn Statement delivered by the Chancellor of the Exchequer Jeremy Hunt on 17 November 2022. They highlight that although the planned additional funding for the NHS and social care is welcome, abandoning planned changes to introducing a cap in social care costs will leave older and disabled people without the care they need, with many facing catastrophic costs. They also highlight that although the Chancellor committed to publishing long-term workforce projections, he did not offer additional funding or any plan to actually expand the workforce.
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Content ArticleThe Health Survey (Northern Ireland) has run annually, on a continuous basis, since 2010/11. The 2021/22 survey included questions relating to general health, mental health and wellbeing, smoking and drinking alcohol. The sample size for the survey was 3,154 individuals aged 16 and over. This article presents the key findings of the Health Survey (Northern Ireland): First Results 2021/22 report. One important finding was that of respondents who had been in contact with the health and social care system in the last year, 73% were either very satisfied or satisfied with their experience (down from 85% in 2020/21), while almost a fifth (18%) were either dissatisfied or very dissatisfied (double that in 2020/21 – 9%).
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Content Article
Survey - Keeping up to date with NICE guidance (November 2022)
Patient-Safety-Learning posted an article in NICE
The National Institute for Health and Care Excellence (NICE) is looking for feedback on how people currently keep up to date with NICE guidance and what they do when an update has been made to NICE guidance. NICE will use your feedback to help shape the future of its guidelines. The survey takes around 10 minutes to complete. The closing date of the survey is 28th November 2022. -
EventuntilThis free event celebrates the global health data revolution, and aims to help build the knowledge, collaborations and public trust needed to enable data-driven discoveries which improve peoples’ lives. The last few years have demonstrated the enormous power of data to advance medical knowledge and deliver radical improvements to people’s lives. Treatments, vaccines and life-saving policies have all been delivered in record time thanks to large-scale data, advanced analytics and innovative developments in data governance. But these benefits must not be limited to Covid-19. They must extend to people living with other conditions such as mental illness, cancer, heart disease and diabetes. And they must be inclusive of and accessible to the entire global population. Health Data Research UK’s annual scientific conference will be a free one-day, hybrid event hosted in Birmingham, UK, to celebrate this progress and allow us to come together and build momentum in the health data research revolution. Register for an in-person or virtual ticket
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Content ArticleThe National Audit of Inpatient Falls (NAIF) has published its latest report into the care given to patients who fell while they were in hospital and sustained a hip fracture. Based on data from 1,394 patients in 2021, the report presents information on post-fall management and tracks performance against National Institute for Health and Care Excellence (NICE) Quality Standard 86, which includes checking the patient for injury before moving, using safe lifting equipment and prompt medical assessment after the fall.
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Content ArticleAntimicrobial resistance (AMR) is a major challenge to the UK’s health security, and is already responsible for a significant burden of death, disability and prolonged illness globally. The growing resistance of bacteria, viruses and fungi to the drugs commonly used to treat them threatens modern medicine, and our ability to carry out standard medical procedures. This report draws on the expert input of a roundtable held by public service think tank Reform in October 2022, to assess progress made against proposals published by Reform in 2020.
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Content ArticleThis 15-minute training video by the Parkinson's Excellence Network pulls together the key symptoms and issues that can impact on a person with Parkinson's and their care when admitted to a hospital ward. it aims to help ward staff understand the key issues when caring for people with Parkinson's.
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Content ArticleIn 2021, cybersecurity attacks on healthcare providers in the US reached an all-time high, with one study indicating that more than 45 million people were affected by these attacks in 2021 – a 32% increase on 2020. This report published by the Office of Senator Mark R Warner outlines the risk to patient safety posed by cyberattacks and proposes ways to improve federal leadership, enhance healthcare providers' preparedness for cyber emergencies and establish minimum cyber hygiene practices for healthcare organisations.
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Content ArticleThis opinion piece in the BMJ by Partha Kar, Director of Equality for Medical Workforce in the NHS, explores racial inequalities in the NHS workforce. Partha is currently leading work on the Medical Workforce Race Equality Standard (MWRES), which aims to challenge trusts and systems openly and transparently about race-based inequalities faced by NHS doctors.
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Content ArticleThis article in the HSJ explores the challenges in implementing the Patient Safety Incident Response Framework (PSIRF) and looks at how it will help achieve effective learning and improvement. Liz Hackett, health advisory partner at Hempsons law firm, addresses the following questions: Who does PSIRF apply to? How does PSIRF help achieve effective learning and improvement? What is required? Involving patient safety and addressing inequalities The challenge
