Patient-Safety-Learning
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Everything posted by Patient-Safety-Learning
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Content ArticleThe involvement of patients or next of kin after a serious adverse event (SAE) is evolving. Beyond providing mandatory information, there is growing recognition of the need to incorporate their interests. This Dutch qualitative study in the Journal of Patient Safety explores practical manifestations of patient and next of kin involvement and identifies significant considerations for hospitals. The findings highlight the importance of promoting meaningful involvement, recognising the significance of patient and next of kin experiences, and fostering a culture of transparency and collaboration. By examining the dynamics of involvement, this research aims to inform policy development and facilitate the implementation of patient-centred approaches to post-SAE care.
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Content ArticleArtificial intelligence (AI), the next health technology disruptor, is upon us and could greatly improve patient safety. Examples include detection and prediction of sepsis, pressure ulcers, postpartum haemorrhage, adverse drug events and patient decompensation, to name a few. However, if it is not designed, developed, implemented and used appropriately, AI in clinical settings may contribute to patient harm. This JAMA Health Forum viewpoint article looks at how potential harm caused by AI can be mitigated in healthcare, including through the introduction of implementation guidelines, monitoring systems and traceability.
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Content ArticleThis study in the Journal of Patient Safety aimed to determine the incidence and types of adverse events (AEs) in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs. The authors found that AEs were common for patients transitioning from the ED to the inpatient setting. They conclude that further research is needed to understand the underlying causes of AEs that occur when patients transition from the ED to the inpatient setting. Understanding the contribution of factors such as length of stay in the ED will significantly help efforts to develop targeted interventions to improve this crucial transition of care.
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Content ArticleIt is widely agreed that collaboration with people with lived experience of specific health conditions or health services is both a moral imperative and improves research quality, validity and impact. However, there is little agreement about how to practise public involvement. This article describes the formation and work of the Nottingham Maternity Research Network, an ongoing research reference panel that supports public involvement in maternal health research. Drawing on nine years’ experience, researchers and public contributors reflect together on the key issues to consider when co-producing research with maternity service users: first, pragmatic considerations, and second, creating a safe space for drawing on intimate and sometimes traumatic experiences. The authors argue that a sustained model of public involvement and engagement—that is, a standing group rather than a series of project-based, time-limited opportunities for involvement—brings opportunities to build trust and to develop a community that is supportive and inclusive. However, the sustained model of public involvement also brings practical challenges.
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Content ArticleThe estimated number of Americans who are medically disenfranchised—at risk of lacking access to primary care due to an inadequate supply in their local community—has nearly doubled since 2014. The insufficient number of primary care providers in the United States poses a serious public health threat, leaving nearly one-third of the population vulnerable to preventable chronic diseases and emerging threats like Covid-19 and influenza. This report describes America’s medically disenfranchised population and how, with expanded resources, Community Health Centers can begin to address gaps in primary care.
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Content ArticleThis prospective, observational cohort study examined data from 13,647 adults participating in the Researching Covid to Enhance Recovery (RECOVER-Adult) study. It aimed to update the research index for classifying symptomatic Long Covid and five symptom subtypes that differ in associated demographic features and quality of life. The researchers believe this update may help researchers identify people with symptomatic Long Covid and its symptom subtypes. Refinement of the index will be needed as research advances and the understanding of Long Covid deepens. Listen to a short podcast about the update of the RECOVER-Adult study.
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Content ArticleMany healthcare networks strive to become a high reliability organisation (HRO)—an organization that maintains a safe environment despite the challenges and complexities of its daily operations, many of which are considered high-risk. This study in Patient Safety looks at how Ascension health, a multistate health system, has built a customised learning management system to help it become a HRO. Network-based learning systems have been recognised as an effective way to share knowledge and collaborate toward safety, but there has been little published on how they have been applied in healthcare organisations. A team at Ascension has been developing a comprehensive learning management network that provides continuous, widespread patient safety education through various channels, including event reporting, data analysis, storytelling and causal analysis. This article shares the lessons they learned about what did and didn’t work and promising strategies. These insights can be used by other health systems who want to introduce a similar framework to foster a supportive environment for patient safety.
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Content ArticleThis blog looks at what the Government's decision to launch a national conversation about the NHS—called 'Change NHS'—says about its wider health policy. Andy Cowper, Editor of health Policy Insight, highlights three key areas that the author believes the Government should focus on in order to tackle the problems facing the health service: An urgent ‘Fireman Sam’ bucket of improvements that are needed to stop things all over the English NHS being 'on fire'. Rebuilding and restoring credibility to the management systems and structures. Building the future.
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Content ArticleThis guidance from the World Health Organization (WHO) updates and adapts the previous work of WHO on research capacity for well-designed and well-implemented clinical trials as framed in resolution WHA75.8 (2022). It aims to enhance clinical research efficiency, minimise research waste and provide guidance on sustained clinical trials that are always functional and active for endemic conditions and can pivot in time of emergency or pandemics.
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Content ArticleUnsafe care results in over three million deaths each year globally and it is estimated that over half of these deaths are preventable. The majority of harm occurs in low resource setting, where systemic factors relating to context, complexity of care, organisational behaviour, human factors, wider socio-political influences and significant workforce shortages contribute to an increased risk of adverse events. The scope and nature of challenges impacting patient safety in low resource settings remain under-studied and largely undocumented. The journal Frontiers in Health Services is inviting articles to contribute to the Research Topic that explore the challenges of providing high-quality care in low resource settings. It is also looking for studies that explore the strategies, methodologies and evidence of good practice that might be used to overcome these challenges in a wide range of low resource settings across both high- and low-income contexts, and across all healthcare disciplines, including mental health. Research papers may include (but are not limited to): Empirical research studies that aims to explore and/or improve quality and safety of care in low-resource settings globally. Review articles that identify and describe strategies and policies that have led to improvements in patient safety in low resource settings. Evidence syntheses that explore patient safety or quality of care for specific populations in resource-constrained sett
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Content ArticleRacial and ethnic disparities in thyroid cancer care may be reduced by improving enrolment of more diverse patient populations in clinical trials. This study in the journal Surgery looked at trial eligibility criteria and enrolment to assess barriers to equitable representation. The authors found that over the last 3 decades: 1 in 13 thyroid cancer–related clinical trials excluded patients based on language. In the fraction of published studies to report on racial and ethnic demographics, Asian/Native Hawaiian, Black and Hispanic patients were under-represented. They concluded that improving the reporting of demographics in published studies and eliminating exclusion criteria such as language could improve equitable representation of patients in thyroid cancer clinical trials.
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Content ArticleThis webpage explains the structured judgment review (SJR) case note review method developed by Professor Allen Hutchinson and the University of Sheffield. It describes how it has been used in acute, mental health and ambulance trust settings to improve the quality and safety of patient care.
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Content ArticleTo deliver value for money over the medium to long term, a government needs to turn its objectives into outcomes in a way that delivers the best value for every pound of taxpayers’ money while managing its fiscal position. It needs to: plan and prioritise its spending (and other activities) to address those objectives. monitor and manage both costs and value delivered. evaluate the results. adjust as necessary. report to Parliament on how it has used taxpayers’ money. This report by the National Audit Office aims to provide useful insights as officials and ministers are making changes to the planning and spending framework. It will also be useful to Parliamentarians and stakeholders seeking to scrutinise government spending and delivery.
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Content ArticleThis briefing paper summarises the main points of the national guidance on Learning from Deaths, published in March 2017, and how it relates to the LeDeR programme. The national guidance provides a framework for NHS Trusts and NHS Foundation Trusts to identify, report, investigate and learn from deaths that occur in their care.
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Content ArticleEvery two years The Neurological Alliance runs the largest national neurological patient experience survey of its kind in the country – the My Neuro Survey. Data from the survey has been used to inform campaigning and influencing activities as well as supporting and informing service improvement in the health system. This rapid literature review was carried out by The Patient Experience Library as part of preparations for the 2024 iteration of the My Neuro Survey. Undertaken during a four week period in May 2024, it supports the Neurological Alliance in deepening its understanding of how patient experience data and insights are used to inform service improvement in the NHS.
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Content ArticleThis opinion piece in the Irish Times outlines the results of an independent report into medication errors at Galway Hospice in 2004. The report uncovered medication errors and breaches of the Misuse of Drugs Act (1988) that had resulted in patient harm. It outlines the role of Dr Dympna Waldron, consultant in palliative medicine with the Western Health Board in speaking up to prevent harm to patients from medication errors.
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Content ArticlePatient-Safety-Learning posted an article in Other electronic health records (ambulance, care homes)In this article for the Journal of mHealth, Victoria Betton looks at the importance of a user-centred design approach to developing electronic patient records (EPRs). She highlights four key principles, based on human factors, that should be considered when designing an EPR: Start early with user needs—take time to build user needs and goals into your thinking from the start of your business case and keep them at the core of your requirements. Use observation, interviews and analysis of data (for example, clinical incident reports) to give you the insights you need. Bake in adoption from the get-go—make sure there is sufficient resource and time in the business case to engage and involve EPR users at each stage of the process, from defining needs through to procurement, implementation and ongoing optimisation over time. Get it right before you configure—use wireframes and simulation to test out before you start to configure the EPR. Make it as easy as possible for users to enter data in the right place the first time. Iterate—create a process that allows for ongoing iteration, learning and optimisation of the EPR. Don’t send floor walkers in for two weeks and ask them to leave. Ongoing adaptation and improvement are key.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)Failures in interpersonal communication are considered to be the main cause of serious avoidable incidents in high-risk settings. The European Institute for Safe Communication (EISC) aims to prevent these incidents by the promotion of interpersonal "safe" communication skills. The EISC website explains how safe communication can be achieved through the SACCIA approach. SACCIA is an acronym that summarises the five communicative practices that, according to extensive scientific analysis, repeatedly lead to avoidable harm. At the same time, these five practices represent evidence-based core competencies for "safe communication," because they convert harm-triggering communication weaknesses into competencies. Beyond these safety practices, fundamental misconceptions about interpersonal communication are also being addressed. The letters "SACCIA" stand for Sufficiency, Accuracy, Clarity, Contextualisation and Interpersonal Adaptation.
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Content ArticleThe Maternal, Newborn and Infant Clinical Outcome Review Programme has published an MBRRACE-UK Perinatal Confidential Enquiry report on the care of recent migrant women with language barriers who have experienced a stillbirth or neonatal death. Looking at the care of 25 women and their babies, this report found that services did not meet the needs of these women effectively. Other key findings include: 96% of the women had a documented need for an interpreter, however, only 27% took place with a documented professional interpreter over 589 separate contacts with healthcare services. 68% of women didn’t book their pregnancy, or booked late in their pregnancy, highlighting gaps in antenatal care. Only 51% of women whose baby died received documented bereavement care in the community. There was a lack of research to inform service development for women new to the UK and non-English speakers.
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Content ArticleThis blog shares extracts and learnings from 'A user centred design blueprint for NHS trusts', a dissertation written by Tracey Watson for her Degree Master of Science in Digital Health at Imperial College. In her dissertation, Tracey sought to answer the question: "What are the key success elements of user centred design that need to be understood in order to gain use and optimise digital transformation?" She investigated her question through semi-structured interviews with NHS Trust executives, change practitioners and user centred design experts. This blog summarises Tracey’s exploration of the challenge and context for user centred design in NHS trusts.
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Content ArticleThis article in JAMA aimed to assess whether electronic sepsis screening based on quick Sequential Organ Failure Assessment score (qSOFA), compared with no screening, reduces the mortality of patients admitted to hospital wards. It was carried out as a stepped-wedge, cluster randomised trial at five hospitals in Saudi Arabia. The results show that among hospitalised ward patients, electronic sepsis screening compared with no screening resulted in significantly lower in-hospital 90-day mortality.
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Content ArticlePatient-Safety-Learning posted an article in Medicines and Healthcare products Regulatory Agency (MHRA)The laws which regulate the way clinical trials are carried out in the UK are changing. The Health Research Authority (HRA) and the Medicines and Healthcare products Regulatory Agency (MHRA) have been working for the past two years to draft proposals to update clinical trials regulations. The updated regulations will be debated in the new year and after a 12 month implementation period will come into force in early 2026. Updating this law started in 2022 with a public consultation which asked for feedback on how the regulation of clinical trials could be improved and strengthened in the UK. The statutory instrument to amend the Medicines for Human Use (Clinical Trials) Regulations 2004 was laid before Parliament on 12 December 2024. This article explains the changes to the regulations which aim to create a faster, more efficient, more accessible and more innovative clinical research system in the UK.
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Content ArticleThis is a 2013 progress report that follows up on the Parliamentary and Health Service Ombudsman and Local Government Ombudsman’s 2009 ‘Six Lives’ report which investigated the deaths of six people with learning disabilities, first highlighted by Mencap in their 2007 report ‘Death by Indifference’. The report covers: what has happened since the publication of the report in October 2010 in the areas the Department of Health said it would give immediate priority to. These areas include early learning from the Learning Disabilities Public Health Observatory, monitoring progress in the Confidential Inquiry into the premature deaths of people with learning disabilities, supporting improvements in the take-up of annual health checks for people with learning disabilities and promoting good practice. what the regulators – CQC, Monitor and the Equality and Human Rights Commission – have reported at the Ombudsmen’s request on what has happened in this area since 2010. progress and key developments in other areas since the 2010 report, which we believe will be very important in continuing to improve the healthcare of people with learning disabilities. These include new responsibilities for improving the healthcare of people with learning disabilities following changes to the health system since 2010. The report then looks at three other developments that will help to improve the health and wellbeing of people with a learning disability: work on
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Content ArticleMost hospitals have stopped testing all patients for Covid-19 when they are admitted and no longer require masking. Ten hospitals in the Mass General Brigham hospital system ended both these precautions simultaneously in May 2023 but restarted masking for health care workers in January 2024 during a winter respiratory viral surge. This study in JAMA Network Open looked at the association of these changes with the relative incidence of hospital-onset Covid-19, influenza and respiratory syncytial virus (RSV). The study showed that stopping universal masking and Covid-19 testing was associated with a significant increase in hospital-onset respiratory viral infections relative to community infections. Restarting the masking of health care workers was associated with a significant decrease.
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Content Article
In this interview, David Osborn, chartered occupational safety and health practitioner and member of the Covid-19 Airborne Transmission Alliance (CATA), speaks to Lotty Tizzard, Digital Content Manager at Patient Safety Learning, about how CATA was established during the pandemic to advocate for adequate respiratory protection for NHS employees. David explains how CATA advocated for the government and heath service to recognise that Covid-19 is passed on by aerosol transmission (through microscopic particles in the air). He also outlines why surgical masks do not adequately protect people against catching airborne viruses and describes how inadequate respiratory protective equipment (RPE) contributed to thousands of NHS staff catching Covid-19 at work. As a result, many healthcare workers died and a large number still live with the ongoing symptoms of Long Covid. David describes CATA's involvement as a Core Participant in the Covid-19 Inquiry and outlines what he hopes will be done to ensure the UK is better prepared for future pandemics. Patient Safety Learning is also a member of CATA.
