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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This 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?
  2. Content Article
    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.
  3. News Article
    Chinese health officials are reportedly monitoring an increase in cases of human metapneumovirus (HMPV). There is currently no evidence that the outbreak is out of the ordinary or that a new respiratory virus or illness has emerged in China. HMPV is a virus that can cause upper and lower respiratory disease, according to the CDC. It was discovered in 2001 and is in the Pneumoviridae family along with respiratory syncytial virus, or RSV, the CDC said. A spokesperson for the World Health Organization (WHO) said data from China indicates "there has been a recent rise in acute respiratory infections" but that "the overall scale and intensity of respiratory infectious diseases in China this year are lower than last year." Cases of HMPV have been steadily increasing in the U.S. since November 2024 with 1.94% of weekly tests positive for HMPV as of Dec. 28, 2024, according to data from the Centers for Disease Control and Prevention (CDC). By comparison, 18.71% of weekly tests were positive for flu and 7.10% were positive for COVID during the same week, the data shows. Public health experts told ABC News that HMPV is well-known to health care professionals and commonly circulates during respiratory virus season. MORE: Cases of RSV, flu ticking up among young children in US as respiratory virus season begins "This is that winter respiratory virus season, indeed," Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, told ABC News. "So, all of these respiratory viruses -- influenza, COVID, RSV, human metapneumovirus -- they all increase this time of the year, in part because we get so close to each other." Read full story Source: ABC News, 7 January 2025
  4. News Article
    Black men in England are more likely to be diagnosed with late-stage prostate cancer than their white counterparts, while being less likely to receive life-saving treatment, analysis by the National Prostate Cancer Audit has found. The analysis found that black men were diagnosed with stage three or four prostate cancer at a rate of 440 per 100,000 black men in England, which is 1.5 times higher compared with their white counterparts, who had a diagnosis rate of 295 per 100,000. Furthermore, the research also found that black men in their 60s who had a later diagnosis were 14% less likely to receive life-saving treatments that have been approved by the National Institute for Health and Care Excellence for use on the NHS. The research was conducted by analysing new prostate cancer diagnoses by ethnicity in England from January 2021 to December 2023, using data from the Rapid Cancer Registration dataset and the National Cancer Registration dataset. Prostate cancer is the most common cancer among British men, with about 52,300 new cases and 12,000 deaths recorded in the UK each year. Black men are twice as likely to be diagnosed and 2.5 times more likely to die from the disease compared with white men. Prostate Cancer UK is calling for the government’s guidelines to be updated as, under current guidance, it is an individual’s responsibility to find out his risk and decide if he would like to request a blood test. Read full story Source: The Guardian, 9 January 2025
  5. News Article
    University Hospitals Birmingham has ordered an independent review into a major international medical training programme, after concerns the scheme may be routinely underpaying overseas doctors. The foundation trust confirmed to HSJ it was “now in the process of commissioning an independent review” into its three international medical training programmes. A spokesman said the decision to order an external review had been sparked by an earlier internal review of its medical training, which itself followed “concerns raised by clinical and non-clinical colleagues”. And a bulletin sent to UHB staff today from chief medical officer Kiran Patel, seen by HSJ, said “pay parity” issues had come to light through the internal reviews. It follows previous reports that overseas doctors were being paid substantially less than domestic peers working at a comparable level. Details about who will carry out the external review, how long it will take, and the terms of reference are yet to be confirmed. Read full story (paywalled) Source: HSJ, 9 January 2025
  6. News Article
    A robot-guided “smart biopsy” technique has been tested on UK patients for the first time, with researchers hopeful it could spell the end of invasive procedures for those with suspected cancer. Medics used advanced MRI scans to identify different areas of tumours and take multiple samples at once to better understand their biology. This could potentially help personalise cancer treatment, they suggest, with hopes that patients could one day forego biopsy completely as doctors would be able to study tumours from scan images the same way they would under a microscope. For the study, led by a team at the Royal Marsden NHS Foundation Trust, 12 patients with suspected etroperitoneal and pelvic sarcomas (RPS) – a rare group of soft tissue tumours that develop in the pelvis and the back of the abdominal cavity – were given smart biopsies. Dr Edward Johnston, consultant interventional radiologist at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, told the PA news agency: “Current biopsy just involves sampling one region rather than multiple regions. Secondly, it doesn’t have a very detailed MRI acquisition beforehand. So we want to make it a lot more thought out.” The team is now exploring expanding the technique for other tumour types. Read full story Source: The Independent, 9 January 2025
  7. News Article
    The NHS is experiencing intense winter pressure, with critical incidents declared at a dozen hospitals across the UK by Wednesday. The BBC has spoken to nurses dealing with demand in A&Es. "Patients are collapsing in the waiting room. It's just hectic," Lorraine, a nurse in Birmingham, told BBC Radio 5 Live on Tuesday. "There's women that are 90 that have been waiting for a bed for 24 hours," she said. "We try our best but if there's no beds what can we really do? We just make the old lady as comfortable as she can, just make sure that she's okay. But there's no beds." She said she felt sorry for paramedics who due to the lack of space in hospitals are being forced to hold patients on board for a long time. "And then when we do get them in they need a bed and there isn't one. It is really bad." Prime Minister Sir Keir Starmer visited a hospital in London's south-east on Monday, revealing a new plan involving the private healthcare sector to help reduce waiting times for appointments. But nurses like Lorraine say he needs to witness the reality of emergency wards currently. "The prime minister should actually sit in the waiting room, see the abuse that we get, the poor old ladies and pensioners, the young people that are trying to kill themselves, people collapsing, people having cardiac arrests in the waiting room," she said. Read full story Source: BBC News, 8 January 2025
  8. Content Article
    The 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.
  9. Content Article
    In 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.
  10. Content Article
    Learning 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.
  11. Content Article
    New 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 safety enables healthcare providers to prevent harm before it happens. Understanding how safety incidents affect patients, caregivers and healthcare teams can lead to better safety outcomes. 
  12. Content Article
    This 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.
  13. Content Article
    In 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.
  14. Content Article
    Over 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.
  15. Content Article
    In 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.
  16. Content Article
    One 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.
  17. Content Article
    We 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.
  18. Content Article
    The 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.
  19. Content Article
    Artificial 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.
  20. Content Article
    This 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.
  21. Content Article
    It 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.
  22. Content Article
    The 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.
  23. Content Article
    This 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.
  24. Content Article
    Many 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.
  25. Content Article
    This 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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