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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 settings globally. Impact evaluation of patient safety and/or quality improvement initiatives, and their generalisability to low-resource settings. Articles which capture the range of methodologies that might be used to measure and evaluate patient safety and quality of care Studies which explore the role of patient and public involvement in patient safety for low resource settings. Manuscript Summary Submission Deadline 20 January 2025 Manuscript Submission Deadline 10 May 2025
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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 Article
Structured judgement review programme outline
Patient-Safety-Learning posted an article in Quality Improvement
This 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. -
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 Article
Protecting patients (20 March 2004)
Patient-Safety-Learning posted an article in Whistle blowing
This 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. -
Content ArticleIn 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 ArticleFailures 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. Recommendations In addition to stating the continued relevance of previous recommendations, this report contains five new recommendations for improvement: Ensure that the number of women who require language support, and the support provided at each visit, is recorded systematically. This includes documenting the use of professional interpreting services at clinical care interactions and when supporting women through the navigation of care pathways, as well as recording when these services are not available. The resulting data should be used to implement quality improvement measures, and be assessed against existing NICE guidance. Ensure services provide advocacy for women who have been in the UK for less than a year, or do not speak or understand English, to support care navigation. This should incorporate midwifery and obstetric care when indicated. Support research to understand women’s and healthcare professionals’ views on the barriers and facilitators to accessing and navigating maternity and neonatal care for women who have been in the UK for less than a year, or do not speak or understand English and require professional interpreting services. Use the findings to co-design services. Pilot the provision of an initial assessment appointment for migrant women of childbearing age when they first access health care services. The purpose would be to carry out a holistic assessment of their reproductive healthcare needs, provide information about reproductive health and availability of maternity services, and to understand any concerns they may have about accessing healthcare services. Develop provision for multiple routes of access to maternity care. These routes should include the ability for a health or social care professional, in any setting, to make a direct referral to maternity services on behalf of a woman with her consent.
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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 ArticleThe 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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News ArticleA national probe has been launched into the deaths and harm of thousands of NHS patients waiting for cardiac surgery, as doctors and experts warn of a “crisis in heart care”, an investigation by The Independent has revealed. The audit was ordered by NHS England after concerns were raised about the impact on patients left waiting too long for specialist surgery, according to a leaked memo. Waiting times for all types of cardiac surgery are also under review. Senior doctors have described how the NHS is struggling to provide life-saving care to those suffering heart attacks and strokes, with worsening ambulance delays meaning patients are being deprioritised. The latest figures show waiting lists for cardiology services have doubled since the onset of the pandemic in March 2020 with 412,164 patients waiting for routine care in October 2024 – up from 397,956 the year before. As of October this year, just 58 per cent of heart patients were seen within the NHS target of 18 weeks. An NHS spokesperson said: “Patients who come to emergency departments with heart attacks and strokes should be transferred as quickly as possible to units that are able to offer this care and prioritised accordingly. Despite significant pressure on services and thanks to staff across the country, the NHS is making good progress with the overall waiting list coming down, however, we know boosting capacity for cardiovascular care remains crucial to improving outcomes. We’re committed to using innovations like surgical hubs and implementing the “right procedure, right place model” to help release capacity and speed up access for patients.” Read full story Source: The Independent, 9 December 2024
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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 identifying the determinants of good healthcare, addressed in the Health Equalities Framework for People with Learning Disabilities 2013. the development of Personal Health Budgets, including the commitment that everyone receiving Continuing Health Care will be offered a Personal Health Budget by 2014 developments on safeguarding in the Care Bill, crucial for this vulnerable group. The report includes an easy read summary.
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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. Clarification David wishes to clarify a point raised in the interview: "When talking about the “IPC Cell” I said that they 'didn’t produce minutes'. In fact, notes or minutes were taken at all IPC Cell meetings. The point I was making is that they were not published ('produced' in the sense of being released into the public domain), when the minutes of most other groups such as SAGE and NERVTAG were published. The few IPC Cell minutes that have trickled into the public domain have mostly been as a result of Freedom of Information requests by a colleague and a few that I have managed to obtain myself. In some cases, public authorities have taken around 18 months to disclose documents, and it has required the intervention of the Information Commissioner's Office. I anticipate that more minutes will be disclosed for public scrutiny as time goes on." You can read more about CATA and the Covid-19 Inquiry in David's blogs and presentations on the hub: Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn Healthcare workers with Long Covid: Group litigation – a blog from David Osborn Covid-19 : A risk assessment too far? A blog by David Osborn CATA and the UK Covid-19 Public Inquiry: Presentation from David Osborn Join the conversation Were you working in health and social care during the pandemic? We'd like to hear about your experience of health and safety at work. Were you provided with adequate PPE to carry out your job safely? Did you catch Covid-19 while at work? You can join the conversation by commenting below (you'll need to sign up first) or get in touch with us directly by emailing [email protected] -
Content ArticleIn February 2024, Change Healthcare, a data processing firm, was the target of a cyberattack by the ransomware group ALPHV Black Cat. An active ransomware operation, ALPHV Black Cat is thought to also be behind a 2021 attack on Colonial Pipeline that disrupted the nationwide fuel supply chain. In the wake of the attack on Change Healthcare, hundreds of thousands of healthcare organisation were unable to submit claims or receive payments. With the weeks-long paralysis and ponderous shift to alternative protocols, many facilities found themselves unable to deliver care and facing financial collapse. This article in JAMA Health Forum looks at what healthcare organisations can learn from the incident to protect against future ransomware attacks and mitigate their impact.
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Content ArticleThis article by BD looks at the the risks related to irritants and vesicants when medications are administered to patients via vascular access (into their blood vessels through a cannula). It highlights the immediate risks of vein irritation, pain, discomfort and potential tissue damage during an infusion, as well as looking at the impact of damage to vascular endothelial cells caused by irritants and vesicants. It offers guidance on selecting the right vascular access device (VAD) and includes a Vascular Access Device Assessment Decision Tree, which is free to download.
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Content ArticleIt is widely recognised that pharmaceutical marketing contributed to the ongoing US opioid epidemic, but less is understood about how the opioid industry used scientific evidence to generate product demand, shape opioid regulation and change healthcare professionals' behaviour. This qualitative study looks at select scientific articles used by industry to support safety and effectiveness claims and uses a novel database, the Opioid Industry Documents Archive, to look at industry and non-industry documents citing the scientific articles to advance each claim. The authors found that 15 scientific articles were collectively mentioned in 3666 documents supporting five common, inaccurate claims: Opioids are effective for treatment of chronic, non-cancer pain. Opioids are “rarely” addictive. “Pseudo-addiction” is due to inadequate pain management No opioid dose is too high Screening tools can identify those at risk of developing addiction. The articles contributed to the eventual normalisation of these claims by: symbolically associating the claims with scientific evidence building credibility expanding and diversifying audiences and the parties asserting the claims obfuscating conflicts of interest. These findings have implications for regulators of industry products and corporate activity and can inform efforts to prevent similar public health crises.
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Content ArticleIn this article, doctor and researcher Rageshri Dhairyawan discusses how the medical practice of silencing is a systemic issue that extends further than global health to every level of healthcare and research. She outlines how it predominantly affects the same minoritised communities that experience health inequities as well as other forms of social injustice, and exacerbates them.
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EventECRI's Top 10 Health Technology Hazards for 2025 will identify the most significant and emerging risks in healthcare technology that require urgent attention this year. This influential annual report, now in its 18th year, has become a trusted resource for hospitals, health systems, ambulatory surgery centres and other care providers, as well as for medical device manufacturers and regulatory agencies. The report serves as a guide to help these organizations identify and address potential hazards that can impact both patient safety and staff well-being. Each year, ECRI evaluates and prioritizes risks across a wide range of healthcare technologies, offering actionable recommendations and specific calls to action for the industry to mitigate these dangers. The 2025 report covers 10 technology-related patient safety threats that warrant priority attention in today's rapidly evolving healthcare landscape. By identifying these risks early, ECRI helps healthcare providers and manufacturers take proactive steps to minimize harm, improve patient outcomes, and enhance the overall safety and reliability of healthcare systems. We invite you to join ECRI's Device Evaluation leaders as they examine the 10 hazards covered in our 2025 report. A panel of ECRI experts will describe the risks and offer insight into how each issue impacts both healthcare organizations and patients, and how all stakeholders can take effective action to reduce these risks. Learning Objectives This lab webcast will cover: The Challenges: Overview of the 10 technology safety topics selected for ECRI's 2025 report, along with discussion of the potential consequences for patient safety, clinician efficiency, and operational effectiveness. Practical Solutions: Step-by-step strategies and best practices for mitigating these risks, including recommendations for device selection and implementation, user training, and risk management practices that can help prevent harm. Industry Collaboration: Discussion of the current state of technology development and recommendations for how device manufacturers and other stakeholders can respond to these risks and improve the safety and reliability of these products. By participating in this webcast, you will gain a deeper understanding of the technology hazard landscape, learning how to identify and address the most pressing health technology hazards in your organization, and how collaboration across the healthcare ecosystem can drive meaningful change. Speakers Rob Schluth, Principal Project Officer I, Device Evaluation Francisco Rodriguez-Campos, Principal Project Officer I, Device Evaluation Priyanka Shah, Principal Project Officer I, Device Evaluation Kallie Smith, Vice President, Information Security Officer Karen Haberland, Senior Project Officer, Device Evaluation Jeremy Suggs, Senior Engineering Manager, Device Evaluation Brad Bonnette, Senior Project Officer, Device Evaluation Mukui Mutunga, Senior Project Officer, Device Evaluation Amanda Sivek, Principal Project Officer II, Device Safety Austin Hwang, Senior Project Officer, Device Safety Barbara Malanga, Director, Preventative Solutions and Device Safety Operations Patrice Hughes, Principal Project Officer I, Device Safety Register for the webcast
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Content ArticleThis systematic review in JAMA Network Open aimed to assess the magnitude and moderators of the association between nurse burnout and healthcare quality and safety. The meta-analysis covered 85 studies which included 288, 581 nurses. The results show that nurse burnout was associated with: a lower patient safety climate and patient safety grade more nosocomial infections, patient falls, medication errors and adverse events lower patient satisfaction ratings lower nurse-assessed quality of care. The associations were consistent across nurse age, sex, work experience and geography. Based on these findings, the authors of the study suggest that systems-level interventions for nurse burnout may improve patient outcomes.
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Content ArticleThis article in Mayo Clinic Proceedings looks at the impact that doctors' communication can have on patients with serious illness. Acknowledging the challenges of such communication, the authors of this article argue that certain words and phrases—'never-words'—should be avoided as they can close down a patient's ability to speak openly with their healthcare team, affecting the safety and quality of their ongoing care. The article lists these words and phrases, offering alternative language that doctors and other healthcare professionals can use.
