Patient-Safety-Learning
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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.
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Content ArticleThis report by the Neurological Alliance shares the results of the My Neuro Survey, the largest national neurological patient experience survey in the UK, which is carried out every two years. The survey and report aim to inform and support improvement in services for people affected by neurological conditions.
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Content ArticleBlack men face twice the risk of getting prostate cancer and 2.5 times the risk of dying from it than white men. They are also diagnosed younger, in a world where the majority of treatments and diagnostics have been designed based on data from white men, and in which the health of Black men can also be affected by factors such as entrenched racism, barriers in accessing care, economic injustice, nutrition and education. This report by Prostate Cancer Research (PCR) shares data from a survey conducted in March 2024 that asked 2,000 Black adults living in the UK their views on prostate cancer in Black men. The report shares what PCR is doing to tackle inequalities in screening, representation in research, treatment and support, with the aim of improving prostate cancer care for Black men.
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Content ArticleThis US cohort study looked at whether the shift from face-to-face to virtual mental health service delivery is associated with the risk of suicide-related events. The results suggest that offering virtual mental health care in addition to in-person care may reduce suicide-related events.
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EventThe 2024 EIDO conference, ‘The Consent Conundrum: Legal Insights and Practical Solutions’, explores medical consent through various lenses. Taking place on Tuesday 26 November at the East Midlands Airport Raddison Blu Hotel, this FREE event is open to surgeons, consultant nurses, legal service managers and anyone with an interest in shared decision making and informed consent. Reasons to attend the EIDO conference: Get FREE access to EIDO’s CPD-certified e-learning course The Legal Aspects of Informed Consent: Foundation Course after the event Gain insight into medical negligence, international perspectives on consent, and collaboration in patient information. Listen to expert speakers discuss digital transformation in patient care, system interoperability and consent issues in recent inquiry reports. Earn CPD points and receive a CPDUK certificate after the event. Register for the conference
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Content ArticleThis cohort study examined how hospital six early warning scores compare with one another, based on 362,926 patient encounters. The authors compared three proprietary artificial intelligence (AI) early warning scores: Simultaneous Epic Deterioration Index (EDI) Rothman Index (RI) eCARTv5 (eCART) against three publicly available simple aggregated weighted scores: Modified Early Warning Score (MEWS) National Early Warning Score (NEWS) NEWS2 scores. In the study, eCART outperformed the other AI and non-AI scores, identifying more deteriorating patients with fewer false alarms and sufficient time to intervene. NEWS, a non-AI, publicly available early warning score, significantly outperformed EDI. The authors concluded that, given the wide variation in accuracy, additional transparency and oversight of early warning tools may be warranted.
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- AI
- Data
- Deterioration
- Monitoring
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The Healthcare Services Safety Investigation Body (HSSIB) is hosting a free After Action Review (AAR) webinar including guest speakers from NHS England, Isle of Wight NHS Trust and Northumbria Healthcare NHS Foundation Trust. This highly practical webinar is for those who are currently undertaking AARs or planning to do so. It will be of particular interest to those using AAR as a learning response under the Patient Safety Incident Response Framework (PSIRF). The webinar will be an opportunity to share practice and to hear experiences from those embedding AAR within their organisations. You will hear about their challenges and what helped and hindered their efforts. There will also be discussion groups of topics chosen by participants in which the nuts and bolts of implementing AAR, and learning so far, will be shared. You will go back to your organisation better informed about how to implement this learning response tool, and with a ready-made community of colleagues to link with going forwards. Practice-based learning from the event will be collated for wider dissemination. Register for the webinar -
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The University of Manchester’s Healthier Futures Research Platform is mobilising research across disciplines at the University of Manchester to address health inequalities and ensure healthier futures for all. The University of Manchester's Healthier Futures research platform is hosting its inaugural annual lecture event, taking place at the Renold Innovation Hub, in Manchester's Sister innovation district, on the evening of 28 November 2024. Join the University of Manchester's President, Professor Duncan Ivison, and Director of Healthier Futures, Professor Dame Nicky Cullum, for this year’s opening lecture, which will be delivered by Dr Cordelle Ofori, Director of Public Health for Manchester. Cordelle will focus on health inequalities in Manchester and beyond. The lecture will start at 6.00pm, and will be followed by a Q&A session and drink’s reception. This event marks the beginning of an annual tradition that aims to foster interdisciplinary connections, share innovative research, and inspire collaborative efforts to address pressing health inequalities and challenges. Register for the event -
Content Article
In this interview, Helen Hughes speaks to Asif Qasim, Consultant Cardiologist and Founder of MedShr, about the role of physician associates (PAs) in the NHS. They discuss the patient safety issues arising from inappropriate use of PAs in both primary and secondary care and outline concerns about the planned rapid increase in the number of PAs working in the healthcare system. Asif describes the risks associated with PAs being employed to fill gaps in the doctor workforce and discusses how the lack of clarity for patients has contributed to serious patient safety incidents. He highlights the need for regulation, a clear scope of practice and a consistent level of supervision to ensure that patients receive safe care from PAs. -
Content ArticleThis article in JAMA Internal Medicine looks at the impact of language barriers on healthcare safety and quality in the US. Research shows that language discordance between patients and healthcare professionals worsens health outcomes, especially when there are no available, affordable and adequate interpreter services. The article describes the case of a mother who tried to raise concerns about her newborn baby's breathing and had her concerns dismissed, likely because she was unable to speak English and therefore could not communicate sufficiently with midwives and doctors. The author, Tamara Huson, a doctor in Ohio, describes how she had to convince the NICU unit to take the baby in for observation. On arrival at NICU, the baby's condition quickly deteriorated and she was intubated to save her life. This near miss illustrates the impact of language discordance, and the author argues that statutory requirements for translation service in the US are not being fulfilled by healthcare providers which receive Medicare and Medicaid funding.
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Content ArticleType 1 diabetes with disordered eating (T1DE), or diabulimia as some experts call it, is a serious eating disorder that people with type 1 diabetes can develop where the person reduces or stops taking their insulin as a way of managing their weight. The condition can be life-threatening. Although studies are limited, it’s estimated that eating disorders affect more than a third of patients with type 1 diabetes. This episode of the Healthcare Improvement podcast looks at diabulimia and a new toolkit published by SIGN, part of Healthcare Improvement Scotland, which sets out recommendations to raise awareness and provide guidance on how best to support people living with the diabulimia. Guests in this episode include: Lawrence Smith, who was diagnosed with type 1 diabetes when he was four years old and went on to develop an eating disorder in his teens. Safia Qureshi, Director of Evidence & Digital at Healthcare Improvement Scotland, who talks about the key recommendations in the toolkit. Dr Louise Johnston, Consultant and Clinical Lead on the inpatient unit for eating disorders, NHS Grampian.
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Content ArticleUK pharmaceutical industry self-regulatory bodies require member companies who sign up to their code of conduct to publish details of their payments to healthcare professionals and organisations. They are also required to publish the methodologies underlying these payments in the form of methodological notes. This study in Health Policy aimed to analyse UK pharmaceutical companies’ methodological notes. It also looked at their adherence to the Association of the British Pharmaceutical Industry code of conduct and other relevant guidance. The authors conducted a content analysis of methodological notes for the years 2015, 2017 and 2019 and assessed companies’ adherence to self-regulatory bodies’ requirements and recommendations for methodology disclosure. Overall, 90 companies made payment disclosures in all three years, publishing 269 methodological notes. The study found gaps in adherence to self-regulatory requirements. Only three companies provided clear information for all self-regulatory body recommendations and regulations in all of their notes and there was evidence of widespread non-adherence to requirements. This suggests that there are flaws in the concept of self-regulation and a need for greater enforcement of rules or consideration of a publicly mandated disclosure system.
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This free webinar will cover the current state of serious events involving newborns related to labour and delivery in Pennsylvania facilities and provide a deeper look into the most commonly reported event: shoulder dystocia. We will review and response when a shoulder dystocia occurs, as well as steps that can be taken after such an event, to inform practitioners with the aim of improving outcomes to future instances. Register for the webinar -
Content ArticleAlthough shame is an inevitable human experience, it is often experienced as a negative emotion that drives disconnection, psychological distress, impaired empathy and disengagement. The work of healthcare is infused with risk for shame and this Lancet article looks at the impact it can have on both staff and patients. Healthcare encounters are intimate interactions that can be overshadowed by perceived judgement and negative self-evaluation. Patients may feel ashamed, embarrassed or negatively judged about their bodies, their behaviours or their circumstances. Patient shame can be related to stigmatised experiences such as mental illness, obesity, sexually transmitted infections or substance use. The often well-intentioned “lectures” from doctors that such conditions evoke can increase shame feelings in patients who may already feel insecure or ashamed about their bodies or health conditions. Healthcare professionals can also be subject to the impact of shame as for many, identity and self-esteem are linked to achievement, reputation and belonging in their profession, all of which are, in turn, linked to patient care. They may feel inadequate or negatively judged about their skills, failures and errors, their own mental or physical illness, or their inability to “fix” a patient. The authors argue that engaging healthily with shame presents an opportunity for meaningful transformation in healthcare. Competently acknowledging, recognising and responding to sha
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Join Helena Wang, Lancet Asia Senior Executive Editor, and expert panellists as they explore the gap in medical research and care experienced by girls and women globally, before examining recent developments in work aiming to address inequalities in medicine. Register for the webinar -
Content ArticleDiverse ethnic groups are under-represented in health research, which can mean healthcare treatments and services are less safe, accessible and effective for these groups. This spoken word video aims to increase the number of people with lived experience from diverse ethnic groups who are actively involved in health research, and ultimately improve health treatments and services. The film focuses on why diversity in patient and public involvement (PPI) and in health research matters for people, families and communities.
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Content ArticleThis investigation by the Healthcare Service Safety Investigation Body (HSSIB) is one of a series on the theme of patient safety in mental health inpatient settings. This investigation focused specifically on the conditions that contribute to safe and therapeutic care for adults who are staying in mental health wards or units. The demand on mental health inpatient services in England is high and has been increasing. It is reported that the quality of care received by patients admitted to these services varies, meaning patients may not receive the therapeutic care they need. Issues include limited shared decision making and a lack of consideration of recovery-focused goals. Patients may also be placed in situations that create safety risks associated with mental, physical or sexual harm. This investigation examines the impact of workforce challenges on the delivery of safe and therapeutic care to adult patients in acute mental health inpatient settings (settings for people who need urgent care and are experiencing a severe mental health problem). It also looks at the wider workplace conditions and the organisation of care to see how these factors affect care. The investigation’s scope included adults, older-adults and secure (adults who pose a risk to the public) inpatient settings. The investigation's findings and recommendations offer opportunities to make improvements to systems, practices and future plans to support the delivery of therapeutic care, and ther
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Content ArticlePatients, particularly those with long term conditions, have a pivotal role in managing their own health, but too often they are left to struggle without the tools to do the job, the most basic of which is being able to view their medical record. In this article, members of the BMJ's patient advisory panel look at variations in patient access to health records, and the nature and number of portals that patients have to use to access this information. They examine the benefits of giving patients access to their health information and argue that providing easy to use portals will allow patients to effectively manage their conditions and advocate for their own health.
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Content ArticleHospitals rely on their electronic health record (EHR) systems to help them provide safe, high quality and efficient health care. However, EHR systems have been found to disrupt clinical workflows and may lead to unintended consequences associated with patient safety. This study sought to explore the differences in staff perceptions of the usability and safety of their hospital EHR system by staff position and length of service. The authors found significant differences in results across staff positions and hospital tenure: In comparison to registered nurses, pharmacists had significantly lower scores for EHR system training. Doctors, hospital management and IT staff were significantly more likely to report high frequency of inaccurate EHR information. Compared to staff with 11 or more years of hospital tenure, new staff had significantly lower scores for EHR system training, but higher scores for EHR support & communication. Dissatisfaction with the EHR system was highest among doctors and staff with 11 or more years tenure at the hospital.
