Patient-Safety-Learning
PSL ModeratorsContent Type
Forums
Learn
News
Events
Gallery
Everything posted by Patient-Safety-Learning
-
Content ArticleThis infographic accompanies the TeamSTEPPS for diagnosis improvement course from the US Agency for Healthcare Research and Quality (AHRQ).
-
Content Article
AHRQ course- TeamSTEPPS® for diagnosis improvement
Patient-Safety-Learning posted an article in Diagnosis
Diagnostic harm is an area of concern in healthcare quality and patient safety. A growing body of patient safety and care delivery research shows that diagnostic harm is both widespread and costly. TeamSTEPPS is an evidence-based program built on a framework composed of four teachable, learnable skills—communication, leadership, situation monitoring and mutual support. The TeamSTEPPS for Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error. On the course. teams will learn about how improved communication among all members of the team can help lead to safer, more accurate and more timely diagnosis in all healthcare settings. The course can be delivered virtually, in a classroom setting or as individual self-paced learning modules. Additional resources for trainees include: Team assessment tool for improving diagnosis Case study of the diagnostic journey of Mr. Kane Reflective practice tool Postcourse knowledge assessment -
Content ArticleThese tools and resources from the National Institute for Health and Care Excellence (NICE) accompany the NICE guidance on Hypothermia: prevention and management in adults having surgery. Resources available for download include: Audit and service improvement baseline assessment tool Implementation support advice document Education information Shared learning information Practical steps to improving the quality of care and services using NICE guidance
-
Content ArticleThis report by pharmaceutical company ViiV Healthcare focuses on results from wave two of their Positive Perspectives study. It investigates how people living with HIV (PLHIV) rate their own health and how living with HIV impacts their lives and affects their outlook for the future. It also examines their interactions and relationships with healthcare professionals and their experiences with antiretroviral treatment. The report highlights the importance of open and active dialogue and shared decision making between PLHIV and their healthcare professionals in improving outcomes.
-
Content ArticleHealth information technology (health IT) has potential to improve patient safety, but its implementation and use has had unintended consequences and has raised new safety concerns. This viewpoint article in BMJ Quality & Safety introduces a new framework—the health IT safety (HITS) framework—to provide a conceptual foundation for health IT-related patient safety measurement, monitoring and improvement.
-
Content ArticleThis literature review in The Operating Theatre Journal examines why the decision was made not to class surgical fires as a 'Never Event', even though research has identified them as a preventable hazard. The author also examines steps that could be taken to further reduce the risk of surgical fires in the NHS and other health systems. You will need to create a free online account to view this article.
-
Content ArticleThe Health and Care Act 2022 placed Integrated Care Systems (ICSs) on a statutory footing in July 2022, and trusts will play a critical role in delivering the key purposes of ICSs in order to benefit patients and service users. This briefing from NHS Providers: provides a brief overview of how provider collaboratives are developing across England. illustrates some of the emerging benefits that collaboratives are working to realise. explores how trust leaders see the role of provider collaboratives developing within ICSs. identifies some key enablers and risks trust boards need to consider.
-
Content ArticleIn this episode of The Mind Full Medic podcast, host Cheryl Martin talks to Dr Chris Turner, a consultant in Emergency Medicine at University Hospitals of Coventry and Warwickshire. Chris is also the co-founder of Civility Saves Lives, an organisation dedicated to raising awareness of the impact behaviour has on individuals, teams and organisations. In this conversation, Chris discusses his own professional journey and experience as a healthcare leader and safety and quality lead. He talks about the challenging start to his consultant career, the powerful impact of a trusted mentor and critical friend, and how this experience has informed his future work. He also describes the spectrum of approaches to improving safety and quality in the challenging, complex healthcare environment, including the Safety I and Safety II approaches.
-
Content Article
The 'So What' of maternity data (August 2022)
Patient-Safety-Learning posted an article in Maternity
This report from the Healthcare Quality Improvement Partnership (HQIP) aims to explore how the multiple national data sets and national audits are used in maternity services across the UK. Based on data from a survey of over 100 people working in a variety of roles across maternity services and a series of in-depth interviews with a diverse group of clinicians and methodologists working in this area, the report explores what data is being reviewed and how it might influence quality improvement, as well as the burden of data. -
Content ArticleThis study in the journal Health Policy uses an innovative methodology to provide further understanding of the implementation process in the English NHS, using the examples of two distinctly different National Institute for Health and Care Excellence (NICE) clinical guidelines. The authors conclude that NICE and other national health policy-makers need to recognise that the introduction of planned change ‘initiatives’ in clinical practice are subject to social and political influences at the micro level as well as the macro level.
-
Content ArticleThis blog by global law firm Clyde & Co describes the background to the new Patient Safety Incident Response Framework (PSIRF) and how it will change the way that NHS services will investigate patient safety incidents. The authors offer an overview of the framework, its implementation and who it affects.
-
Content ArticleThis guide by the Royal College of Physicians explains what a hip fracture is and answers questions about how patients will be cared for before and after a hip operation. It is written for patients and their families and carers. The guide covers aspects of hip fracture care such as: pain relief memory problems who should be involved in your care how soon an operation should take place eating and drinking bladder problems rehabilitation and physiotherapy following surgery when you will be able to go home future falls prevention bone strengthening medication
-
Content ArticleThis letter accompanies the publication of the Patient Safety Incident Response Framework (PSIRF) by NHS England. The PSIRF forms a major part of the NHS Patient Safety Strategy and replaces the Serious Incident Framework (SIF) that has been in place since 2015. It aims to improve safety management across the healthcare system in England and to support the NHS to embed the key principles of a patient safety culture. In his letter, Dr Aiden Fowler, National Director of Patient Safety in England outlines how PSIRF was developed, describes how the transition from the SIF to PSIRF will take place and highlights the tools available to support organisations to implement the changes. The letter is addressed to: NHS trust and foundation trust chief executives, medical directors and nursing directors Integrated Care Board medical directors and nursing directors NHS England Regional Team medical directors and nursing directors NHS England regional direct commissioning leads
-
Content ArticleNon-ventilator-associated hospital-acquired pneumonia (NVHAP) is one of the most common and deadly healthcare-associated infections, but it is not tracked, reported or actively prevented by most hospitals. This article in the journal Infection Control & Hospital Epidemiology highlights a national call to action to address NVHAP in the US. This national call to action includes: launching a national healthcare conversation about NVHAP prevention. adding NVHAP prevention measures to education for patients, healthcare professionals, and students. challenging healthcare systems and insurers to implement and support NVHAP prevention. encouraging researchers to develop new strategies for NVHAP surveillance and prevention.
-
Content ArticleThis article and video tell the story of Rihan Neupane, a baby born prematurely in Dhapasi, Nepal, who was left in a vegetative state following a series of medical errors including a missed diagnosis of meningitis. His parents had chosen a private international hospital for their maternity care, but were let down by a series of medical errors including Rihan being mistakenly given a massive paracetamol overdose. Although external hospital safety inspectors found the hospital negligent on many counts, the hospital continued to deny any wrongdoing or responsibility for Rihan's condition. Rihan's father Sanjeev Neupane talks about his family's experience in the embedded video.
-
Content ArticleWhen hospital patients do not have their teeth brushed it can lead to them developing pneumonia—poor dental hygiene in hospital is believed to be a leading cause of hundreds of thousands of cases of pneumonia a year. In this blog for Medscape, reporter Brett Kelman looks at the link between dental hygiene and hospital-acquired pneumonia, which kills up to 30% of patients who are infected with it. He highlights a lack of understanding of the impact of failing to brush inpatients' teeth, in spite of a growing body of research evidence that links lack of adequate toothbrushing to pneumonia infection.
-
Content Article
This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here -
News Article
Hip fracture care too slow in some hospitals, study says
Patient-Safety-Learning posted a news article in News
There are big differences in how well patients with hip fractures are cared for by hospitals in England and Wales, a Bristol University study says. In some hospitals one in 10 people died within a month of surgery - more than three times worse than in the best. Getting patients into theatre quickly and out of bed the next day for physio are key ways to improve care. People should receive the same, high-quality care wherever they live, the researchers said. "If you get it right for older people with hip fractures, you're probably getting it right for older people in general," says Professor Celia Gregson, who led the study of more than 170,700 patients in 172 hospitals between 2016 and 2019. An NHS spokesperson said hip fracture care in the UK had "seen dramatic improvements in recent years". Read full story Source: BBC News (31 August 2022) -
EventuntilThe Covid-19 pandemic has led to a dramatic increase in the percentage of adults showing moderate or severe symptoms of depression. The Office for National Statistics said that over 16% of adults were affected in 2020 – compared with around 10% in 2019. Those affected were more likely to feel stressed or anxious and worried about their future than in 2019. Many of these people will need support and treatment from the NHS – and may not have sought it during the pandemic. In addition, financial pressures over the coming years may lead to more cases of depression. Some will seek help from their GP and be referred onwards for treatment – often to the sort of “talking therapies” used in IAPTs. But getting access to these is not always straightforward or quick, and patients can often represent to their GP seeking help. In addition, patients can suffer low points but not be able to access support until their next IAPTs session. This HSJ webinar, in association with Ethypharm Digital Therapy, will look at these issues and ask what solutions are available. What is the current situation with support for those with depression and how does it impact on GPs and other primary care professionals, as well as patients? What are the challenges around existing IAPTs capacity? Is there scope for other existing mental health services to assist? How can digital solutions be used to increase capacity? How can solutions be scaled up for use across an integrated care system area? Speakers include: Dr Kate Lovett, consultant psychiatrist, former dean of the Royal College of Psychiatrists Andy Bell, deputy chief executive, Centre for Mental Health Hélène Moore, Pharmaceutical, Ethypharm Claire Read, HSJ contributor (webinar chair) Register for the webinar
-
Content ArticleBabylon is a US company that offers AI-powered online apps to health systems. Several UK hospital trusts have used Babylon apps to triage patients and reduce attendances at accident and emergency departments since 2018. In this blog, Nicole Kobie, contributing editor at technology website Wired, looks at Babylon's recent cancellation of its last contract with an NHS trust. She highlights that although some welcome Babylon's exit from the NHS, the disruption caused by the apps' implementation was costly and has left some trusts with large bills. The apps also triggered complaints from the Medicines and Healthcare products Regulatory Agency (MHRA) after concerns that Babylon's AI was missing signs of serious illness. The article highlights the need to carefully consider patient safety and cost-effectiveness when introducing new technologies into health systems, and take a slower approach to rolling out AI innovations.
-
EventuntilMedication-related harm accounts for up to half of the overall preventable harm in medical care. Patients in low- and middle-income countries are twice more likely to experience preventable medication harm than patients in high-income countries. Considering this huge burden of harm, “Medication Safety” has been selected as the theme for World Patient Safety Day 2022. To commemorate the day, WHO is organizing a Global Virtual Event, calling on all stakeholders to join efforts globally for “Medication Without Harm”. During the event, stakeholders will discuss medication safety issues within the strategic framework of the WHO Global Patient Safety Challenge: Medication Without Harm, including 1) Patients and the public, 2) Health and care workers, 3) Medicines, and 4) Systems and practices of medication. Interpretations will be available in Arabic, Chinese, English, French, Hindi, Portuguese, Russian and Spanish. Register for the webinar Save the date-flyer_Global Virtual Event WPSD 2022_15 September 2022.pdf
-
Content ArticleThis report revisits the conclusions of The Health Foundation's Covid-19 impact enquiry, which found that poor health and existing inequalities had left parts of the UK more vulnerable to the virus and had influenced its devastating impact. A year on from the impact inquiry, more than 90% of the UK population have had at least one Covid-19 infection, and 74% of adults had received three vaccinations by April 2022. This report considers: the further direct impact of Covid-19 on health outcomes. the broader implications for social determinants of health. the extent to which previously highlighted risks to health have been addressed. the implications for the country of ‘living with Covid-19’.
-
Content ArticleThis report by the Institute for Fiscal Studies (IFS) looks at which staff are more likely to leave the NHS acute sector. There is still little analysis available on the reasons why staff leave the NHS, but increasing our understanding of the complex factors that cause people to leave the health service would allow the NHS to develop more effective retention strategies. The report uses the Electronic Staff Record, the monthly payroll of directly employed NHS staff, to analyse the leaving rates of consultants, nurses and midwives, and health-care assistants (HCAs) between 2012 and 2021. The authors highlight that many other factors that influence retention remain unknown, and much more research is needed in this area.
-
News Article
AHSN Network Innovate Awards 2022 finalists announced
Patient-Safety-Learning posted a news article in News
The finalists for The Innovate Awards 2022 have been revealed following a rigorous round of judging over the summer, and Patient Safety Learning is a finalist in the 'Enabling Safer Systems of Care Through Innovation' category. In its inaugural year, The Innovate Awards saw a grand total of 194 entries from health and care teams across the country covering ten award categories. The ten eventual winners will also compete for ‘Innovation Champion of the Year’ to be announced on the evening of the award ceremony in September. Commenting on the awards, Matthew Taylor, Chief Executive, NHS Confederation from NHS Confederation said: “Judges across all the award categories have remarked on how impressive and inspiring the work contained in these submissions has been. It has been a delight to see the wonderful efforts taking place in terms of innovation in the health and care sector and it is hugely important to recognise and celebrate this.” Read full story Source: AHSN Network (30 August 2022) -
Content ArticleThis paper in the journal Social Science & Medicine reports from an ethnographic study of hospital planning in England between 2006 and 2009. The authors explored how a policy to centralise hospital services was promoted in national policy documents, how this shifted over time and how it was translated in practice. They found that policy texts defined hospital planning as a clinical issue and framed decisions to close hospitals or hospital departments as based on the evidence and necessary to ensure safety. They argue that this clinical rationale is sometimes a false reframing of a political motivation, that it constrains public participation in decisions about the delivery and organisation of healthcare, and that it restricts the extent to which alternatives can be considered.
