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Content Article
This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety. Here we list seven tools and articles related to patient engagement and medication safety, including an interview with a patient advocate campaigning for transparency in medicines regulation, a blog outlining family concerns around prescribing and consent, and a number of projects that aim to enhance patient involvement in using medications safely. -
Content ArticleIssues with medication management and errors in medication administration are major threats to patient safety. This article for the US Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network takes a look at the AHRQ's current areas of focus for medication safety. The authors look at evidence-based solutions to improve medication safety in three areas: High-risk medication use and polypharmacy in older adults Reducing opioid overprescribing, increasing naloxone access and use and other interventions for opioid medication safety Nursing-sensitive medication safety The article also explores future research directions in medication safety and highlights that these will advance patient safety overall.
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Content ArticleOn 24 June 2022, the US Supreme Court overruled both Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey and returned the question of abortion’s legality to the US. The ruling opens the door to additional State efforts to limit access to medication abortions, prevent third parties from assisting anyone seeking an abortion or punish women who end their pregnancy. This opinion piece in The New England Journal of Medicine looks at the implications of the end of Roe v. Wade beyond abortion, examining how it could affect other aspects of healthcare rights in the USA. The author, Zita Lazzarini from the Division of Public Health Law and Bioethics at the University of Connecticut School of Medicine, argues that the Supreme Court's ruling opens the door for state regulation of other healthcare decisions, including those regarding contraception, end-of-life care, care for LGBTQ patients and fertility treatments. She highlights that common forms of birth control including IUDs and emergency contraception are already being targeted by some states as “abortifacients,” and raises concerns that State laws declaring that life begins at fertilization will potentially endow thousands of frozen embryos with rights, imposing impossible burdens on fertility centres and their clients.
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Content ArticleThis poster highlights some key issues associated with by antimicrobial resistance (AMR), which is caused by inappropriate use of antibiotics. It outlines the objectives and results of the AMR Patient Group, a coalition of patient groups across Europe working to address the serious public health threat posed by AMR. It also outlines the AMR Patient Group's policy recommendations to European and national health authorities.
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Content ArticleDespite global consensus that access to pharmaceuticals as a lifesaving commodity is a fundamental human right, 2 billion people globally still lack access to medicines. In this blog, Karrar Karrar, Access to Medicines Adviser at Save the Children, looks at why weak regulatory systems are a major patient safety issue in low- and middle-income countries. He highlights that lack of regulatory capacity results in falsified, substandard and fake medicines making their way into local pharmacies and hospitals. It also delays patient access to new medicines due to lengthy processing times. Karrar argues that governments must prioritise investments in strengthening national regulatory systems and increase cross-country collaboration to strengthen regional and global regulatory networks and systems.
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Content ArticlePatient safety culture is a vital component in ensuring high-quality and safe patient care. This cross-sectional study aimed to assess doctors’ and nurses’ perceptions of patient safety culture in five public general hospitals in Hanoi, Vietnam. The study found that the mean scores among nurses were significantly higher than that among physicians for several categories: supervisor/manager expectations staffing management support for patient safety teamwork across units handoffs and transitions Nurses reported significantly higher patient grades than physicians (75% vs 67.1%) and around two-thirds of physicians and nurses reported no event in the past 12 months (62.8 and 71.7% respectively). The authors recommend that hospitals develop and implement intervention programs to improve patient safety, including around teamwork and communication, encouraging staff to notify incidents and avoiding punitive responses.
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Content Article
RCPath - Medical examiners good practice series
Patient-Safety-Learning posted an article in Processes
This Good Practice Series published by The Royal College of Pathologists is a topical collection of focused summary documents, designed to be easily read and digested by busy front-line staff. The documents contain links to further reading, guidance and support, and cover the following topics: Supporting people of Black, Asian and minority ethnic heritage Urgent release of a body Learning disability and autism Organ and tissue donation Post-mortem examinations Child deaths Mental health and eating disorders Out-of-hours arrangements -
Content ArticleThe Institute of Health Equity (IHE) is working with local authorities up and down the country to help them implement the right approaches to reduce health inequalities. The public health department of Luton Borough Council commissioned IHE to support the local authority and other partners to act on health inequalities and become the first ‘Marmot Town’. This report is based on an assessment of data and local evidence and makes recommendations to reduce health inequalities and make Luton a fairer place to live, work, grow up and grow old in.
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Content ArticleIn this blog for Psychology Today, Gary Klein looks at the psychological causes of diagnostic errors, arguing that being clear about the exact causes of these errors is the only way to reduce them. Drawing on physical causes of diagnostic error identified in an Institute of Medicine report in 2015, he highlights the need to go further in understanding the explanations the report offers for diagnostic errors.
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Content ArticleThis blog describes the experience of Colonel Steven Coffee, Cofounder of Patients for Patient Safety US, who experienced a series of medical errors following the birth of his son. After a missed diagnosis of galactosemia, his son suffered liver failure and underwent a liver transplant at eight weeks old. Following his operation, the hospital where he was being treated did not have access to the powdered soy milk which was essential for his son's recovery. This experience spurred Colonel Coffee on to become an advocate for patient quality and safety in health care. For the last nine years, he has worked toward improved patient safety as the first community chair of MedStar Health’s Patient and Family Advisory Council for Quality and Safety (PFACQ).
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Content ArticleHealthcare service innovations are considered to play a pivotal role in improving organisational efficiency and responding effectively to healthcare needs. However, healthcare organisations often encounter difficulties in sustaining and sharing innovations. This qualitative study aimed to explore how healthcare innovators of process-based initiatives see and understand factors that either facilitated or obstructed the implementation of innovation. The authors found that even though the innovations studied were very varied, innovators often highlighted the significant role of the evidential base of success, the inter-personal and inter-organisational networks, and the inner and outer context.
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Content ArticleIn healthcare, there is a well-recognised gap between what we know should be done, and what is actually done. This article considers new models that look at the implementation of evidence-based practice in healthcare systems, particularly looking at the application of a conceptual model called 'sticky knowledge'.
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Content ArticleHypothermia is a common problem in the operating theatre, and it contributes to many poor outcomes including rising costs, increased complications and higher morbidity rates. This literature review in the Journal of PeriAnesthesia Nursing aimed to determine the best method and time to prewarm a patient in order to prevent hypothermia during or after surgery. The authors suggest that forced-air warming is most effective in preventing perioperative hypothermia. Eighty-one percent of the experimental studies reviewed found that there was a significantly higher temperature throughout surgery and in the post-operative care unit for patients who received forced-air prewarming.
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Content ArticleThe General Pharmaceutical Council (GPhC) has written via email to pharmacists and owners of pharmacies with the GPhC’s voluntary internet pharmacy logo, to address ongoing patient safety concerns affecting the online sector. The emails highlight that over 30% of the GPhC's open Fitness to Practise cases relate to online pharmacy—a disproportionate number for the sector of the market that online services occupy. Common issues raised in these cases include: medicines being prescribed to patients on the basis of an online questionnaire alone, with no direct interaction between the prescriber and either the patient or their GP . prescribing of high-risk medications or medications which require monitoring without adequate safeguards. prescribing of medicines outside the prescriber’s scope of practice. high volumes of prescriptions being issued by the prescriber in short periods of time. The emails also recognise the benefits and risks of online pharmacies, outline how the GPhC may take enforcement action against an online pharmacy, and recommend what actions pharmacists and pharmacy owners should take in response to the patient safety concerns raised. You can view the emails in full: Email to owners of pharmacies with the internet pharmacy logo Email to pharmacists
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Content ArticleThis toolkit from the New South Wales Clinical Excellence Commission (CEC) provides information, resources and quality improvement (QI) tools for managers and clinicians to improve sepsis care. The resources can be adapted to suit local needs and cover: Getting started Making improvements Data for improvement Communicating changes Providing education Sustain and spread
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Content ArticlePoor and ambiguous medication recording is a common issue identified by the Care Inspectorate during inspections or complaints activity. This guidance aims to support care staff working in residential care services who record medication administration and develop personal plans, by giving common sense guidance on medication recording and personal plans.
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Content ArticleThis article in the Anesthesia Patient Safety Foundation newsletter looks at the issues surrounding the contribution of anaesthetic gasses to healthcare pollution and emissions. The authors argue that the next patient safety movement should be sustainable healthcare. They highlight that anaesthetists have the opportunity to lead in the effort to reduce healthcare’s impact on population health, and demonstrate to the wider sector that sustainable healthcare is possible and important to the wellbeing of patients.
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Content ArticleEuropean Union Directive 2010/32/EU legally enforces a set of strategies aimed at preventing sharps injuries and determining the risk of bloodborne infections and psychological distress in healthcare workers. This article in the International Journal of Environmental Research and Public Health looks at the results of a national survey conducted in Italy in 2017 and repeated in 2021 to evaluate the progress of the Directive's implementation. The authors assessed the impact of the Covid-19 pandemic on implementation.
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Content ArticleOnline healthcare services and apps can help people take more control of their health, by getting access to care easily and when it suits them. This guidance for patients aims to help patients keep themselves safe when using online health services. Produced by a collaboration of UK health organisations, it includes six top tips for accessing healthcare online: Check if the online healthcare service and healthcare professionals working there are registered with UK regulators Ask questions about how the service works Answer questions honestly about your health and medical history Find out your options for treatment and how to take any medicines you’re prescribed Expect to be asked for consent for information to be shared with other healthcare professionals involved in your care Check what after-care you will receive
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Content ArticleCrisis resolution teams (CRTs) provide treatment at home to people experiencing mental health crises, as an alternative to hospital admission. This study in the International Journal of Mental Health Nursing aimed to measure whether CRTs adhere to a model of good practice, using one-day fidelity reviews of UK crisis teams. The authors found that despite a national mandate to implement the CRT model, there are wide variations in implementation in the UK and no teams in the sample achieved overall high fidelity.
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Content ArticleThere is a paradox of representation in public involvement in research; public contributors are seen as either too naïve to meaningfully contribute or too knowledgeable to represent ‘the average patient’. More expert contributors who have experience in research can therefore be a target for criticism. This study in the journal Health Expectations aimed to examine how representation was discussed in two different scenarios—expert involvement and lived experience. The authors analysed the case of a Lived Experience Advisory Panel (LEAP) chosen for direct personal experience of a topic and the case of an expert Patient and Public Involvement (PPI) panel. They concluded that researchers tend to enact a confirmation logic that seeks a simple, unified patient voice to legitimise decisions. Contributors are therefore limited in their ability to realise a synthesis logic that would actively blend different types of knowledge.
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Content Article
This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list six helpful reads related to medication safety in hospital settings. -
Content ArticleThe Irish Health Service Executive (HSE) has produced a selection of resources and guidance to help people use medicines safely. It offers information about the Know, Check, Ask campaign, encouraging members of the public to: Know your medicines and keep a list Check that you're using the right medicine the right way Ask your health professional if you're unsure The page also includes videos about: how to use the My medicines list tool designed to ensure patients and healthcare professionals know which medications and doses the patient should be taking. 5 moments for medication safety, a campaign linked to the World Health Organizations' WHO Medsafe app.
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Content ArticleThis article looks at the benefits and process of prewarming patients before surgery, in order to maintain normothermia (a normal, safe temperature) throughout the peri-operative process. Increasing the patient's core temperature helps prevent hypothermia later on in surgery, reducing the need to deal with temperature issues during and after surgery. The author highlights the link between warming and patient safety and describes different approaches that can be taken for different lengths and types of surgical procedure.
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Content ArticleImproving health care quality and ensuring patient safety is impossible without addressing medical errors, so it is important to accurately estimate incidence rates and implement the most appropriate solutions to reduce medical errors. This systematic review in the journal Frontiers in Medicine aimed to identify interventions that have the potential to decrease medical errors. The authors concluded that although many interventions have been suggested and tried, patient safety has not significantly improved. They call on policymakers to focus more on implementing selected interventions effectively.
