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Content ArticleThis recording is part of a series of webinars by the Patient Academy for Innovation and Research (PAIR Academy), The International Alliance of Patients’ Organizations (IAPO) and Dakshama Health, to introduce the Strategic Framework of the World Health Organization's Global Patient Safety Challenge - Medication Without Harm. The theme of this sixth webinar is "Medication Safety in Polypharmacy and Transitions of Care."
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Soojin talks to us about how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions. -
Content ArticleThe General Medical Council (GMC) is the UK's statutory body responsible for taking action to prevent a doctor from putting the safety and confidence of patients at risk. In this blog for The Spectator, doctor Max Pemberton argues that the GMC has lost the trust of doctors by bringing a series of inappropriate cases, resulting in the British Medical Association (BMA) calling for an overhaul of how the GMC is run. He describes some recent investigations as being about 'petty' issues and highlights the significant impact being under investigation can have on doctors' mental health.
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News Article
Large hospital trusts still missing key crisis support in A&E
Patient-Safety-Learning posted a news article in News
Some of the country’s leading acute hospitals are not meeting a key NHS standard for mental health support in emergency departments, HSJ research suggests, with some regions faring better than others. Latest official estimates indicate that more than a third of EDs (36 per cent) are not yet meeting ‘core 24’ standards for psychiatric liaison – which requires a minimum of 1.5 full-time equivalent consultants and 11 mental health practitioners. The long-term plan target is for 70 per cent of acute trust emergency departments to have the optimum ‘core 24’ standard service by 2023-24. The NHS appears to be on track to hit this, with significant progress made, despite the pandemic. Annabel Price, chair of the Royal College of Psychiatrists’ liaison faculty, said tackling the workforce crisis with a fully funded plan would “prove instrumental in boosting recruitment across all acute trusts”. Read full story (paywalled) Source: HSJ, 23 August 2022 -
Content Article
Communication in the operating theatre (14 November 2013)
Patient-Safety-Learning posted an article in Surgery
Communication is extremely important to ensure safe and effective clinical practice. This systematic literature review of observational studies addressing communication in the operating theatre aimed to gain an understanding of actual communication practices, rather than what was reported through recollections and interviews. In all of the studies reviewed, communication was found to affect operating theatre practices. Further detailed observational research is needed to gain a better understanding of how to improve the working environment and patient safety in theatre. -
Content ArticlePoor communication among healthcare professionals contributes to widespread barriers to patient safety. The word “communication” means to share or make common. In research literature, two communication paradigms dominate: communication as a transactional process responsible for information exchange communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. This article in the journal Implementation Science debates the merits of encompassing both approaches.
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Content ArticleHip fracture is a serious, life-changing injury that can affect older people, and is the most common reason for them to need emergency anaesthesia and surgery. The Physiotherapy Hip Fracture Sprint Audit (PHFSA) was the biggest ever audit of UK physiotherapy, and has implications for physiotherapists working in many settings.
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Content ArticleThis report by the consultancy firm Deloitte looks at patient safety across biopharmaceutical (biopharma) value chains, arguing that change is needed to make medications safer for patients and add value to pharmaceutical products. The authors highlight that there is currently great potential for strategies to increase safety, improve equity and enhance patient engagement and experience. Advances in artificial intelligence (AI) technologies and data analytics, combined with increased incidence of adverse event reports (AERs) and increasing expectation of more personalised, preventative, predictive and participatory (4P) medicine, present an opportunity to improve pharmacovigilance.
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Content ArticleThis blog on the NHS England website looks at how Written Medicine, a service that provides bilingual medication information, is helping to reduce healthcare inequalities and medical errors in London. Written Medicine’s software allows pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bilingual labels help patients take ownership of their treatment, giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. The blog also looks at the experience of London North West University Healthcare NHS Trust (LNWH) using Written Medicine. A 2019 audit showed that the service was valued by patients and highly successful in increasing medication adherence through empowering patients.
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Content ArticleThis document from the Department of Health and Social Care (DHSC) contains guidance for integrated care partnerships on the preparation of integrated care strategies. It contains an introduction, two sections of statutory guidance on the preparation of the integrated care strategy including involvement and content, and a section of non-statutory guidance relating to the publication and review of the integrated care strategy. It also includes case studies that demonstrate some of the innovative approaches taking place throughout England.
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Content ArticleThese slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
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Content ArticleThis article by Penelope Hawe from the Menzies Center for Health Policy at the University of Sydney, looks at complexity and how it increases the unpredictability of interventions in systems. She argues that new metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners as much as it comes from intervention researchers.
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Content ArticleThese Quality Standards have been developed by the Resuscitation Council UK. They enable healthcare organisations provide a high-quality resuscitation service, with guidance tailored for different settings including acute care, primary care, dental care, mental health units, community hospitals and in the community.
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Content ArticleIn this blog, Grace Annan-Callcott, Programme Adviser at the Understanding Patient Data programme (UPD) outlines the findings of a new report on the impact of including information about patient data in health charities' guidance. The report investigates whether adding small explanations about the role of patient data in developing health guidance affects people’s: perception of the information or advice general awareness or understanding of how patient data can be used. Working with a group of charities including Asthma + Lung UK, Best Beginnings, Cystic Fibrosis Trust, MS Trust, Stroke Association, National Autistic Society, British Heart Foundation and the Patient Information Forum (PIF), UPD set up a community of practice to research the impact of patient data in health guidance.
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Content ArticleIn this blog, Charlotte Clayton, midwife and clinical advisor at the Organisation for the Review of Care and Health Apps (ORCHA), explores how providing the right training and support for maternity staff is key to seeing the benefits tech can bring to quality of care and workload.
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Content ArticleThis paper by Professor Paul Bate, Emeritus Professor of Health Services Management at University College London, looks at the importance of considering context in healthcare initiatives. It introduces various frameworks for viewing context and looks at key themes in existing research. It concludes by looking at key questions for future research on context.
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Content ArticleThis article in The BMJ examines the case for vaccinating children under five against Covid, following the US recently recommending that children aged six months to five years should receive Covid-19 vaccines. It looks at the risks and benefits of vaccination for young children, citing recent Moderna and Pfizer trials. It highlights that children are more likely than adults to experience asymptomatic Covid-19 or very mild illness, and are much less likely to have severe disease requiring hospital admission. But for children with underlying health conditions, such as long term neurological disease, vaccination may be beneficial in preventing severe disease.
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Content ArticleNeonatal intensive care unit (NICU) admission among term neonates is associated with significant morbidity and mortality, as well as high healthcare costs. This study in the Journal of Clinical Medicine aimed to identify and quantify risk factors and causes of NICU admission of term neonates. The study looked at NICU admission for term babies at a maternity unit in Israel. The authors suggest that a comprehensive NICU admission risk assessment that uses an integrated statistical approach may be used to build a risk calculation algorithm for this group of neonates prior to delivery.
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Content Article
AYPH Youth health data website
Patient-Safety-Learning posted an article in Children, young people and families
This website from the Association for Young People's Health (AYPH) aims to provide useful data about young people’s health for healthcare professionals, researchers and other professionals working with young people. At its heart is a data compendium called ‘Key Data on Young People’s Health’ produced AYPH, which gives up to date national data on key health outcomes for 10-24 year olds. The website also include links to other resources and sources of data about the key issues facing young people. -
Content ArticleDefining whether a diagnostic error has occurred can be difficult, but in order to reduce harms from diagnostic errors, hospitalists must first understand how these errors occur and then develop practical strategies to avoid them. This article in the journal Annals of Internal Medicine explores these issues and highlights new opportunities for reducing diagnostic error in hospitals.
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Content ArticleThis leaflet produced by Group B Strep Support and the Royal College of Obstetrics and Gynaecology provides information about group B Strep (GBS) aimed particularly at pregnant women. It includes; an explanation of what group B Strep is. what GBS could mean for a baby. how to reduce the risk of GBS infection to a baby. a list of the signs of GBS infection in newborn babies.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jordan talks to us about his journey from drama school to patient safety, how the new Patient Safety Incident Response Framework (PSIRF) will change the way the NHS looks at safety, and how his love of driving makes him think differently about his role. A transcript of the interview is also available below.- Posted
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Content ArticleThis report by the Academy of Medical Royal Colleges looks at the possibilities for establishing a system of staggered changeover start dates for trainee doctors. Evidence suggests that there is an increase in patient morbidity and mortality at the beginning of August each year, which corresponds with the time when trainee doctors rotate positions. The paper, produced by the Academy’s Staggered Trainee Changeover Working Group (STCWG), recommends that the most effective solution for safe trainee changeover is a roll forward model of staggering, where the more senior trainees rotate one month later. A survey of Foundation doctors demonstrated support for a system where all Specialty Training programmes start at the beginning of September, one month after the end of the Foundation Programme.
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Content ArticleThe fishbone diagram is a widely-used patient safety tool that helps to facilitate root cause analysis discussions. The authors of this article in the journal Diagnosis expanded this tool to reflect how both systems errors and individual cognitive errors contribute to diagnostic errors. They describe how two medical centres in the US have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets their patient safety and educational needs.
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Content ArticleThe Department of Health today published the 2021/22 Inpatient, Day Case and Outpatient Hospital Statistics for Northern Ireland. Analysed by HSC Trust, hospital and specialty, these Hospital Statistics publications outline: the number of inpatient and day case admissions. the number of attendances at consultant led outpatient services in Northern Ireland during 2021/22.
