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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    Closed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm. This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer. The case study suggests safety actions that should be considered to prevent this error from happening again.
  2. Content Article
    This blog by management consultancy McKinsey & Co looks at how to harness the power of people with informal influence to enact transformation within an organisation. It explores a tool known as 'snowball sampling', a simple survey technique originally used by social scientists to study hidden populations reluctant to participate in formal research, such as street gangs, drug users and sex workers. In snowball sampling, recipients take a very short survey and are asked to identify acquaintances who should also be asked to participate in the research. The process instils trust in participants as referrals are made anonymously by peers rather than through formal identification, and one contact quickly snowballs into many. The blog explores how snowball sampling can be adapted to better understand the patterns and networks of influence that operate below the radar in an organisation.
  3. Content Article
    Over the past few years, concerns have been raised about the level of funding and intervention regulators have received from the pharmaceutical industry. In this article for The BMJ, investigative journalist Maryanne Demasi examines whether regulators of medical devices and medications have enough independence from the companies they are meant to regulate. She asked six of the world's biggest regulators about their funding and transparency and found that industry money permeates the world's leading regulators. This casts doubt on their ability to provide effective regulation, especially in the wake of a string of drug and device scandals.
  4. Content Article
    This article in The Milbank Quarterly summarises an extensive literature review addressing the question, "How can we spread and sustain innovations in health service delivery and organisation?" The authors identify three key outputs of the systematic review: A parsimonious and evidence-based model for considering the diffusion of innovations in health service organisations Clear knowledge gaps on which further research on the diffusion of innovations in service organisations should be focused A robust and transferable methodology for systematically reviewing complex research evidence
  5. Content Article
    The government has published a draft Mental Health Bill for pre-legislative scrutiny. The bill aims to modernise the Mental Health Act for the 21st century.
  6. Content Article
    This document outlines the final terms of reference for the Public Inquiry into the government's response to the Covid-19 pandemic, chaired by Baroness Heather Hallett. The Inquiry will examine, consider and report on preparations and the response to the pandemic in England, Wales, Scotland and Northern Ireland. Baroness Hallett has also recorded a video statement to the public about the Inquiry, which includes a British Sign Language translation.
  7. Content Article
    This blog by the charity Picker explores concerns about the safety of staffing levels in the NHS, highlighted by the 2021 NHS Staff Survey. It talks about the potential impact of a recent drop in staff morale. The blog draws out these key findings from the survey: The proportion of staff who felt unwell as a result of work-related stress in the last 12 months rose to 46% – almost half. This was an increase of nearly 3% from the 2020 figure (44%) and continued a trend: the figure has risen each year since 2017, when 38% of staff reported work-related stress. Almost one-in-three staff members say they “often think about leaving” their organisation – an increase of 4% points vs the 26% recorded in 2020. And one-in-six (16%) say they will leave their organisation “as soon as I can find another job” – a 2% point increase from 2020. Only 52% of NHS staff say that they look forward to going to work – a decline of more than 6% points from 58% in 2020. New questions in the survey suggest that many staff are experiencing burnout. Overall, more than a third of staff (34%) said that they ‘always’ or ‘often’ “feel burnt out because of [their] work”. The proportion was even higher for staff in patient facing roles (for example, 41% of registered nurses and midwives) and especially for ambulance personnel (51%).
  8. Content Article
    This document summarises the findings of The Health Foundation's analysis on workforce supply and demand in general practice in England up to 2030/31. It focuses on patient care staff including GPs and general practice nurses. The Health Foundation developed three scenarios of potential workforce supply through a mix of in-house modelling and publicly available data: a scenario based on current policy, a more optimistic scenario and a pessimistic scenario. The analysis demonstrates that in all three scenarios, the supply of GPs and general practice nurses is projected to fall short of demand. Under current policy, the NHS faces a shortfall of over 1 in 4 GP and general practice nurse posts by 2030/31. In the pessimistic scenario this increases to around 1 in 2 GP and nurse posts, raising concerns about patient safety, quality of care and equity of access. In the optimistic scenario, the GP shortfall can be substantially mitigated by 2030/31, but this would require sustained and concerted policy action to boost GP retention and integrate newer roles within multidisciplinary practice teams.
  9. Content Article
    This observational study in The Lancet Public Health analysed the effects of outsourcing health services to private, for-profit providers. The authors evaluated the impact of outsourced spending to private providers on treatable mortality rates and the quality of healthcare services in England, following the 2012 Health and Social Care Act. The authors found that: an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable mortality of 0·38% in the following year. changes to for-profit outsourcing since 2014 were associated with an additional 557 treatable deaths across the 173 CCGs in England. They conclude that private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services.
  10. Content Article
    The consultancy firm McKinsey & Company explored the effects of the Covid-19 pandemic on the nursing workforce in a global survey that included nurses from United States, the United Kingdom, Singapore, Japan, Brazil and France. The survey findings show a consistency around how nurses feel in their roles today, despite the different healthcare systems and delivery networks in each of the six countries. A substantial population of nurses are expressing a desire to leave direct patient care, with between 28% and 38% of nurse respondents in the United States, the United Kingdom, Singapore, Japan and France indicating that they were likely to leave their current role in direct patient care in the next year. This article explores in detail some of the reasons why nurses are choosing to leave direct patient care, and highlights approaches that might encourage retention, including positive leadership initiatives.
  11. Content Article
    This retrospective cohort study in JAMA Internal Medicine aimed to determine whether there are systematic racial and ethnic biases in pulse oximetry among patients with Covid-19, and whether these biases result in patients not being accurately recognised as candidates for oxygen threshold–specific therapy. The authors found that patients from racial and ethnic minority groups with Covid-19 are often subject to overestimation of arterial oxygen saturation levels. This contributes to them not being recognised, or a delay in them being recognised, as eligible to receive Covid-19 therapies.
  12. Content Article
    Complexity is often talked about in health services research, but it has not been sufficiently studied. In this article in the journal BMC Medicine, the authors argue that in open systems characterised by dynamically changing inter-relationships and tensions, conventional research designs must be augmented by the study of how we can best deal with uncertainty, unpredictability and emergent causality. They propose an agenda for future research and invite researchers to contribute to the conversation.
  13. Content Article
    The health and social care system’s long-term sustainability depends on effective digital transformation. This document outlines the government's plans to reform and develop the use of digital technologies in health and social care in order to deliver a system that will be faster, more effective and more personalised. The plan pulls together the four goals of reform for the health and care system identified by the Secretary of State for Health and Social Care: prevent people’s health and social care needs from escalating personalise health and social care and reduce health disparities improve the experience and impact of people providing services transform performance
  14. Content Article
    This cross-sectional study in JAMA Network Open looked at patients in the USA with pneumonia who are admitted to hospitals with higher risk-standardised readmission rates. It aimed to assess whether these patients have higher rates of adverse events. The authors found that patients with pneumonia admitted to hospitals with high all-cause readmission rates were more likely to develop adverse events during hospitalisation. This strengthens the evidence that readmission rates reflect the quality of hospital care for pneumonia.
  15. Content Article
    When critically ill premature infants require transfer by ambulance to another hospital, they frequently require mechanical ventilation. This observational study investigated acceleration during emergency transfers and looked at whether they result from changes in ambulance speed and direction, or from vibration due to road conditions. It aimed to assess how these forces impact on performance of neonatal ventilators and on patient-ventilator interactions. The authors found that infants are exposed to significant acceleration and vibration during emergency transport. Although these forces do not interfere with overall maintenance of ventilator parameters, they make the pressure-volume loops more irregular.
  16. Content Article
    This webinar by the Institute for Safe Medication Practices is aimed at healthcare providers and patient safety specialists. The conversation covers lessons learned in the aftermath of a fatal medication error and looks at common, yet often unresolved, system vulnerabilities. It also examines key strategies and priorities needed to advance an organisation's safety journey.
  17. Content Article
    This blog describes No Wrong Door (NWD), an adult community mental health transformation programme being rolled out across Hampshire, Southampton, Isle of Wight and Portsmouth. The NWD model takes a partnership approach and recognises that mental health is affected by quality of housing, employment, family and personal contacts, leisure and cultural activities, technological solutions and other community resources such as green spaces. Mental health services will work together with the community to ensure that care can be provided locally, and that support can be received in several settings for multiple aspects of a person’s life.
  18. Content Article
    This report by researchers at the University of Birmingham is the first granular analysis of the known and hidden waiting lists for elective procedures in England. There has been previous analysis of the NHS waiting list, but it has been based on the overall waiting list and has included patients waiting for all types of consultant-led care, including outpatient clinic visits and non-surgical treatments. The authors of this report have used procedure-level data to produce estimates for the need for elective procedures.
  19. 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. Claire talks to us about her role as a Patient Safety Lead and why she thinks the new Patient Safety Incident Response Framework will make her work more practical and patient-centred. She also describes why she set up the Patient Safety Management Network and highlights why patient safety roles would benefit from more standardisation across trusts.
  20. Content Article
    Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers are following national guidance and safety recommendations. In this blog John Tingle, a lecturer at Birmingham Law School, raises concerns about the number of Never Events that continue to take place within health services, the lack of public awareness about Never Events and the need to develop a safety culture that allows learning from Never Events to actually take place.
  21. Content Article
    This thesis by Suzette Woodward describes a project that aimed to identify how the National Patient Safety Agency (NPSA) could support improvement in implementing patient safety guidance. It explored the factors that help or hinder successful implementation and its findings led to the design and development of an implementation toolkit, initially targeted at NPSA staff and other national bodies responsible for issuing guidance about safer practices.
  22. Content Article
    The poor treatment of autistic people and people with learning disabilities has been a long-standing problem for the NHS and care system. Although successive governments have focused on supporting autistic people and people with learning disabilities to live independent and fulfilled lives in the community, over 2,055 people remain in secure institutions where they are unable to live fulfilled lives and are often subject to unacceptable and inhumane treatment. This report by the Health and Social Care Select Committee chaired by Jeremy Hunt MP outlines the finding of the committee's Inquiry into the treatment of autistic people by health and care services.
  23. Event
    until
    The Human Factors in Patient Safety Conference 2022 will take place in the O’Flanagan Lecture Theatre, 123 St Stephen's Green, on Friday 23 September 2022. Bringing together a community of human factors in patient safety advocates across Ireland and abroad, the annual Human Factors in Patient Safety Conference will offer the opportunity to gain valuable knowledge and insights from human factors experts. The conference will include contributions from: Martin Bromiley OBE, Founder of Clinical Human Factors Group UK – Listening Down to Develop your Safety Behaviours Mr Peter Duffy, Consultant Urologist – Whistle in the Wind: a Personal Exploration of the Consequences of Whistleblowing in Healthcare Professor Eva Doherty (Chair), Director of Human Factors in Patient Safety – The Irish Context, panel discussion Healthcare professionals can register for the event here. For more information, please email mschumanfactors@rcsi.ie Note: 3 CPD credits are available for this event.
  24. Content Article
    This storyboard poster explains the aims, methods and results of No Wrong Door, a project run by North Yorkshire County Council to ensure young people access the right services, at the right time and in the right place to meet their needs. Young people who enter care during their teenage years tend to spend considerable periods in residential care. They are more likely to have placement breakdowns and can follow a path of multiple placements, over time becoming distrusting of positive relationships, disengaging from education and training and falling into patterns of risky behaviour. No Wrong Door is an integrated service for complex and troubled young people. Their needs are addressed within a single team. Operating from two Hubs, No Wrong Door brings together a variety of accommodation options, a range of services and outreach support under one management umbrella. It is a partnership between seven district councils, nine housing providers, health services (including child and adolescent mental health services) and the police.
  25. Content Article
    The Better End of Life programme is a collaboration between Marie Curie, King's College London Cicely Saunders Institute, Hull York Medical School, the University of Hull and the University of Cambridge. It's first research report outlines key findings of the programme relating to the experience of death and dying during 2020, at the height of the Covid-19 pandemic. This interactive webpage presents graphics which highlight the key findings of the research.
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