Patient-Safety-Learning
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Everything posted by Patient-Safety-Learning
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Content ArticleThis update by Charlie Massey, Chief Executive of the General Medical Council (GMC), outlines progress and key milestones ahead of the start of regulation for physician associates (PAs) and anaesthesia associates (AAs) in December 2024. It covers: Update on GMC consultation How the GMC will regulate PAs and AAs PA and AA registration process Upholding professional standards Setting standards for high-quality education and training Taking action when concerns arise Setting expectations for appraisal ahead of future revalidation
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Content ArticleWords convey empathy, demonstrate competence and generate trust in conversations between patients and healthcare providers. Small wording changes can affect the nature of interactions and the outcomes of an appointment or visit. This JAMA article provides examples of how subtle changes in word choice affect the information patients provide, patients’ uptake of information from healthcare professionals and patients’ adherence to recommended interventions.
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Content ArticleRachel Wright, founder and director of Born at the Right Time, is a qualified nurse, wife of a GP and parent of a young man with complex disabilities. In this BMJ opinion piece, she describes her experience of navigating the healthcare system on behalf of her son, and highlights the gap between narratives about empowering parents and the reality of her experience as a parent carer. She describes the mistrust and institutionalised bias that the healthcare system shows parents and the impact this has on parents' mental health. She calls on the healthcare system to examine the causes of this bias, rather than focusing on empowering parents to deal with the problems the system presents as they advocate for their children.
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Content ArticleIn this Lancet article, Jeremy Greene reflects on Carl Elliott's book 'The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No'. He highlights a case that Elliott examines in the book, in which 80 people—mostly black patients on low incomes—were enrolled by Eugene Saenger to take part in human radiation experiments. Between 1960 and 1972, Saenger tested megadoses of total body radiation that were not primarly intended as therapy, but to observe the effects of different doses of radiation on the human body. Patients believed they were receiving a potentially life-saving therapy, but were being exploited in the name of research. Nearly a quarter of the patients died within two months of irradiation—the higher the dose, the higher the risk of death. After decades of denial, the hospital was forced to apologise only after the outcome of a Congressional inquiry, a Presidential bioethics commission, and a series of civilian lawsuits. Elliot highlights the difference in the way in which the victims and Saenger are treated in memorials at the University of Cincinnati Medical Center—Saenger is memorialised through a glass cabinet full of his medals, photographs of his research team and historical research instruments. In contrast, the victims are remembered in a small plaque overgrown by plants in the hospital courtyard, funded by the patients' families.
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Content ArticleThe National Audit of Inpatient Falls (NAIF) is a continuous audit of all inpatients who have a fall that results in a femoral fracture. This report looks at clinical data on falls collected in 2023. Based on 1,609 cases, it states that falls prevention activity should not focus solely on older people’s wards, finding that nearly half of all inpatient femoral fractures (IFFs) occur on general medical wards. To address the potential for harm caused by hospital-acquired deconditioning, this report presents a new approach to risk factor assessment that focuses on promoting activity to ensure each patient is fit to move as safely as possible. This covers factors such as vision, medication review, delirium, mobility and continence, and provides information on the proportion of patients affected by each in 2023, compared to 2022 and 2021. It contains five key recommendations, four of which state that Trusts and health boards should: Review their policies and practice to ensure that older hospital inpatients are enabled to be as active as possible Ensure that there are robust governance processes in place to understand when post-fall checks fail to correctly identify a fall related injury’ Have processes in place to hasten time to administration of analgesia after an injurious fall Prepare for the audit expansion in January 2025. The fifth recommendation states that NHS England and the Welsh Government should implement national drivers t
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Content ArticleLyme disease is a tick-borne, bacterial infection that causes chronic fatigue, headaches, swollen joints and fever, among other symptoms. Following the actor Miranda Hart's having recently shared that she has been living with the effects of Lyme disease for years, Zoë Beaty looks at the issues surrounding diagnosis and treatment of the condition. She outlines why some doctors believe the condition does not exist, or that people with ME/chronic fatigue syndrome are being misdiagnosed with it. The lack of research and evidence around the condition means that many of the people who live with its symptoms—a large proportion of which are female—struggle to access effective treatment.
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EventIn 2014 Seth Goodburn died from pancreatic cancer, 33 short and heart-breaking days after diagnosis. Seth wanted to die at home, however the weight of systems and processes meant that he sadly died in an acute hospital. After Seth died, his wife Lesley shared their story via a play, a film and an educational resource called Seth's Story. Sharing the story aims to: improve end of life care highlight the need for psychosocial support raise awareness of pancreatic cancer signs and symptoms. 10 years later, join this free conference to hear the impact of sharing Seth's Story, the improvements that have been made and future plans to help others share their experiences through creative artforms. Seth's Legacy Conference will take place at Keele University, where there will be an amazing line of presenters and performers covering pancreatic cancer, compassion and creativity in the impressive chapel on the campus. Sign up for the conference
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This webinar will look at a review by the UCL Institute of Health Equity (IHE), which concludes that racism damages health and wellbeing and drives inequalities in London. Racism in the capital is widespread and persistent causing damage to individuals, communities and society as a whole. Its impacts are experienced in different ways and to varying levels of intensity related to individual experiences, socioeconomic position and other dimensions of exclusion such as disability, age and gender. The intersections with other dimensions of exclusion can amplify the effects of racism. Our focus is on the effects of racism on health and its contribution to avoidable inequalities in health between ethnic groups – a particularly unacceptable form of health inequity. It is urgent that society tackle the damage to health and wellbeing as a result of racism. The review is part of a series of evidence reviews funded by the Greater London Authority (GLA) to build the evidence for reducing health inequalities in London through action on specific social determinants of health. The other three reviews cover housing, the cost of living and adult skills. Register for the webinar -
Content ArticleClinical decision support (CDS) systems, which aim to support healthcare professionals in making more efficient and evidence-based decisions, are now prevalent in clinical practice. Although many CDS tools, such as clinical calculators and automated order sets, involve low complexity, other CDS systems incorporated into electronic health records are increasingly sophisticated, deployed in time-sensitive settings and built on artificial intelligence (AI) or machine-learning models. This Lancet article looks at the reasons why CDS tools might pose unclear or unacceptable risks to patient safety and equitable care.
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Content ArticleThis study in JAMIA aimed to examine changes in technology-related errors (TREs) in paediatrics. It looked at how errors manifest and their underlying mechanisms at three time points after the implementation of computerised provider order entry (CPOE) in an electronic health record. It also evaluated the clinical decision support (CDS) available to mitigate technology-related errors at five-years after the implementation of CPOE. The authors found that technology-related errors persisted 4-years post-CPOE with no difference in the rate compared to immediately post-CPOE. They highlight the need for greater attention to address technology-related errors and enhance the safety benefits of systems.
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Content ArticlePatient-Safety-Learning posted an article in Australian Commission on Safety and Quality in Health CareThis status report by the Australian Commission on Safety and Quality in Healthcare looks at achievements against the recommendations in 'Medication without harm – WHO Global Patient Safety Challenge: Australia’s response'. The report examines data published to the end of June 2023 and published papers to the end of February 2024. It examines the impact of programs implemented to address the priority actions identified in the three WHO flagship areas: Monitoring polypharmacy and responding to inappropriate polypharmacy Reducing harm from high-risk medicines, with focus on insulin, opioid analgesics, anticoagulants and antipsychotics Improving medication safety at transitions of care.
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Content Article
In this interview, Richard von Abendorff explores the concept of epistemic exclusion. Epistemic exclusion can be defined as the continual rejection of a person’s expertise and knowledge because of their lack of power or position. Richard describes his experience of epistemic exclusion both as a family member and during his time in patient involvement roles. He explains how and why he believes epistemic exclusion dominates the health system’s response to harmed patients and their families and contributes to ongoing harmful care. Richard argues that this failure to take on the perspectives of people harmed by healthcare happens at every level and means that the system cannot effectively learn from harm incidents. He also describes the trauma, stress and feeling of alienation that not being listened to or taken seriously has on patients and families. This interview is Richard’s final call to action before he leaves the patient safety field. He hopes the challenge of tackling epistemic exclusion will be taken up by those in the health system who have the power to change how the voices of patients and their advocates are valued and utilised—at all stages of learning and change from harm events. A transcript of the interview is available below the video. -
Content ArticleIn this Independent article, author and podcaster Lorraine Candy comments on a recent BBC Panaroma episode which looked into private menopause clinics. She criticises the programme for creating fear around hormone replacement therapy (HRT) and misrepresenting the issues facing women's health services in the UK. She argues that rather than focusing on the practice of one private clinic, the question being asked should be why private clinics need to exist in the first place. The answer, she states, is that GPs are ill-informed about menopause, leading to women being patronised, gaslit and not having their symptoms taken seriously. She also highlights the dangers of GPs wrongly prescribing antidepressants instead of HRT, leaving women taking drugs with serious side-effects that don't appropriately treat the cause of their symptoms.
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This webinar will shine a spotlight on the exceptional projects recognised at the recent Patient Experience Network National Awards. This event serves as a follow-up to the awards ceremony and provides a unique opportunity to hear directly from a select group of winners and runners-up as they present their initiatives. Discover innovative solutions, best practices, and inspiring stories from the forefront of patient experience improvement. Learn how these dedicated individuals and teams are making a significant impact in healthcare and social care, as they share their insights, challenges, and successes. Register for the webinar -
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In this interview, we speak to Barbara Molony-Oates, public involvement manager at the Health Research Authority about why it's important to involve patients and members of the public in health research. Barbara tells us about the Shared Commitment to Public Involvement, a partnership of research organisations working together to promote, support and improve public involvement in health and social care research. She describes how the Shared Commitment was developed and how it is helping researchers involve individuals and communities who have never before considered taking part in research. -
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Speak Up For Safety is a Just Culture training workshop that aims to help staff at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. It was developed by Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust. This presentation has been shared by the authors and is designed to be used in Speak Up for Safety training workshops. Bella has also written a blog for the hub about how Speak Up for Safety was developed and how it is helping staff feel safe and empowered to speak up. -
Content ArticleWorkers tasked with specific responsibilities around patient and public involvement (PPI) are now routinely part of the organisational landscape for applied health research in the United Kingdom. The National Institute for Health and Care Research (NIHR) has had a pioneering role in developing a robust PPI infrastructure for publicly funded health research in the United Kingdom. However, there are still considerable barriers to embedding worthwhile and sustainable public input in the design and delivery of research. Notably, researchers and healthcare professionals report a tension between funders’ focus on deliverables and the resources and labour required to embed public involvement in research. This study explored this issue and found five overarching themes which signal a growing tension between expectations put on staff in PPI roles and the structural limitations of these roles: the instability of support the production of invisible labour PPI work as more than a job accountability without control delivering change without changing.
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Content ArticleAntimicrobial resistance (AMR) poses an important global health challenge. Evaluating changing trends in AMR mortality across time and location is necessary to understand how this important global health threat is developing and prepares us to make informed decisions regarding interventions. This study presents the first comprehensive assessment of the global burden of AMR from 1990 to 2021, with results forecasted until 2050. The results showed a high variability of AMR burden by location and age, so it is important that interventions combine infection prevention, vaccination, minimisation of inappropriate antibiotic use in farming and humans and research into new antibiotics to mitigate the number of AMR deaths that are forecasted for 2050.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)It has been suggested that 1 in 30 patients are affected by preventable medication-related harm, with the highest prevalence (around 50%) occurring during prescribing. If you consider this statistic in the context of an average prescriber, a pharmacist who prescribes for ten patients a day could potentially cause a medication-related harm every six days. This article in the Pharmaceutical Journal outlines how human factors can help in developing safe prescribing practices and reduce error risk. It aims to help pharmacists: describe the prevalence and types of prescribing errors that commonly occur; understand the relationship between human factors and patient safety; apply knowledge of human factors in a clinical or professional setting; recognise unsafe prescribing practices and develop potential strategies to reduce the risk of prescribing errors. It looks at James Reason's Swiss cheese model and outlines how the Systems Engineering Initiative for Patient Safety (SEIPS) model can be applied in prescribing. The article is free to access, but you will need to sign up for a free Pharmaceutical Journal account to view it.
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Content ArticleThis case example in the Pharmaceutical Journal explores how off-label drug holidays and other behavioural changes can be used to treat a patient with obsessive compulsive disorder taking sertraline who is experiencing sexual dysfunction. It demonstrates the importance of open communication, shared decision making and consistent follow up in finding ways to mitigate the impact of medication side effects on patients' lives. The article is free to access, but you will need to sign up for a free Pharmaceutical Journal account to view it.
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Content ArticleAlthough most healthcare is delivered in outpatient settings, knowledge about outpatient adverse events (AEs) and harm remains limited. The SafeCare Study aimed to assess the frequency of adverse events in both inpatients and outpatients across several healthcare systems in Massachusetts, USA. This paper in the Annals of Internal Medicine presents the results of the SafeCare Study which relate to adverse events in outpatients. The results showed that outpatient harm was relatively common and often serious. Adverse medication events were most frequent adverse event and rates of harm were higher among older adults.
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This GovConnect webinar focuses on addressing the critical issue of wrongful hospitalisation for neurodivergent youth. Often, misunderstandings of neurodivergent behaviours or lack of appropriate support lead to unnecessary hospitalisations, causing distress for young people and their families. The session will cover strategies for preventing these situations, including early intervention, effective communication between caregivers and healthcare professionals, and the importance of building robust community support systems. It will also explore systemic changes needed in healthcare and education to ensure neurodivergent individuals receive the right care in the right settings. This webinar is designed for parents, educators, healthcare providers and advocates, offering practical tools to reduce wrongful hospitalization and improve outcomes for neurodivergent youth. Register for the webinar -
Content ArticleAs plans to roll out Martha’s Rule continue in the NHS in England, Executive Nurse Director at the Nursing & Midwifery Council (NMC), Sam Foster, explains the significance of Martha’s Rule and how it relates to nursing and midwifery professionals’ practice.
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Content ArticleOver twenty years ago, the Agency for Healthcare Research and Quality (AHRQ) developed its Patient Safety Indicators (PSIs) to monitor potentially preventable and severe adverse events within hospitals. Application of PSIs outside the US has been explored, but it is uncertain whether they remain relevant within Europe as there are no up-to-date assessments of overall PSI-associated adverse event rates or interhospital variability. This study in Health Affairs assesses the nationwide occurrence and variability of thirteen adverse events across all 101 hospitals in Belgium. The authors found that: although adverse event rates were generally low, they were higher than equivalent US rates. there was considerable variability between hospitals in rates of adverse events. They recommend that policy makers and hospital managers should prioritise PSIs that have high adverse event rates or large variability to improve the quality of care in Belgian hospitals.
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Content ArticleSystemic racism refers to systems in which norms and practice patterns reinforce racial and ethnic inequalities even in the absence of individual intentions to do so. Uncovering subtle, overt and pervasive instances of racism that influence and change the trajectory of patient care is important. Emergency departments (EDs) offer a distinct environment where equity is not just a concept, but a fundamental practice that should be woven through all interactions between the patient, healthcare professionals and the system. For this reason, EDs are poised to lead health equity advocacy in the delivery of high-quality care. This JAMA Health Forum viewpoint article looks at evidence relating to ED systems’ vulnerability to systemic racism and maps a path forward to dismantle racism in the ED.
