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Content ArticleThe Accessible Information Standard is a set of principles for the presenting, sharing and discussing information with patients. It aims to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need from health and care services.
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Content ArticleThe Peer Network for Advancing Equity through Quality and Safety is a year-long program offered by the Center for Health Equity at the American Medical Association (AMA) in collaboration with the Brigham & Women’s Hospital (BWH) and The Joint Commission (TJC). It is designed to help health systems apply an equity lens to all aspects of quality and safety practices and improve health outcomes for historically marginalised populations. This article covers the program's strategic plan, goals and activities and includes embedded videos containing an introduction to the program and a simulated case review.
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Content ArticleBullying, discrimination and harassment between healthcare workers can have an impact on how well individuals do their job, and may therefore lead to an increase in medical errors, adverse events and medical complications. This systematic review in BMJ Quality & Safety aimed to summarise current evidence about the impact on clinical performance and patient outcomes of unacceptable behaviour between healthcare workers.
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Content ArticleSpecialty referrals—when a clinician refers a patient to a specialist for evaluation or treatment—are on the rise in the US. Despite the introduction of electronic health records (EHRs), the referral process is often hindered by lack of clarity over roles, communication breakdowns, workloads and variations in requirements among specialists. These difficulties can lead to missed or delayed diagnoses, delays in treatment and other lapses in patient safety. This guide from the Institute for Healthcare Improvement offers recommendations that aim to help standardise how primary care practitioners activate referrals to specialists and then keep track of the information over time. It describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels, in a timely manner.
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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. Bill talks to us about how patient safety and transparency have been key priorities throughout his career as an Operating Department Practitioner (ODP) and then a leader in the NHS. He highlights the need for a longer-term approach to workforce planning and talks about how leaders can set a culture that engages with and prioritises patients. -
Content ArticleClinicians play an essential role in implementing infection prevention policy, but little is known about how infection control policy is implemented at an organisational level or what factors influence this process. This study explores the policy implementation process used in the introduction of a national large-scale, government-directed infection prevention policy in Australia.
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Content ArticleThis mixed methods study in BMC Medical Informatics and Decision Making explored approaches to implementing Electronic Patient Record systems (EPRs) into NHS acute, mental health and community care hospitals throughout England. It also looked at the challenges and benefits of implementing EPRs. The authors conducted an online survey and semi-structured telephone interviews with chief information officers at NHS trusts. The study found that there was no single approach taken to implementing EPRs among participating English NHS trusts, who cited various benefits and challenges. The authors conclude that policymakers and researchers need to provide clearer guidance for trusts at various stages of implementation and ensure that intelligence is shared across England’s NHS trusts.
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Content ArticleThis report outlines the Royal College of Psychiatrists in Scotland's priorities for the Scottish Parliament. The report centres on the idea that there should be 'no wrong door' for individuals in all communities to accessing the right care, in the right place, at the right time for mental ill health. It highlights the significant effects of the Covid-19 pandemic on the mental health of the population: The number of people with high levels of psychological distress (indicating a potential psychiatric disorder) has doubled during the Covid-19 pandemic to 35.6%. Those most vulnerable to psychological distress (67%) were those with pre-existing mental ill health–the population already supported by psychiatrists. Women, young people, ethnically diverse communities and the economically disadvantaged have also been disproportionately affected.
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Content ArticleThis study in Best Practice & Research Clinical Rheumatology aimed to determine the systemic effects of surgical mesh implants. The study looked at patients referred to an autoimmunity clinic between January 2014 and December 2017 and concluded that mesh implants may increase the risk of developing autoimmune diseases by acting as an adjuvant (increasing the body's own immune response).
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Content ArticleThis study in Clinical Epidemiology aimed to investigate the long-term complications associated with surgical mesh devices used to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP). The authors looked at rates of diagnoses of depression, anxiety or self-harm (composite measure) and sexual dysfunction, and rates of prescriptions for antibiotics and opioids in women with and without mesh surgery, with a diagnostic SUI/POP code, registered in the Clinical Practice Research Datalink (CPRD) gold database. The study found that mesh surgery was associated with poor mental and sexual health outcomes, alongside increased opioid and antibiotic use, in women with no history of these outcomes and improved mental health, and lower opioid use, in women with a previous history of these outcomes. The authors highlight the need to carefully consider the risks and benefits of mesh surgery on an individual basis.
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Content ArticleThis report considers the extent of the gap between the diversity in the workforce and local population of London, and that visible among NHS trust boards and senior management. It highlights the impact of this gap on the effectiveness of healthcare provision and patient experience, in light of research demonstrating that a diverse workforce in which all staff members’ contributions are valued is linked to good patient care.
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Content ArticleThis qualitative descriptive study in the journal BMC Nursing aimed to analyse the experiences of patients with type 2 diabetes during the stay-at-home order in place during the first wave of the Covid-19 pandemic. It looked at the experiences of ten patients with type 2 diabetes living in Catalonia and identified the strategies and resources they used to manage their care. The study found that many people with type 2 diabetes reported effective self-care during confinement and were able to adapt well using the resources available, without face-to-face contact with primary care health staff.
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Content ArticleThis animation by The King's Fund explains the changes that are happening to the way the NHS in England is organised and run. It outlines the key organisations that make up the NHS and how they can collaborate to deliver joined-up care. It describes the impact of the Health and Care Act 2022 and talks about how Integrated Care Systems foster collaboration between healthcare and other local services to improve people's experience and health outcomes.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the decontamination of surgical instruments. It focuses on the work of sterile services departments (SSDs) in hospitals, where reusable medical equipment is cleaned, disinfected and sterilised to make it safe before it is used again. The investigation looked at the regulatory framework which SSDs work within, and their use of assurance models, which provide evidence that a service is running according to the relevant policies and procedures. These mechanisms are designed to keep patients safe and enable NHS trusts to manage risk within their organisations. For its reference case, the investigation used the case of a 56 year-old woman who underwent surgery to remove a kidney stone in her right kidney. During the procedure, 'black stuff' came out of one of the instruments being used, which was later analysed and found to be dried blood. The surgeon stopped the surgery immediately and proceeded with an alternative procedure to remove the kidney stone, for which the patient had already consented. The patient was tested for blood-borne viruses as she had been exposed to another person's dried blood, but tests did not show any evidence that she had contracted any.
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Content ArticleIn this article for The BMJ, Matthew Limb looks at the findings of the British Medical Association's (BMA's) review of the UK's management of the pandemic. The review found that many doctors had traumatic experiences during the pandemic, and highlights the following areas where the government could have better supported doctors: Preparedness including chronic underfunding of the NHS Personal protective equipment (PPE) shortages Inadequate infection prevention and control guidance Testing failures Lack of risk assessment and failure to protect vulnerable staff Deaths Long Covid Exhaustion Mental health and emotional wellbeing Anxiety and moral injury Isolation Lack of support Career prospects The review did also highlight the vaccination campaign and rollout as a notable success in the government's response to the pandemic.
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Content ArticleIn 2016, 18 year-old Oliver McGowan died after being inappropriately prescribed antipsychotic medications. Oliver had high functioning autism, mild hemiplegia and epilepsy, and had experienced previous well-documented adverse reactions to these medications. On admission to hospital, both Oliver and his parents had been clear about the fact that he should not be given any form of antipsychotic. In this interview for Woman's Hour, Oliver's mum Paula talks about Oliver and the events that led to his death, as well as discussing new mandatory training for all health and social care staff that was passed into law as part of the Health and Care Act 2022 - The Oliver McGowan Mandatory Training in Learning Disability and Autism. This will ensure that all staff working health and social care receive learning disability and autism training appropriate for their role, which will in turn improve outcomes for people with learning disabilities. The interview can be found at 34 minutes 10 seconds into the programme.
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Content Article
UK Government guidance - Whistleblowing for employees
Patient-Safety-Learning posted an article in Whistle blowing
This guidance by the UK Government provides information and advice for employees who want to understand their rights regarding whistleblowing. It includes information on: What is a whistleblower? Who is protected by law Complaints that count as whistleblowing Who to tell and what to expect What to do if you're treated unfairly after whistleblowing -
EventIn this conversation, James Munro, CEO of Care Opinion, will speak with Dr Lauren Paige Ramsey of the University of Leeds. They will be talking about the safety of people with learning disabilities in care settings, and what we can learn about that from feedback shared on Care Opinion. Here is the research we will be discussing: Systemic safety inequities for people with learning disabilities: a qualitative integrative analysis of the experiences of English health and social care for people with learning disabilities, their families and carers Do join us for this conversation: everyone is welcome. You don't need any academic or research experience. You don't even have to read the paper! Each conversation will last about 15 minutes, followed by time for questions. Once you register for this event you will be able to post comments and questions, in advance or during the conversation. You can also share the event, or post questions, on Twitter using the hashtag #corc The conversation will be recorded and available here immediately after the event, or later via the Care Opinion blog.
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Content ArticleIntegrated care systems (ICSs) will gain their full statutory footing in July 2021, after years of development. This blog by The King's Fund aims to explain how ICSs will function and includes a diagram showing the main features and interactions within an ICS. It outlines the roles of the integrated care board (ICB) and integrated care partnership (ICP) in each ICS, and describes the different partnership and delivery structures.
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Content ArticleThis opinion piece in The BMJ looks at the importance of doctors being honest in all settings. Daniel Sokol, medical ethicist and barrister, uses the behaviour of the character Adam in the BBC series 'This is Going to Hurt' to look at why it is so important that doctors are honest. In one episode, Adam pretends not to be a doctor in order to avoid intervening when someone needs medical attention in the community. Daniel discusses the ethical and legal issues associated with this kind of behaviour, highlighting that it could lead to suspension or removal from the GMC register. He discusses how dishonesty undermines public trust, and the fact that dishonesty in any area of life can have professional consequences for doctors.
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Content ArticleMaternal outcomes for Black women are significantly worse than for white women - Black women are four times more likely to die during pregnancy, labour, or postpartum and are twice as likely to have their baby die in the womb or soon after birth. They are also at an increased risk of readmission to hospital in the six weeks after giving birth. This report by the organisation Five X More presents the findings of a survey into black women's experiences of maternity services in the UK. The survey aimed to understand how maternity care is delivered from the perspective of women from the Black community, and 1,340 Black and Black mixed women responded, sharing their experiences. It seeks to highlight the real life encounters behind the known disparities in maternal care. Women reported far more negative experiences than positive, and most of these experiences centred around interactions with healthcare professionals. The authors highlight three factors related to healthcare professionals that contribute to damaging interactions, to do with their attitudes, knowledge and assumptions. The report includes many quotes from Black women about their experiences of NHS care and the damaging long-term consequences of this, such as fear of having another baby, reluctance to engage with health services and mental health issues.
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Content ArticleThe pandemic led to major disruption to services right across health and social care, as well as a huge shift in where patients are dying, with more than 105,000 extra deaths at home in the UK over the first two years of the pandemic. The reasons for this are not fully understood, but have profound implications for the experience of people dying and their families and carers, and for the type and quality of care they receive. There is currently a large gap in our understanding of the services that the hospice sector provides across the UK. This report by the Nuffield Trust seeks to begin to close that gap by analysing the important role of hospices in supporting people at the end of life and their families, both in hospice settings and at home.
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Content ArticleIn this three-year strategy, NHS Resolution outlines its strategic priorities to 2025. The four priority areas in the new strategy are: Deliver fair resolution – focussing our resources to avoid patients and healthcare staff having to go through formal processes that can be distressing and costly Share data and insights to improve services – sharing our unique data and insights to reduce risk and help improve the healthcare system Collaborate to improve maternity outcomes – working with others in the maternity care system to reduce neonatal harm Invest in our people and systems – building up our corporate capacity and capabilities internally to support the health and legal systems. These priorities aim to help the organisation contribute to: a reduction in harm to patients. a reduction in the distress caused to patients and healthcare staff involved when a claim or concern arises. a reduction in the cost required to deliver fair resolution. This will release public funds for other priorities, including healthcare. ensuring indemnity arrangements are a driver for positive change across the healthcare system. NHS Resolution has also produced a video summary of the strategy.
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Content ArticleThe SingHealth Duke-NUS Institute for Patient Safety & Quality (IPSQ) based in Singapore has developed several training courses to improve the skills of healthcare workers in patient safety. The courses are part of the Academic Medicine – Enhancing Performance, Improving Care (AM-EPIC) Framework and cover six areas of competency: Patient safety Improvement sciences Innovation and system design Patient centeredness and advocacy Clinical governance and risk Staff resilience and care support To find out more and book IPSQ to deliver any of these courses to your organisation, email ipsqworkshop@singhealth.com.sg
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Content ArticleThis practice pointer in The BMJ explains why diagnostic errors occur and provides five strategies that healthcare workers can use to achieve diagnostic excellence. Each of these strategies is explored in detail: Seek diagnostic feedback, which includes tracking patient outcomes and seeking feedback from patients, families and other healthcare workers. "Byte sized" learning, which involves digital learning activities. Consider bias by getting to know patients and treating them as individuals, and through taking a 'diagnostic pause' to consider whether bias is playing into decisions. Make diagnosis a team sport through multidisciplinary huddles that include healthcare workers from different professions. Foster critical thinking by using intentional strategies to foster reflective scepticism and regular review.
