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Content ArticleThis study in The Joint Commission Journal on Quality and Patient Safety aimed to investigate factors affecting length of time to diagnosis in primary care in the USA. The authors found that patients presenting with new or unresolved problems in ambulatory primary care often remain undiagnosed after a year. There were no provider or patient-level variables associated with lack of diagnosis and further research is needed into the causes and consequences of lack of timely diagnosis.
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Content ArticleThis article in the journal Trends in Neurology & Men's Health provides an outline of the role of human factors in preventing harm in healthcare. The authors describe the scale of medical errors and look at some specific ways that changes to personal and team working factors can improve safety for staff and patients.
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Content Article"Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
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Content ArticleThis US study in BMJ Quality & Safety aimed to assess whether limiting the hours worked by first-year resident doctors' had an impact on patient safety. In 2011, The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy that restricted first-year resident doctors in the USA to working no more than 16 consecutive hours. This policy was rescinded in 2017, and this study assessed the impact of the policy change by comparing the number of medical errors reported by first-year doctors in the five years before the ACGME was enacted (2002/2007) and in the three years following its implementation. The authors found that the 2011 work-hour policy was associated with a: 32% reduced risk of resident physician-reported significant medical errors 34% reduced risk of reported preventable adverse events 63% reduced risk of reported medical errors resulting in patient death They conclude that rescinding the policy in 2017 may be exposing patients to preventable harm.
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EventFollowing the publication of the NHS England and NHS Improvement’s ‘Framework for involving patients in patient safety’, NHSE&I has designed a brand new collaborative to support organisations to fulfil the framework implementation. The NHS Patient Safety Strategy includes the ambition for all safety-related clinical governance committees (or equivalents) in NHS organisations to include two Patient Safety Partners by June 2022, and for them to have received the required training by June 2023. Based around a Breakthrough Series Collaborative model, there will be four learning sessions per year (1 per quarter), followed by an action phase, giving you the opportunity to take the learning back to your organisation and implement. This programme will support you to lead, recruit, govern and train both Patient Safety Partners and wider experience networks. Find out how to register for this programme
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Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.
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Content ArticleThis infographic by the Royal College of Anaesthetists shows some of the common events and risks that healthy children and young people of normal weight face when having a general anaesthetic (GA) for routine surgery. It highlights that modern anaesthetics are very safe and that most common side effects are usually not serious or long lasting. It also outlines the conversations children and their families should expect to have with their anaesthetist prior to their procedure.
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Content ArticleThis study in the International Journal of Environmental Research and Public Health examines the demographic, clinical and socioeconomic factors associated with diagnosis of Long Covid in children aged 5 to 18 years. The authors conducted a population-based cross-sectional study using data from 20,601 children living in Israel who tested positive for Covid between 1 February 2020 and 30 June 2021. They found several variables associated with the development of Long Covid, including: the severity of acute infection being hospitalised recurrent acute infection ADHD diagnosis chronic allergic rhinitis chronic urticaria. The authors call for heightened clinical awareness that Long Covid can be present in children, and highlight that this should affect public health policy because of Covid-19's long-term health impacts.
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EventuntilPatient Academy for Innovation and Research (PAIR Academy) and the International Alliance of Patients’ Organizations (IAPO) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The 3rd webinar of the medication without harm webinar series is scheduled on 21 May 2022, from 11.30 to 12.30 GMT. The theme is "Understanding the process of Medication Management to reduce medication harm”. Register for the webinar
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Content ArticleIn this letter to Maria Caulfield MP, the All Party Parliamentary Group (APPG) First Do No Harm raises concerns that several recommendations from The Independent Medicines and Medical Devices Safety (IMMDS) Review have not so far been taken up by the government. The IMMDS Review looked at how the health system responds to reports from patients about harmful side effects from medicines and medical devices. It specifically looked at the cases of Primodos (a hormone pregnancy test), sodium valproate (an epilepsy medication) and pelvic mesh, and found that significant harm had been caused as a result of problems in the regulatory system and the reporting of side effects. It made a number of key recommendations to the government. The APPG highlights the urgent need to establish a redress scheme for those who have suffered avoidable harm related to the products in the IMMDS Review, a recommendation for which there is widespread cross-party support. They also express disappointment that the government continues to promote the litigation route for those who have suffered harm, arguing that it is an adversarial and difficult process for patients and families who have already suffered significant harm. The letter does recognise that the government has decided to appoint a Patient Safety Commissioner, as recommended by the IMMDS Review, and highlights the significance of this step.
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Content ArticleIn this guest blog for the Professional Records Standards Body (PRSB), Taffy Gatawa, Chief Information and Compliance Officer at everyLIFE Technologies, talks about the importance of ensuring that healthcare technologies comply with recognised standards. She discusses everyLIFE's experience on PRSB’s Standards Partnership Scheme, and their journey to implementing standards in their digital products. Taffy describes a process of learning and feedback, achieved through desktop research, clinical reviews and critical engagement with PRSB and customers.
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Content Article‘Digital clinical safety’ refers to avoiding harm to patients and staff that could be caused by technologies manufactured, implemented and used in the health service. In this blog, Dr Kelsey Flott, Deputy Director of Patient Safety at the NHS Transformation Directorate, looks at the importance of digital clinical safety in driving quality improvement. She talks about how the Digital Clinical Strategy is being implemented and the drive to collect better evidence about the effectiveness of improvement technologies.
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Content ArticleThis video is based on research interviews with acute medical patients and examines how staff and patients in hospital can create safe care together. It includes quotes from real-life patient experiences and highlights the importance of listening to and reassuring patients, and involving them in their care.
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Content ArticleThis first report in National Voices' ‘Behind the Headlines’ series gathers insight and intelligence from member organisations on what the cost of living crisis means for people living with ill health. It examines the close link between poverty and health, highlighting that people living in poverty are more likely to be living in poor health. Equally, lack of support for people living with ill health and disability can make people poor. The report gathers case studies and data on topics including include cancer, kidney conditions, older people and homelessness. It makes a set of recommendations based on this insight.
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EventuntilJoin the National Academies of Sciences, Engineering, and Medicine’s Committee on Improving the Representation of Women and Underrepresented Minorities in Clinical Trials and Research as it discusses its newly released report Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups. This new report makes a compelling case for why we need more equitable participation in clinical trials and clinical research, including an economic analysis on the cost of health disparities in the United States. It provides a review of the barriers to having more equitable participation in clinical trials, describes strategies to overcome those barriers, and provides actionable recommendations to drive lasting change on this issue. The webinar will take place at 11:00-13:00 EST (16:00-18:00 GMT+1) Register for the webinar
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Content ArticleThis French study in the Journal of Hospital Infection evaluated the frequency and factors associated with environmental air and surface contamination in rooms of patients with acute Covid-19. It aimed to increase understanding of how the virus is transmitted in hospitals. The authors found that surfaces seemed to be more frequently contaminated with Covid-19 than air or mask samples, and noted that viable virus was rarely found. They suggest that samples from the inside of patients' face masks could be used to identify patients with a higher risk of contamination.
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Content ArticlePersonalised care and support planning (PCSP) is a systematic process based around 'better conversations' between the person and their health and social care practitioners. The aim is to identify what is most important to each person for them to achieve a good life, and to ensure that the support they receive is designed and coordinated around their wishes. It's goal is to empower people to be the main decision-maker in their own care, and to arrive at one plan that encompasses all the person's care needs. This tool has been developed by Think Local Act Personal to support PCSP for people with health and social care needs. Featuring example characters who help bring the process to life, it covers the following stages of the PCSP process: Context Preparation Conversation Record Making it happen Review
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Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Lou worked in family liaison for the police service for thirty years, and she talks to us about how this experience is helping her develop family engagement services at the Healthcare Safety Investigation Branch (HSIB). She describes the importance of valuing the voices of patients and their families, and the vital role of their input in improving safety in the healthcare system. She also talks about the challenges the Covid-19 pandemic posed to HSIB's family engagement work, and how speaking to patients and their families is being increasingly valued and professionalised by the healthcare system. -
Content ArticleThis study in the journal Health and Social Care Delivery Research mapped interventions aimed at reducing restrictive practices in children and young people’s institutional settings around the world. It also assessed which process elements led promising behaviour change techniques, and compared the results with a companion review of adult psychiatric inpatient settings. In the first evidence review of its kind, the authors found that interventions tend to be complex, reporting is inconsistent and robust evaluation data are limited. But they did find some behaviour change techniques that warrant further research. They argue that better evidence could help address the urgent need for effective strategies.
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Content ArticleThe Reducing Restrictive Practice Collaborative (RRP) aimed to reduce restrictive practice by one third in participating wards, measuring the following practices: Restraint – to prevent, restrict or subdue movement of the body, or part of the body of another person Seclusion – confinement in a room or physical space Rapid tranquillisation – use of sedative medication by injection. This webpage contains a number of resources related to the work of the collaborative, including a resource booklet outlining learning about running successful quality improvement projects.
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Content ArticleNext Steps is a tool created by the Dementia Change Action Network to help patients find the right support, at the right time, while waiting for their memory assessment appointment. Some patients are facing longer waits as a result of the Covid-19 pandemic, and it can be an uncertain time. Next Steps provides information about what to expect from the memory assessment process and about organisations who can help.
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Content ArticleThere are an estimated 3.8 million people with a wound being managed by the NHS, which is equivalent to 7% of the UK population. The impact of wounds on patients is significant and can lead to deteriorating mental health as well as further physical health issues. In addition, the cost to the NHS of providing wound care services is around £8.3 billion annually. This report by Mölnlycke and the Patients Association provides an outline of the state of wound care services in England by mid-2021. It features patient stories and data analysis on the following topics: Wound care in the health service The impact of Covid-19 Supported self-care Getting wound care right first time What next for wound care?
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Content ArticleSurgical smoke or surgical plume is the smoke created by electrical and cauterisation devices used in surgery. When surgical staff are exposed to this smoke, it may cause harm, with some studies finding that exposure increased cancer risk for surgeons. This study in the journal Scientific Reports aimed to compare the concentration of surgical smoke produced by different tissues and electric diathermy modes, and to measure the effectiveness of different local exhaust ventilations. The authors found that: there were varying levels of particulates given off by different devices and different tissues. in the cutting setting, all three smoke extractors had more than 96% efficiency in clearing surgical smoke. adapting an electric diathermy device with a urethral catheter is a simple and effective way to exhaust smoke in surgical operations. They highlight the need for more research to ensure surgical staff are well protected from the risks of surgical smoke.
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Content ArticleVolunteers make a huge contribution to the NHS, and there is evidence that the role of volunteers has expanded in recent years. The most recent NHS workforce plan recognises and commits to maximising the value of volunteers as services are rebuilt and reformed after the Covid-19 pandemic. This resource by The King's Fund provides a framework for identifying how to move from volunteering as an ‘added extra’ to it making an integral contribution to the delivery of health care. It also explores ways in which volunteering can have a positive impact for all involved.
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Content ArticleMore than 100,000 additional people have died across the UK since the start of the pandemic, compared to long term rates. Many of these people have died at home, and we know little about their experience, or the level of care and support they and their relatives received from the healthcare system. In this blog for the charity Hospice UK, Maureen describes her experience of caring for her parents after they were discharged from hospital to die at home during the first wave of the Covid-19 pandemic. Maureen describes how she and her siblings were left to care for their parents with very little practical, clinical or emotional support. Hospice UK have also shared a video of Maureen telling her story as part of their Dying Matters campaign.
