Patient-Safety-Learning
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Everything posted by Patient-Safety-Learning
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Content ArticleThis article in BMJ Quality & Safety looks at why healthcare regulators have failed to keep pace with the rapid pace of change to care and treatment happening within healthcare systems around the world. The authors identify key drivers for change in healthcare and outline the implications for systems and the healthcare professionals that work within them. They argue that in spite of the wide acceptance of a systems-based approach to healthcare safety, regulators still often target individuals with sanctions as this is what they have power to do. The article concludes by outlining the need for a new and future-oriented mindset from regulatory and supervisory bodies, characterised by dynamic responsiveness.
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Content ArticleThe Johari Window is a tool that examines the difference between how you perceive your own attributes, and how they are perceived by people around you. It was developed in 1955 by psychologists Joseph Luft and Harrington Ingham. It consists of a quadrant diagram, which plots descriptors that are “known to self” against those that are “known to others”, with all combinations of those in between. This blog examines the different uses of the Johari Window including how it can be used to increase the areas in which we are 'open' others. The author also highlights that if the tool is misused. it can increase an individual's anxiety about the way they are perceived by others.
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Content ArticleIn this interview with BDJ In Practice, British Orthodontic Society (BOS) President Nikki Atack discusses the society's 30th birthday and the changing landscape within orthodontics. She talks about new guidance on integration new technologies into orthodontist practice, the rise of 'DIY orthodontics' and the importance of maintaining funding for research in the field of orthodontics.
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Content ArticleThrough online health portals, patients receive complex medical reports without interpretation from their healthcare provider. This study evaluated the usability of MedEd, a patient engagement tool providing definitions of medical terminology in breast pathology and radiology reports. People who underwent a normal screening mammogram were invited to complete semi-structured interviews where they downloaded MedEd and discussed their download experience. The authors then evaluated the acceptability, appropriateness and feasibility of MedEd. Participants reported ease of downloading and navigating MedEd while raising concerns about privacy and others’ abilities to download.
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Content Article
The correct and timely diagnosis of a health condition is a first step in ensuring that it is properly treated or managed. However, most people will experience at least one diagnostic error in their lifetime, sometimes resulting in severe patient harm. Research shows that up to 80% of all harm caused by delayed or misdiagnosis could be preventable. Deficits in health system design and governance, clinical environments and individual provider competencies can drive poor diagnostic outcomes. This brief introduces work being done by the Organisation for Economic Co-operation and Development (OECD) to assess key drivers and barriers of diagnostic safety and estimate the economic impacts of poor diagnostic safety practices on health systems. -
Content ArticleIn this article for the Independent, James Moore describes his experience of a diabetes technology failure and outlines the risks associated with these medical devices. James has type 1 diabetes and was using a continuous glucose monitor (CGM) to track his blood glucose levels via an app on his iPhone. The graph showed that his blood glucose had been within the target range for many days. However, after noticing a lack of response from the CGM, he checked his blood sugar using a 'finger prick' test and discovered that his blood glucose level was actually dangerously high. Although James managed to get his levels back under control, he notes that it could have been much worse, had he not realised the error. Having high blood glucose for a period of time can lead to dangerous and life-threatening complications. The article also looks at the risks associated with insulin pump failures. James notes the huge benefits of wider access to diabetes technology, but highlights the need for healthcare professionals to ensure patients understand the risks and how to manage them.
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Content ArticleThis opinion paper looks at how healthcare organisations identify and act upon different types of risk signals. These signals may be acknowledged, but they might not be because they have become a part of normal practice. The authors outline why risk signals from patients and families should be acknowledged as system-level safety critical information, which can contribute to understanding and changing safety culture in healthcare. They discuss how healthcare organisations could work more proactively with patient experience data in identifying risks and improving system safety.
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Content ArticleBiomedical research has long struggled to reflect the demographic balance of the general population. Certain communities are under-represented, including people from minority ethnic groups, rural populations, disabled people and sexual and gender minorities. Meanwhile, adoption of digital technologies has increased in the past decade, particularly since the Covid-19 pandemic. This Lancet article argues that this expansion of smartphone adoption and digital literacy needs to be more widely harnessed to improve access to clinical research. Remote, self-directed, digitally enabled participant experiences can expand core outreach efforts in health research and clinical trials. The authors suggest that digital pathways can help improve accessibility and representation, making research participation available to populations who face barriers in engaging with healthcare.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)Learning from excellence is a philosophy and practice designed to capture positive events in healthcare in order to improve quality and safety, while also providing positive feedback to staff. This study aimed to identify themes in staff-reported excellence to understand the conditions and behaviours that can allow excellence to occur. The study identified five overarching, interdependent themes: Pro-social behaviours could have a positive impact on staff experience and patient care. Witnessed expertise in technical and non-technical skills were a source of appreciation and gratitude for staff. A positive work ethic could benefit patient experience, staff productivity and morale. Staff appreciated personalised patient care that deviates from the norm but results in a positive outcome. Effective leadership and teamwork were often characterised by resilience and excellent interpersonal skills.
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Content ArticleThere are more than 350,000 health apps available in public app stores. The stated benefits of health apps are numerous and well documented. However, there are also concerns that poor-quality apps, marketed directly to consumers, threaten the tenets of evidence-based medicine and expose individuals to the risk of harm. This study aimed to address this issue by assessing the overall quality of evidence publicly available to support the effectiveness claims of health apps marketed directly to consumers. The authors found the quality of evidence available to support the effectiveness claims of health apps marketed directly to consumers to be poor. Less than half of the 220 apps (44%) audited state that they have evidence to support their claims of effectiveness and, of these allegedly evidence-based apps, more than 70% rely on either very low or low-quality evidence.
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Content ArticleGP Margaret McCartney looks at the influence big pharma has on the NHS—through payments and payments-in-kind to doctors, health charities and medical royal colleges. She discusses how this leads to conflicts of interest and a lack of independence, eroding the health system's commitment to evidence-based medicine.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)Learning from excellence is a non-hierarchical system for staff to report episodes of good practice that they observe in the workplace, aiming to share learning from good practice, in line with the Safety-II approach. This study aimed to analyse staff perspectives of the impact of a learning from excellence system in place at a hospital in the south east of England. The results showed that perspectives on the impact of learning from excellence were generally positive, particularly regarding the benefits for staff morale and motivation.
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Content ArticleElectronic health records (EHRs) are now used for many functions in healthcare beyond simply record keeping. For healthcare professionals, the EHR is a central platform for pulling together, organising and visualising diagnostic information. It helps with clinical reasoning, record management and communication between the care team. This issue brief by the Agency for Healthcare Research and Quality (AHRQ) reviews the history of EHR documentation legislation, including rules and regulations, and outstanding challenges and best practices to improve documentation. It also identifies future developments and opportunities for improvement, including emerging technology-based strategies to improve the traditional documentation process.
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Content ArticleEvery year, over 70,000 people in England, Wales and Northern Ireland will fall and fracture their hip. This report by the Falls and Fragility Fractures Audit Programme (FFFAP) provides a simple guide for healthcare services to the data and resources available. It also describes the care that hip fracture patients should receive on their journey to recovery.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)The hierarchy of effectiveness model illustrates which risk-mitigation strategies are more effective than others in addressing factors that contribute to patient safety incidents. This illustration of the model was produced by Cassie McDaniel.
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Content ArticleThis report outlines the findings of the Directors of Adult Social Services (ADASS) spring 2024 survey. It calls on the new Government for a change of approach, warning that without major reform, the challenges it highlights will continue to intensify and have a negative impact on people’s lives.
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Content ArticleSimulation—where scenarios are recreated in a practice environment as a tool for learning—can be used to improve patient safety. Simulation has a number of functions in healthcare, including helping identify and mitigate latent safety threats, testing quality improvement changes before they are implemented and revealing information that would not have otherwise been discovered. This issue brief from the Agency for Healthcare Research and Quality (AHRQ) discusses practical strategies to advance patient safety through simulation and debriefing.
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Content ArticleShoulder dystocia is an uncommon but high-risk obstetric emergency that happens when a baby's shoulders fail to deliver spontaneously following delivery of their head. When it happens, the healthcare team has to carry out specialised obstetric manoeuvres designed to correct the positioning of the baby. This guide was co-produced by the Pennsylvania Patient Safety Authority (PSA), the Institute for Safe Medication Practices (ISMP) Patient Safety Organization and ECRI. It records the findings of a 'safe table' meeting—a protected environment where Pennsylvania healthcare professionals had an opportunity to discuss the risk factors, challenges and mitigation strategies associated with shoulder dystocia. The guide includes comments and recommendations relating to debriefing and documentation after a shoulder dystocia event, reporting and legal concerns, risk assessment and simulation and training.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)This study assessed the impact of Schwartz Center Rounds, an interdisciplinary forum where attendees discuss psychosocial and emotional aspects of patient care. The authors investigated changes in attendees' self-reported behaviours and beliefs about patient care, sense of teamwork, stress and personal support.
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Content ArticleIn this study in the International Journal of Environmental Research and Public Health, Rodney Jones examines different methods for understanding hospital bed numbers and their impact on patient outcomes. Using the NHS in England as a case study, Jones demonstrates the relative benefits of different approaches to modelling hospital bed numbers.
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Content ArticleIn this article, Siva Anandaciva, Co-Director of Policy, Events, and Partnerships at The King's Fund, takes a look at the practical issues NHS staff face at work that a major impact on morale. He highlights issues with the physical work environment, such as lack of availability of food and drink, broken toilet facilities and lack of accommodation for staff on call, and suggests that many of these issues can be fixed on a local level to greatly improve staff wellbeing and satisfaction.
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Content ArticlePatient-Safety-Learning posted an article in Human factors (improving human performance in care delivery)In this episode of the Royal College of Surgeons in Ireland's Safe & Sound podcast, Dr Chris Turner, founder of Civility Saves Live, talks about the impact of interpersonal behaviour on performance and patient safety. He discusses his interest in governance and high-performing teams and how this has led him on a journey from focusing on blame and process to exploring the power of relationships and behaviour.
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Content ArticleIn September 2019, the Cabinet Secretary for Health and Sport announced that a public inquiry would be held to look at issues at Glasgow's Queen Elizabeth University Hospital Campus (QEUH), the Royal Hospital for Children and Young People (RHCYP) and Department of Clinical Neurosciences sites following concerns about patient safety and wellbeing. The Inquiry aims to determine: how vital issues relating to ventilation and other key building systems gave rise to those concerns how they occurred what steps can be taken to prevent this being repeated in future projects. Lord Brodie was appointed as chair of the Inquiry in November 2019 and the Inquiry was launched on 3 August 2020. Anyone can submit evidence to the Inquiry in the form of a written statement and/or by providing documents. Someone who has done this or who has otherwise been identified as having potentially useful information may be asked by the Inquiry to give oral evidence at a hearing. Members of the public can watch the live stream of hearings or to attend in person, if that is practical. You can also view Inquiry documents such as transcripts of evidence given at hearings and witness statements.
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Content ArticleShared decision making is when healthcare professionals work together with a patient to make choices about their care and treatment, the medicines the take and any operations they have. This short animation by The Patients Association explains what shared decision making is and how you can make it happen when you're seeing your doctor or other healthcare professional.
