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Becky T

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Everything posted by Becky T

  1. Content Article
    This report looks at an incident where a neonate suffered an oesophageal perforation following endotracheal and nasogastric tube insertion.
  2. Content Article
    This article looks at the issue of distinguishing between haemofilters and plasma filters, which are used in similar clinical settings, to reduce the risk of mis-selection that could result in patient death.
  3. Content Article
    This report looks at how when face-to-face midwife visits were replaced by virtual appointments during the Covid-19 pandemic, the health of the some babies deteriorated. Guidance has been amended to state that initial visits should be face-to-face.
  4. Content Article
    This report looks at several incidences of pregnant women with Covid-19 symptoms being sent to a maternity unit, when it would have been more appropriate for them to attend A&E. It highlights some confusion amongst health professionals and states that the Coronavirus (Covid-19) Infection in Pregnancy Guidance was updated to make care pathways clearer.
  5. Content Article
    Case study looking at how a Covid patient on a ventilator deteriorated due to their heat and moisture exchanger filter (HMEF) being flooded with secretions. The identified incident highlighted a possible under-recognised patient safety risk of the need to replace such filters.
  6. Content Article
    This report highlights the risk of patient overdose when converting tacrolimus (a medicine used following organ transplantation) from an oral to intravenous route.
  7. Content Article
    Through its core work to review patients safety events, recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a patient safety issue where the antibiotic ceftazidime was infused over 24 hours.
  8. Content Article
    This case study looks at the issue of using ethyl chloride spray during fetal blood sampling procedures, which leaves a plastic residue on the babies scalp.
  9. Content Article
    This case study looks at how plastic cord clamps used in caesarean sections are not visible on x-ray, which could be a patient safety issue.
  10. Content Article
    This blog explores men's mental health – how men are reluctant to seek support when they are struggling, why the suicide rate is so high, what initiatives exist to encourage men to seek help and what more could be done.
  11. Content Article
    This article, published in the Enhanced Recovery After Surgery e-book, explores the multimodal approach to improve overall patient recovery after surgery. The idea of implementing specific interventions throughout the perioperative period to improve patient recovery has been proven to be beneficial. Whereas many approaches to enhanced recovery after surgery (ERAS) implementation may seem straightforward, careful advanced planning, multiple stakeholder involvement, and addressing other contextual constraints are needed if there is to be improvement.
  12. Content Article
    This article looks at the issue of oxygen hoses becoming disconnected from transport ventilators when patients are moved between hospitals, which led to a patient death. Following the incident, the National Patient Safety team worked with national partners involved in transfer of patients to ensure a ‘tug test’ is incorporated into local practice.
  13. Content Article
    This article discusses the use of wireless heart monitoring in hospitals - telemetry - and the safety standards that need to be met.
  14. Content Article
    This article, published in the BMJ Quality & Safety, discusses the value of incident reporting systems. Reporting systems, both local and national, are overwhelmed by the volume of reports they receive and fall short in defining recommendations for improving healthcare safety. Focusing incident reporting systems on the local learning process of healthcare providers could mitigate many of the problems that have been attributed to reporting systems.
  15. Content Article
    This study, published in the International Journal for Quality in Health Care, examined the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. It highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
  16. Content Article
    This article, published by the BMJ, discusses mandatory and voluntary medical error reporting programmes and comments that voluntary reporting by practitioners is usually more useful.
  17. Content Article
    Mandatory and voluntary safety reporting policies are an extremely important part of providing guidance for safety reporting in aviation safety management systems (SMS). This blog highlights the purpose of safety reporting policies, how to train employees on voluntary vs mandatory reporting, and how to encourage mandatory and voluntary safety reporting. Although written for the aviation industry, many of the principles can be applied to healthcare.
  18. Content Article
    This article, published on SKYbrary, discusses the importance of correct safety reporting in the aviation industry. Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies; the aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware.  Although for the aviation industry, some of the principles can be applied to healthcare.
  19. Content Article
    The 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Recently there has been greater research attention on patient safety in low- and middle-income countries due to the global awareness of the need to improve safety standards for all patients, including in maternal care. In this blog, I highlight the scale of maternal and newborn death in low- and middle-income countries, the contributing factors to this, and the need to improve maternal health and safety.
  20. Content Article
    This article, published in Medical Economics, looks at the Ethical Principles in Health Care (EPiHC), established June 2020. EPiHC serves as a global network of private health care providers, payors and investors committed to ethical conduct. It provides health care organisations with ten clear principles to navigate complex ethical decisions – principles that have never been more critical than in the midst of the COVID-19 pandemic.
  21. Content Article
    This article, published in the BMJ, looks at the declining mental health of staff in ICU during the height of the Covid-19 pandemic, based on research by King's College London in 2020.
  22. Content Article
    This editorial, published in the BMJ, comments on the 2019 paper by Daisy Fancourt examining how receptive arts engagement could have a protective association with longevity in older adults.
  23. Content Article
    This article, published in the BMJ, looks at a study exploring associations between different frequencies of arts engagement and mortality over a 14 year follow-up period. It concludes that receptive arts engagement could have a protective association with longevity in older adults.
  24. Content Article
    This toolkit, produced by the Canadian Patient Safety Institute, is intended to support healthcare leaders and policy makers to develop, implement or improve healthcare worker support models. It includes tools, resources and templates from organisations across the globe who have successfully implemented their own healthcare worker support models, such as peer support programs for healthcare providers.
  25. Content Article
    This manuscript provides a comprehensive overview of what healthcare worker support models are available in Canada and internationally. It outlines best practice guidelines, tools and resources that policy makers, accreditation bodies, regulators and healthcare leaders can use to assess the support needs of healthcare workers. The Canadian Peer Support Network is intended as a forum for healthcare organisations seeking guidance in the development of their Peer Support Programs to assist providers who have experienced a patient safety incident. These interventions aim to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients.
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