Sam
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Content ArticleSince January 2019, the Health Information and Quality Authority (HIQA) has been the competent authority for regulating medical exposure to ionising radiation in Ireland and receives incident notifications of significant events arising from accidental or unintended medical exposures. As part of its role, HIQA is responsible for sharing lessons learned from significant events. HIQA has published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. This report provides an overview of the findings from these notifications and aims to share learnings from the investigations of these incidents.
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EventA record excess of four million people are now awaiting hospital treatment in England. This number includes more than 83,000 who have been waiting more than a year. On Thursday 17 September, RSM President Professor Roger Kirby will interview Professor Derek Alderson, immediate past President of the Royal College of Surgeons, Ben Challacombe, Consultant Urological Surgeon at Guy’s and St Thomas’ and Hannah Warren, Specialist Registrar at King’s College Hospital to discuss the impact of the COVID-19 pandemic on surgeons, surgery and surgical waiting lists. In addition, the panel will discuss whether the mass testing proposed by the Prime Minister in his “Operation Moonshot” initiative could help to resolve the situation. The webinar will include plenty of opportunities for questions. Registration
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Content ArticleMedical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved. Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.
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EventThe International Society for Quality in Healthcare (ISQua) presents three of the leading world experts on Human Factors who will share with you the importance of Human Factors to improve safety for healthcare professional and patients. This session will be moderated by Eric de Roodenbeke, CEO of the International Hospital Federation (IHF). Registration
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EventThis webinar from the International Society for Quality in Healthcare (ISQua) presents research that takes an in-depth look at what psychological safety means for health workers, how it differs within and across teams and how it is influenced by leaders and by team characteristics and team dynamics. Register
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COVID-19 has shown clearly why governments need to prepare for an uncertain future. Preparation means more creative strategic thinking, more analysis of what might be ahead, and an acceptance of the value of reserve capacity to mitigate risk. Could the pandemic be a re-defining moment for how the UK government prepares for uncertainty, plans for the long-term and thus builds resilience? This won’t happen by accident: policymakers have strong incentives to pay attention only to the short-term. What are convincing arguments as to why they should change? What else would make them, and their successors, do it? Join The Health Foundation for this webinar, where they will consider these issues and what practical steps can be taken now to strengthen capacity for long-term thinking and dealing with uncertainty in UK policymaking – steps that might be hard-wired into normal policymaking now and in the future. -
Community PostThe UK government is seeking views on proposed changes to the Human Medicine Regulations 2012 to help with the safe and efficient distribution of a COVID-19 vaccine and expanded flu vaccine programme in the UK, along with treatments for COVID-19 and any other diseases that become pandemic. Ministers say there will be no shortcut on safety or effectiveness, and that any vaccine will be approved for the UK only if it meets the highest standards. The deputy chief medical officer for England, Prof Jonathan Van-Tam, said: “If we develop effective vaccines, it’s important we make them available to patients as quickly as possible but only once strict safety standards have been met. The proposals consulted on today suggest ways to improve access and ensure as many people are protected from Covid-19 and flu as possible without sacrificing the absolute need to ensure that any vaccine used is both safe and effective.” What do you think? Are there patient safety concerns here? We'd love to hear your views. Comment below.
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The development and use of artificial intelligence (AI) in healthcare is one of the fastest growing industries. In the UK, there is the political will to accelerate the digitisation of the NHS and make the health system a world-leading testbed for AI and digital technologies. The Chartered Institute of Ergonomics & Human Factors (CIEHF) has set up a special interest group (SIG) with the mission to provide human factors guidance on AI in healthcare to regulators, developers and users of AI and digital technology in the health sector. This webinar launches the AI and Digital Health SIG to the membership and beyond, with a view to highlighting what the aims and ambitions of the group are, but also to engage with interested parties early on, so people have an opportunity to influence the direction of the group and its outputs, especially in this formative time. The webinar will take the format of a panel discussion, facilitated by the chair, Barry Kirby. Further information and registration -
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Swedish National Patient Day - Patients and care in cooperation seminar will be streamed live on World Patient Safety Day. It will also be possible to watch it afterwards using the same link. The program in short: The Director of Health Care in Region Stockholm, Dr Björn Eriksson, will talk about how the region handled the corona pandemic, experiences and thoughts for the future. Cases concerning COVID-19 in one way or another, that have been handled by the Patient´s Advisory Committee in Stockholm, will be presented (approx. 460 cases since February). The Executive Director of the Patient´s Advisory Committee in Stockholm, Mrs Steinunn Ásgeirsdóttir, will talk with a former Covid-19-patient about his experiences from having been hospitalized for 105 days. The Chief Physician at Danderyd Hospital (which handled many of the COVID-19-patients in Stockholm), Dr Åsa Hammar, will tell us what she learned and experienced this fall and summer. Please note it will all be in Swedish. Link to stream -
EventThis is the first of a series of webinars Patient Safety Learning, Health Plus Care and BD are holding on patient safety on the frontline, exploring burning patient safety issues and engaging with frontline healthcare workers, clinical leaders and patient safety experts. COVID-19 has had a devastating impact on access to non-Covid care and treatment. We know there are over a million extra patients awaiting hospital treatment. The NHS has issued guidance for ‘accelerating the return to near-normal levels of non-Covid health services, making full use of the capacity available in the ‘window of opportunity’ between now and winter.’ In this webinar we will be discussing these issues with front-line clinicians and patient safety experts. Read Patient Safety Learning's accompanying blog that sets out some key points to inform the webinar. Registration
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This month's QI Connect session is with Michael West, Senior Fellow at The King's Fund. This special session on World Patient Safety Day is definitely one not to be missed! Register -
EventCardiovascular disease (CVD) causes a quarter of all deaths in the UK and is the largest cause of premature mortality in deprived areas. The NHS long term plan identifies this as the biggest area where the NHS can save lives over the next 10 years. What do national plans and local work look like now, in the context of COVID-19? The HSJ Cardio Virtual Forum will bring together national and local leaders, senior managers, clinicians, industry and the third sector to support you to achieve sustainable improvement to cardiovascular disease care and prevention. Together, we will assess the impact of the pandemic on cardiac and stroke services, examine innovations and adaptations that have worked well and learn how to take these innovations forward to improve prevention and care in the long term. Registration
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EventThis year’s programme brings together highly ranked representatives of international and national healthcare authorities, NGOs, policymakers, clinical scientists, researchers, and pioneers in healthcare improvement with the unified goal of improving AMR and sepsis healthcare around the world. The objectives of this free Spotlight online congress are to review achievements, challenges, and potential solutions to combat the threats posed by AMR and sepsis globally. Speakers will describe the current global epidemiology and burden of sepsis and AMR, explore a future research agenda, provide an overview of lessons and challenges from the COVID-19 pandemic and recent Ebola outbreaks, and ultimately explore innovative and cost-effective approaches to preventing and combating sepsis and AMR. The WSC Spotlight is a free online congress and is attended by a large number of clinicians, health decision-makers, and other health workers. For example, more than 40,000 people from 160 countries tuned in to the 2017 WSC Spotlight on maternal and neonatal sepsis (and accessed more than 300,000 times on YouTube and Apple Podcasts in the following weeks). Moreover, at the occasion of this congress, WHO will launch the first Global report on the epidemiology and burden of sepsis. The report describes results from original research and existing published evidence, the methodologies and limitations of the studies, and identifies gaps and priorities for future research. Programme and registration
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Content ArticleHuman factors is a critical component of future aviation success in both military and civil aviation systems, especially where it concerns safety. This white paper from the Chartered Institute of Ergonomics and Human Factors contains the visions of 15 ‘thought leaders’, showing how they believe aviation evolution will unfold between now and 2050, and the critical role of human factors in ensuring system performance and safety. The thoughts in this paper can be applied to human factors in health and social care.
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Content ArticleInformed consent is a person’s decision, given voluntarily, to agree to a healthcare treatment, procedure or other intervention that is made: Following the provision of accurate and relevant information about the healthcare intervention and alternative options available; With adequate knowledge and understanding of the benefits and material risks of the proposed intervention relevant to the person who would be having the treatment, procedure or other intervention. Ensuring informed consent is properly obtained is a legal, ethical and professional requirement on the part of all treating health professionals and supports person-centred care. Good clinical practice involves ensuring that informed consent is validly obtained and appropriately timed. This fact sheet from the Australian Commission on Safety and Quality in Healthcare includes information for clinicians about informed consent in healthcare.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) has published their third annual review. During 2019/20: 109 patient safety referrals received. 515 maternity investigation reports completed. 15 national investigation reports published. 58 national safety recommendations made. 88% of families engaging with the maternity investigations and 87% with the national investigations. Family information available in over 20 languages to ensure greater inclusivity. Keith Conradi, Chief Investigator, said: “There has been a huge amount of hard work from everyone within the HSIB during this period and I want to thank them and acknowledge the support of our stakeholders in the wider healthcare sector, and in particular to all the organisations who responded promptly to our safety recommendations.”
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Content ArticleThere is increasing interest and belief in applying quality improvement (QI) to help solve our most complex challenges in healthcare, yet little published literature to help leaders develop a business case and evaluate return on investment from QI. This is even more pronounced in fields such as mental health and community health services. This paper from Amar Shah and Steven Course presents a framework to help identify, understand and evaluate return on investment from large-scale application of QI in healthcare providers. The framework has been developed at East London NHS Foundation Trust (ELFT), a provider of predominantly mental health and community health services to a population of 1.5 million people, which has been undertaking QI at scale since 2014. This paper presents case studies and examples from ELFT to illustrate return on investment from QI at multiple levels: improving outcomes for patients and service users, improving the experience of staff, improving productivity and efficiency, avoiding costs, reducing costs and increasing revenue.
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Content ArticleFor physicians, the words “I can’t breathe” are a primal cry for help. As many physicians have left their comfort zones to care for patients with COVID-19–associated respiratory failure, the role of the medical profession in addressing this life-defining need has rarely been clearer. But as George Floyd’s repeated cry of “I can’t breathe” while he was being murdered by a Minneapolis police officer has resounded through the country, the physician’s role has seemed less clear. Police brutality against black people, and the systemic racism of which it is but one lethal manifestation, is a festering public health crisis. Can the medical profession use the tools in its armamentarium to address this deep-rooted disease? Evans et al. explore this further in an Editorial in the New England Journal of Medicine.
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Content ArticleDuring the COVID-19 pandemic, health care leaders are working to support staff who are experiencing anxiety, stress, and intense demands. This guide from the Institute of Healthcare Improvement (IHI), which builds on the IHI Framework for Improving Joy in Work, includes actionable ideas that leaders can quickly test during the coronavirus response, and which can build the longer-term foundation to sustain joy in work for the health care workforce.
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Content ArticleSebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October.
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Content ArticleIn this TEN podcast, Dr Aseem Malhotra talks about the UK obesity crisis, the definitions of metabolic syndrome and why, in a very clear way, it’s not too late for us all. He is now advising the Health Secretary, Matt Hancock, about the links between obesity and metabolic syndrome and COVID-19 deaths. Dr Malhotra is an NHS Consultant Cardiologist, and world renowned expert in the prevention, diagnosis and management of heart disease. He is a founding member of Action on Sugar and was the lead campaigner highlighting the harm caused by excess sugar consumption in the United Kingdom, particularly its role in type 2 diabetes and obesity.
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Content ArticleIt is now very common for clinicians to carry out consultations with patients over the telephone. If you have time to prepare for the consulation Steve Turner has some suggestions. The aim being to help all patients / users of health and care services lead on their own care. This is a rolling blog. Steve Turner is a nurse prescriber and clinical educator and Associate Lecturer at Plymouth University.
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Content ArticleThe National Guardian’s Office (NGO) has been operational for four years. Following feedback on its performance, the NGO sets out how they are going to respond to this feedback in the coming year.
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Content ArticleAcute and chronic pain place a huge burden on our society. Approximately 10% of the population in Western countries report suffering from chronic pain, and both chronic and acute pain are responsible for high absenteeism in the workplace. It is therefore crucial that we have effective ways of treating pain. Unfortunately though, we have no objective measures of pain - no blood tests, no urine dipsticks. We have to rely on what the patient tells us. So how then do we know what are and what are not effective pain treatments? It is here that the principles of evidence-based medicine have been of great value - helping us to understand the most effective forms of pain treatment. Bandolier's Little Book of Pain is a unique portable guide to evidence-based pain treatments. For each possible treatment, the book provides the evidence supporting the efficacy of the treatment, along with a clinical bottom line, for those requiring immediate information. Written by world leaders in the field of evidenced-based pain treatments, the book will be indispensable for the multi-disciplinary professionals managing acute and chronic pain in primary and secondary care.
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Content ArticleIn this blog, Shawn Achor and Michelle Gielan discuss resilience, the importance of recovery and how we can build resilience.
