Patient_Safety_Learning
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Content ArticleIn 2023, research suggested adverse events occur in about one-fourth of hospital admissions, prompting NEJM Catalyst to seek insight from leaders on how healthcare organisations can get more strategic around patient safety and quality improvement. Thomas Lee, MD, editor-in-chief and editorial board co-chair of the NEJM Catalyst Innovations in Care Delivery journal, reached out to 13 leaders in response to the study findings led by David Bates, MD, chief of general internal medicine at Boston-based Brigham and Women's, that indicate it is time to revamp patient safety and quality work. This article published by Becker's Hospital Review highlights excerpts from four leaders' responses.
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Content ArticleThe Royal College of Emergency Medicine (RCEM) commissioned Ipsos to conduct an online poll of UK adults aged 16-75 to better understand their views on emergency care. The poll revealed that confidence in the UK Government’s approach to tackling long waits for patients in A&E is low, with 59% of respondents expressing a lack of confidence that the UK Government has the right policies to tackle long patient waiting times in A&E departments in hospitals. RCEM’s five priorities below for UK Governments will #ResuscitateEmergencyCare to ensure the emergency care system is there for us all in our time of need.
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Content ArticleIn this article, published on Richard Smith's non-medical blogs, Richard describes the events surrounding his elderly mothers trip to A&E from her care home. Richard highlights a number of safety issues in his account and improvements that could be made to the system and processes. "The nurses have much more confidence in the benefits of the hospital than I do. Hospitals, I know, are dangerous and miserable places for everybody but particularly for the demented; and the danger is increased in the pandemic. There has to be considerable benefit to outweigh the inbuilt risk."
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Content ArticleThe objective of this analysis, published in the BMJ, was to determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared with England where the scheme continued.
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Content ArticleEarlier this month, 13 leaders shared thoughts in NEJM Catalyst on how healthcare organisations can get more strategic around patient safety and quality improvement - an area that has seen renewed attention after COVID-19-related setbacks. Several themes emerged across leaders' responses, namely the need for more proactive approaches to mitigate risk and intervene, rather than reviewing and assessing harms after they occur. University Hospitals nurses are leading the charge to do just that by embracing the adoption of artificial intelligence to make daily safety huddles more actionable. Read the full article, published by Becker's Hospital Review via the link below.
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Content Article
The Patient Information Forum (PIF) and the Patients Association have published a report setting out simple steps to remove barriers to shared decision making. The aim is to help patients and healthcare professionals make the most of short appointment times. The report, Removing barriers to shared decision-making, is based on a co-production project which ran throughout 2022 in the Nottingham and Nottinghamshire Integrated Care Board. They worked with the My Life Choices lived experience panel, healthcare professionals and the personalised care team to develop resources to support shared decision making for people experiencing joint pain (musculoskeletal conditions). Most of the findings can be applied to shared decision-making in general. This report outlines key findings and recommendations. It also shares the co-produced resources developed throughout the project. -
Content ArticleWork stress is one of the leading causes of physical and mental problems among nurses and can affect patient safety. Nurses experiencing stress are more prone to make errors, which has consequences for the safety culture. This study, published in BMC Nursing, aimed to describe the findings of studies that examined the relationship between job stress and patient safety culture among nurses.
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Content ArticleIn this blog, published by the World Health Organization, we hear about one family's experience of long Covid. Claire Hastie and her children are yet to recover and continue to experience numerous debilitating symptoms that prevent them from taking part in their pre-covid occupations. WHO/Europe has also been working with patient groups to define priority areas where action is needed. It is now calling upon governments and authorities to focus attention on long COVID and its sufferers through greater: recognition: all services must be adequately equipped, and no patient should be left alone or have to struggle to navigate through a system that is not prepared to, or not capable of, recognizing this very debilitating condition; research and reporting: data gathering and reporting of cases, and well-coordinated research with full participation of patients, are needed to advance understanding of the prevalence, causes and costs of long COVID; and rehabilitation: this cost-effective intervention is an investment in building back healthy and productive societies.
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Content ArticleThe objectives of this study, published in JAMIA, were to: characterize persistent hazards and inefficiencies in inpatient medication administration explore cognitive attributes of medication administration tasks discuss strategies to reduce medication administration technology-related hazards.
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Content ArticleThis article describes a patient led a quality improvement (QI) project, working with a multidisciplinary team including pharmacists at East London Foundation Trust (ELFT). Their goal is to develop a better process so that he – and other patients – can get the medications they need in a timely manner. Katherine Brittin, MPH, Associate Director at ELFT says, “All of our work is about how we support service users to get involved to get the best from our services and for us to respond to what matters to them.” In the article, Brittin offers tips to health systems that may be inspired by ELFT’s example.
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Content ArticlePatients have expressed a growing interest in having easy access to their personal health information, and internationally there has been increasing policy focus on patient and care records being more accessible. Limited research from the UK has qualitatively explored this topic from the primary care staff perspective. This study, published in BMC Health Services Research, aimed to understand what primary care staff think about patients accessing electronic health records, highlighting errors in electronic health records, and providing feedback via online patient portals.
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Content ArticleThis webpage from NHS Scotland provides a proforma for writing up Enhanced Significant (learning) Event Analyses and app, booklet, cards and deskpad tools to help analyse significant events.
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Supporting equity-centred engagement
Patient_Safety_Learning posted an article in Patient engagement
This guide was developed through a collaboration between the Public and Patient Engagement Collaborative (PPEC) and the Public Engagement in Health Policy (PEHP) Project at McMaster University. As groups and organisations seek to bring a stronger equity focus to their engagement work, there are many things to consider and a growing number of resources to support this work. The aim of this guide is to help you navigate the many helpful resources that exist to help centre equity in your engagement work. -
Content ArticleMany healthcare leaders are governed by deep-set habits, behaviours and lessons learned over many years in an environment that was much less complex than today's. This creates barriers to success, perpetuating the challenges that we strive to overcome. The author of this article, published by NHS providers, argues that before we can adopt new habits, behaviours and processes, we have to "unlearn" the lessons of old.
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Content ArticleIn this article, published by Inflect Health, ER doctor Josh Tamayo-Sarver explains what happened when he asked artificial intelligence chatbot ChatGPT to provide possible diagnoses based on his case notes.
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Experts in MS: Professional network
Patient_Safety_Learning posted an article in Neurological conditions
A network for everyone who works with people with MS to discover, share, support and innovate together. Discover information, research, evidence and innovative ideas to support your work - developed with and by professionals. Follow the link below to go to the MS Society website for more information. -
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MS and mental health
Patient_Safety_Learning posted an article in Neurological conditions
The emotional effects of Multiple Sclerosis often go undiagnosed. It's not unusual to experience depression, stress and anxiety when you have MS. Medication, talking therapies and self-help techniques can all make it easier to cope. This webpage from the MS Society includes information on: depression stress and anxiety causes of mental health problems other mood and behaviour changes coping with losss grief and guilt supporting someone who has MS getting help staying active mindfulness and MS. -
Content ArticleThere has been increasing public concern that COVID-19 vaccination causes menstrual disturbance regarding the relative effect of vaccination compared to SARS-CoV-2 infection. The objectives of this study, published in Science Direct, were to test potential risk factors for reporting menstrual cycle changes following COVID-19 vaccination and to compare menstrual parameters following COVID-19 vaccination and COVID-19 disease.
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Content ArticleIn this special edition episode of 'I forgot to ask the doctor', host Dr Gail Busby interviews Professor Justin Clark and Dr Helgi Johnannsson about the options for pain relief for the important procedure of hysteroscopy.
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ERIC: The children's bowel and bladder charity
Patient_Safety_Learning posted an article in Paediatrics
ERIC is the national charity dedicated to improving children’s bowel and bladder health. Their mission is to reduce the impact of continence problems on children and their families. The ERIC website includes: advice and resources for professionals advice and resources for parents and young people training and events information about bowel and bladder health for children with additional needs. To speak to an ERIC advisor you can call 0808 1699 949. The Helpline is open Monday - Thursday, 10am to 2pm and is free to call from landline and mobile numbers. To visit the ERIC website, click on the link below. -
Content ArticleReducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study, published in PLOS ONE, aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. Authors conclude: "We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement."
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Content ArticleThe mandated reporting of medication-related errors in community pharmacies including incidents resulting in inappropriate medication use and near misses intercepted before reaching the patient can be utilised as learning opportunities to aid in the prevention of future events. This study examined reporting uptake, trends, and initial learnings from medication errors reported by community pharmacists to the Assurance and Improvement in Medication Safety (AIMS) Program based in Ontario, Canada between April 1st, 2018, and June 30th, 2021. Key findings Community pharmacy engagement with the AIMS Program has grown since implementation. Commonly reported events involved the incorrect drug, concentration, or quantity. In most cases no patient harm was reported. Reporting by pharmacy teams will help develop strategies to prevent future events.
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Content ArticleNear misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED). This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED. It was published in the Journal of Patient Safety. Authors conclude that near-miss events are relatively common (22.7% of their sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.
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Content ArticleThis paper, published in the International Journal of Health Governance, discusses and analyses the need and benefits of a patient safety definition within the context of nursing. The predominant role of nurses due to the proportionate size and significant role along with the need for clarification of patient safety in nursing terms is recognised. Research evidence of nursing areas with safety issues and relevant nursing interventions are presented. Based on all findings, a research-based nursing specific patient safety definition is proposed. This definition includes three axes: What is patient harm? How this harm can be eliminated or reduced? Which are the areas of nursing practice that are identified to provide opportunity for patient harm? These axes include nursing specifications of the patient safety definition.
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Footage from the Black Maternal Health Conference UK 2023 is now available for download. Sessions highlight the gaps within the system and disparities - and provide nuance, to further reiterate the importance of Black women receiving health care that is respectful, culturally competent, safe and of the highest quality. Hosted by Sandra Igwe, Chief Executive of The Motherhood Group. You can purchase the full recording, or specific sessions, from the event via the link below.
