Patient_Safety_Learning
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Content ArticleThe Framework serves to guide efforts to deliver safe and sustainable water, sanitation and hygiene (WASH), health care waste management and reliable electricity in all health care facilities. The ultimate aim is to provide quality care for all. The Framework reflects a global consultative process and includes data and recommendations articulated in recent WHO/UNICEF global reports on WASH, waste and electricity in health care facilities. It also provides an operational roadmap for implementing the 2023 United Nations General Assembly (UNGA) resolution on WASH, waste and electricity in health care facilities. The target audiences for this Framework include health leaders and programme managers at the global and national levels; policymakers; WASH, waste and energy leaders and technical experts; development partners and finance institutions; and actors and experts on gender equality, disability and social inclusion and climate; and, more generally, civil society. The Framework addresses the WASH, waste and electricity elements of the WHO comprehensive approach to build safe, climate-resilient and environmentally sustainable health care facilities.
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Content ArticleAntimicrobial resistance (AMR) is a major global health problem. Efforts to mitigate AMR prioritise antimicrobial stewardship (AMS) interventions. These interventions typically focus on deficiencies in practice and providing negative or normative feedback. This approach may miss opportunities to learn from success. Authors aimed to identify factors that enable success in AMS practices in the paediatric intensive care unit (PICU) by analysing the data obtained from interviews with staff members who had achieved success in AMS. The insights gained in this study originate from frontline staff who were interviewed about successful work-as-done. This strengths-based approach is an understudied area of healthcare, and therefore offers authentic intelligence which may be leveraged to effect tangible improvement changes. The methodology is not limited to AMS and could be applied to a wide range of healthcare settings.
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Content ArticleHow are community groups bridging some of the gaps between Black mothers and health and care services? What can the health and care system learn in response? Siva Anandaciva speaks to Amanda Smith, founder and Chief Executive of Maternity Engagement Action CIC, Benash Nazmeen, Professor of Midwifery and co-founder and co-director of the Association of South Asian Midwives CIC, and Chrissy Brown, founder and Chief Executive of the Motivational Mums Club CIC, to find out.
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Tanya Buxton is a medical tattoo artist providing 3D areola-nipple tattoos within the NHS and private healthcare. In this Blog, she explains more about her work and how it can benefit a patient post-surgery. Tanya also raises a number of safety concerns relating to poor standards of education in this area of healthcare, highlighting the harm this can cause patients both physically and emotionally. -
Content ArticleDuring the diagnostic process, clinicians may make assumptions, prematurely judge or diagnose patients based on their appearance, their speech or how they are portrayed by other clinicians. Such judgements can be a major source of diagnostic error and are often linked to unconscious cognitive biases - faulty quick-fire thinking patterns that impact clinical reasoning. Patient safety is profoundly influenced by cognitive bias and language, i.e. how information is presented or gathered, and then synthesised by clinicians to form and communicate diagnostic decisions. Here, authors discuss the intricate links between interpersonal communication, cognitive bias, and diagnostic error from a patient's, a linguist's and clinician's perspective. They propose that through patient engagement and applied health communication research, we can enhance our understanding of how the interplay of communication behaviours, biases and errors can impact upon the patient experience and diagnostic error. In doing so, they provide new avenues for collaborative diagnostic error research striving towards healthcare improvements and safer diagnosis. This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.
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Content Article
The Voicing Loss project is a collaboration between the Institute for Crime & Justice Policy Research at Birkbeck, University of London, and the Centre for Death & Society at the University of Bath. The research was conducted from May 2021 to May 2024, with funding from the Economic and Social Research Council. The research examined the role of bereaved people in coroners’ investigations and inquests, as defined in law and policy and as experienced in practice. It also explored ways in which the inclusion and participation of bereaved people in the process can be better supported. A range of project outputs are available via the dedicated Voicing Loss project website. They include a short research summary, along with thematic research reports and policy and practice briefings. The website also has an information and resources section for the general public, and an Expert Insights blog to which many stakeholders have contributed. Many of the study’s key findings, and the research context and methodology, are presented in the papers listed on the website. Implications of these findings for policy and practice are considered in a series of briefings also available through the website which you can access via the link below. -
Content Article
I work primarily in the areas of lived experience and in co-production, and I strive to have both of these concepts better understood, and more effectively utilised wherever possible. Nowhere is this more important than the world of patient safety. In this first blog for Patient Safety Learning I will concentrate on lived experience, its definition, its usage, and its impact. -
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Anthony O’Connor is a co-production and lived experience consultant. In Anthony's first blog for Patient Safety Learning, he looked at lived experience, its definition, its usage, and its impact. In this blog, he talks about the benefits of co-production and why it is essential to patient safety. Anthony gives examples of how co-production can be used more in healthcare and encourages everyone to develop their knowledge of co-production and start embedding it into their work. -
Content ArticleIn June 2021, high-profile testimonials in the media about pain during intrauterine device (IUD) procedures in the UK prompted significant discussion across platforms including Twitter (subsequently renamed X). Authors of this study published in BMJ Sexual and Reproductive Health, examined a sample of Twitter postings (tweets) to gain insight into public perspectives and experiences. They harvested tweets posted or retweeted on 21–22 June 2021 which contained the search terms coil, intrauterine system, IUD or intrauterine. They analysed the dataset thematically and selected illustrative tweets with the authors’ consent for publication. They conclude that these findings attest to the need for strategies to improve the patient experience for those opting for IUD as a clinical priority. Further research should explore IUD users' experiences, expectations and wishes around pain management. Read the full paper via the link below.
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This report from National Voices called People’s experiences of diagnosis, brings together insights from people with lived experience and our members on the entire process of diagnosis – from trying to get an appointment for a diagnostic referral, to undergoing tests, and experiences post-diagnosis. The report covers the themes of challenges in diagnosis, inequalities in diagnosis, and new innovation in diagnosis, before concluding with nine recommendations for improving patient experience of diagnosis. These nine recommendations include: Adjustments and adaptations to enable access Provide better support while waiting Listen to the patient Better communication around diagnosis Make sure people have a plan Provide access to support groups Collect better data to understand the driver of diagnostic health inequalities, and act on it rapidly Upskill, coordinate and ultimately increase the workforce Have health equity embedded into new innovations the start. Related reading on the hub: This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more. -
Content ArticleMillions of unpaid carers across the UK provide support to a family member, friend or neighbour due to a disability, illness or frailty due to old age. Yet a majority of unpaid carers have no choice but to take on a caring role. While providing unpaid care can be rewarding, it also comes with significant negative impacts on carers’ lives. Carers Week commissioned YouGov to carry out polling of the general public, including adults who are currently providing unpaid care.
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Community PostHave you or someone you know been affected by a: delayed diagnosis incorrect diagnosis missed diagnosis? Errors can happen at every stage of the diagnostic process and can happen in all healthcare settings. In some circumstances the impact is life-changing. If you have insights to share around diagnostic error and the impact on patient safety, please comment below (sign up first here, for free). Or you can contact us directly at [email protected]. This post has been published as part of our World Patient Safety Day activity, with the 2024 theme of Improving diagnosis for patient safety. #WPSD, #WorldPatientSafetyDay, World Patient Safety Day 2024
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Content ArticleMaternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors of this paper, published in The Joint Commission Journal on Quality and Patient Safety, sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.
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Content ArticleSuad Duale grew up as a Somali refugee. She is now a community activist, a clinician, a mother and a researcher. Every day she says she sees the Somali community suffering and being treated unfairly, which leads to a collective lack of trust in professionals, particularly in the health system. In her work, she tried to address this issue by bridging the gap between the community and health and social care professionals. Read the full article on the Kings Fund website via the link below.
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Content ArticlePublished on Steve Turner's blog site, this article gives a summary of the The Protection for Whistleblowing Bill & the Office of the Whistleblower, and answers some frequently asked questions.
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Content ArticleOne year on from the launch of the Health Innovation Network's Chronic Pain Experience-Based Co-Design (EBCD) project, Natasha Callender, Senior Project Manager at the Health Innovation Network South London (HIN), and Natasha Curran, HIN Medical Director and Consultant in Pain Medicine share reflections on their learnings from working with people living with chronic pain.
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Content ArticleInspired by the work of NYC Health + Hospitals' efforts to embed health equity into their adverse event analysis, WellSpan Health shares their self-assessment so others might likewise learn from their efforts.
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Content ArticleThis study explored the beliefs and organisational contexts of nursing aide (caregivers henceforth) assaults and their subsequent reporting of these events. Although this data is a pretty specific cohort and setting (rural nursing homes), the social and systems lenses that the authors take, and the silence resulting from blame attributions have broader applications.
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Content ArticleOver the past year, the Director of Patient Safety, the Risk and Governance Team, the Legal team, nursing and medical leaders, adult mental health services in Bedfordshire & Luton, as well as the Associate Director of Quality Improvement, have been deploying quality improvement (QI) methods to enhance the development and delivery of the organization’s patient safety strategy. Following sessions with staff, service users, and partner organizations, the strategy was constructed in the form of a Driver Diagram. Follow the link to find out more and to access the diagram.
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Content ArticleQualiScope is... a general public information service on the level of quality and safety of care measured by Haute Autorité de Santé (HAS) in all hospitals and clinics in France; access to all the results of the quality and safety indicators of care and certification of health establishments in France; a search engine and an interactive panorama allow access to data from more than 4 000 hospital sites by search by establishment name, geographical area, activity, certification result, indicator results, etc. ; data developed and measured independently by HAS, with robust methods ensuring their reliability and comparability between health facilities; tools for mapping, comparison, data visualisation or data exports to make information accessible and understandable to all.
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Content ArticleIn 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation. This research, published by Lund Universities Libraries, comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinising five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's categorisation regarding incident investigation models, which delineates three models: sequential, epidemiological, and systemic. The findings show that there are distinctions in both the nature and effects of the investigation reports. Investigations conducted pre-2017 exhibit characteristics of the sequential model due to a focus on what went wrong, (broken) components and measures that mostly aim at the sharp end operator (train drivers, conductors, train dispatcher) such as training and discussing specific findings of the investigations with those involved only.
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Content ArticleSecure and immediate access to health and care data helps to prevent avoidable delays in diagnosis and unnecessary repeat tests and examinations that can slow down the speed at which patients are able to begin treatment. In an emergency situation, the right information at the right time can be life saving. This NHS England webage looks improving individual care and patient safety, within the context of the Data Saves Lives: Reshaping health and social care with data strategy. Content includes: Video: Why do shared care records matter? Video: Why does data matter to adult social care? Case studies
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Content ArticleQuality improvement and patient safety (QIPS) practitioners aspire to improve care for all patients, caregivers and families using improvement methods. While teams are trained to carefully implement the science of improvement, less is known of how to effectively incorporate equity into QIPS work. In this editorial for BMJ Quality and Safety authors ask; should there be more projects focused specifically on equity, or should equity be embedded into all quality improvement?
