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Top picks: Women's health inequity
Patient_Safety_Learning posted an article in Patient Safety Learning's Top Picks
Today (8 March 2023) is International Women’s Day and this year’s theme is #embraceequity. Sex and gender-based inequities in health are widely recognised, with much work needed to improve care, treatment and outcomes for women. In this blog, we’ve selected seven resources to highlight and evidence some of the key patient safety issues and the need for greater investment in this area. -
Content ArticleMany people see their GP with symptoms that could either get better without treatment, or be a sign of serious illness; their diagnosis is uncertain. This article from the National Institute of Health and Care Research (NIHR) summarises recent research looking at how GPs and patients can work together to develop follow-up plans (a process known as safety-netting). The study highlights the importance of patients understanding: why they are receiving this advice what actions are required, and by whom.
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Content ArticlePatient engagement is a key component of quality improvement in health. Patient activation is defined as the patient's willingness to manage their health based on understanding their role in the care process and having the knowledge and skills to do so. For children parents have this role. The Parent Patient Activation Measure (Parent-PAM) is adapted from Patient Activation Measure(PAM), a 13-point questionnaire designed to measure healthcare activation. PAM scores are stratified into "levels of activation": Level 1-does not believe the caregiver role is important (score ≤47.0) through to Level 4-takes action, may have difficulty maintaining behaviours (score ≥71). This study, published in the European Respiratory Journal, aimed to evaluate caregiver activation using Parent-PAM in a paediatric difficult asthma(DA)clinic.
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Content ArticleThis study, published in International Journal for Quality in Health Care, evaluated the efficacy of a patient feedback intervention (PRASE). This hospital intervention comprised two tools: i) a questionnaire which asked patients about factors contributing to safety (PMOS) ii) a proforma for patients to report both safety concerns and positive experiences (PIRT). A report to wards was produced summarising this feedback and action planning meetings were organized with ward staff to develop improvements in safety to address this feedback.
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Content ArticlePatients are increasingly being asked for feedback about their healthcare and treatment, including safety, despite little evidence to support this trend. This review, published in Health Expectations, identifies the strategies used to engage patients in safety during direct care, explores who is engaged and determines the mechanisms that impact effectiveness.
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Content ArticleFew centres in the UK within adult and paediatric diabetes units adopt digital technology, telemedicine or social media within their services. Perhaps this is due to both lack of investments and to some extent clinical leadership to champion and drive change. This paper presented at the 2018 Mary MacKinnon Diabetes UK lecture aims to show how health outcomes, education and patient engagement can be significantly improved using novel digital and technology strategies as effective means of driving change and delivering good quality of care within a paediatric diabetes service.
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Content ArticleThe purpose of this study, published in Archives of Disease in Childhood, was to determine the incidence and nature of prescribing and medication administration errors in paediatric inpatients. Authors conclude that prescribing and medication administration errors are not uncommon in paediatrics, partly as a result of the extra challenges in prescribing and administering medication to this patient group. The causes and extent of these errors need to be explored locally and improvement strategies pursued.
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Content ArticleThe purpose of this study, published in Intensive Care Medicine, was to establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors.
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Content ArticleA UK national survey of primary care physicians has indicated that the medication information on hospital discharge summary was incomplete or inaccurate most of the time. Internationally, studies have shown that hospital pharmacist's interventions reduce these discrepancies in the adult population. There have been no published studies on the incidence and severity of the discrepancies of the medication prescribed for children specifically at discharge to date. The objectives of this study, published in International Journal of Pharmacy Practice, were to investigate the incidence, nature and potential clinical severity of medication discrepancies at the point of hospital discharge in a paediatric setting.
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Content ArticleIatrogenic injuries, including medication errors, are an important problem in all hospitalized populations. However, few epidemiological data are available regarding medication errors in the paediatric inpatient setting. The objectives of this paper, published in JAMA, were to assess the rates of medication errors, adverse drug events (ADEs), and potential ADEs; to compare paediatric rates with previously reported adult rates; to analyse the major types of errors; and to evaluate the potential impact of prevention strategies.
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Content ArticleIn September 2017 the Short Life Working Group (SLWG) was established. The purpose of this group was to advise on the scope of a programme to improve safety in the use of medicines, including how to reduce medication errors and establish the best way to measure progress. The objectives of the group were to: In the context of the WHO Global Patient Safety Challenge Medication Without Harm, advise on the overall strategy and programme required to drive improvement in medicines safety, drawing on work underway across NHS England, NHS Improvement, the Care Quality Commission (CQC), the Medicines and Healthcare products Regulatory Agency (MHRA) and in the NHS and academia. Identify those areas in which efforts need to be targeted in the short, medium and long-term. Provide clinical and academic expertise and advice on the current barriers and issues in medicines safety, and how these can be overcome. Advise on the best ways to measure medication errors and medication safety. This report outlines the main areas of discussion by the group, and although it is not all-encompassing, the report highlights key recommendations for improvement in medicines safety.
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Content ArticleNursing workload is increasingly thought to contribute to both nurses' quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualising and measuring the effects of workload in healthcare. In contrast, this study, published in BMJ Quality & Safety, conceptualised a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes.
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Content ArticleMedication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little external reporting or sharing of this information across institutions. In this paper published Emergency Medicine Journal, authors describe the analysis of paediatric medication events (ME) reported in 18 EDs in a paediatric research network in 2007–2008.
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Content ArticleThis addendum sets out changes to the commitments in Tackling antimicrobial resistance 2019 to 2024: the UK’s 5-year national action plan. The national action plan is in its third year of delivery and these changes aim to make the commitments: more specific, measurable, achievable, realistic and time-bound (SMART) reflect lessons learned from the coronavirus (COVID-19) pandemic reflect progress that has already been made against ambitions to reduce antibiotic prescribing in food-producing animals work towards new sector targets.
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Content ArticleGovernance operates at multiple levels. Regular health service reforms can create new and complex webs of funding, policy and delivery mechanisms and accountabilities often overlain by intricate regulatory systems. In this paper from the Centre for Quality in Governance, authors propose a multi-level governance framework which helps differentiate the different system levels in further depth and defines their accountability, function/purpose and stakeholder involvement.
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Content ArticlePatient-reported outcome measures (PROMs) are increasingly used in health care. To capture the patient’s perspective, patient involvement in PROM development is needed. This study, published in BMC Health Services Research, aimed to investigate why PROM developers do or do not involve patients, how patients can be successfully involved and what the negative aspects and benefits of patient involvement are.
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Content ArticleIn this paper, published in Journal of Patient-Reported Outcomes, authors report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. They tested two overarching programme theories: PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians. PROMs scores raise clinicians’ awareness of patients’ problems and prompts discussion and action. They examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes.
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Content ArticlePatient-reported outcome measures (PROMs) are widely used in the United Kingdom (UK) and internationally to report and monitor patients’ subjective assessments of their symptoms and functional status and also their quality of life. Whilst the importance of involving the public in PROM development to increase the quality of the developed PROM has been highlighted this practice is not widespread. There is a lack of guidance on how public involvement (PI) could be embedded in the development of PROMs, where the roles can be more complex than in other types of research. This paper, published in Journal of Patient-Reported Outcomes, provides a review and sets out an emerging framework for fully incorporating PI into PROM development.
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Content ArticlePatient‐reported outcome measures (PROMs) are questionnaires that collect health outcomes directly from the people who experience them. This review, published in Health Expectations, critically synthesises information on generic and selected condition‐specific PROMs to describe trends and contemporary issues regarding their development, validation and application.
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Content ArticleThis national NHS primary care clinical pathway for constipation in children guidance supports clinicians in the prevention and management of constipation in children and young people by providing a clear and standardised approach, based on guidelines from the National Institute for Health and Care Excellence (NICE), the British National Formulary for Children (BNFc) and clinical expert groups. The pathway promotes available resources for clinicians, families and other care providers and ensures they are easily accessible, as well as raises the profile of constipation in children and young people with a learning disability as a factor in adult mortality rates.
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Content ArticleMidurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). This study, published in Neurourology and Urodynamics, aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh centre.
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Content Article
Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common issues such as abnormal bleeding, unexplained pain or unusually heavy periods. It involves a long, thin tube being passed through the vagina and cervix, into the womb, often with little or no anaesthesia. Studies indicate that some women do not find hysteroscopy procedures painful. However, it is now widely recognised that many women experience severely painful and traumatic hysteroscopies.[1-5] At Patient Safety Learning, we have worked with patients, campaigners, clinicians and researchers to understand the barriers to safe care and call for improvements.[6] We believe that no woman should have to endure extreme pain or trauma when accessing essential healthcare. In this blog we will: outline the key safety concerns around hysteroscopy procedures summarise recent national discussions highlighting these concerns reflect on the new national guidance outline six calls for action. -
Content ArticleAdverse incidents are well studied within acute care settings, less so within aged care homes. The aim of this scoping review, published in Gerontology and Geriatric Medicine, was to define the types of adverse incidents studied in aged care homes and highlight strengths, gaps, and challenges of this research. Authors conclude that: Aged care policy and adverse incident research needs to expand through the inclusion of a broader definition of what is “adverse” to an older person’s health and well-being. A greater level of specific contextual information within aged care adverse incident research could assist in international comparisons and transferability of research. Importantly, greater inclusion of voices of older people themselves through qualitative and multi-method research would provide a key missing perspective on the concept of “adverse” incidents in aged care homes.
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Content ArticleThis cross-sectional study, published in Workplace Health & Safety, used secondary survey data sent to approximately 7,100 health care workers at a large academic medical centre in the United States. Instruments included: the Hospital Survey on Patient Safety Culture a WPV scale measuring physical and verbal violence perpetrated by patients or visitors the Emotional Exhaustion scale from the Maslach Burnout Inventory. Findings suggest that improvements in hospital strategies aimed at patient safety culture, including team cohesion with handoffs and transitions, could positively influence a reduction in physical and verbal violence perpetrated by patients or visitors, and burnout among health care workers.
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Content ArticleECRI’s Top 10 Health Technology Hazards for 2023 list identifies the potential sources of danger they believe warrant the greatest attention for the coming year and offers practical recommendations for reducing risks. Since its creation in 2008, this list has supported hospitals, health systems, ambulatory surgery centres, and manufacturers in addressing risks that can impact patients and staff. Their executive now includes specific calls to action for industry.
