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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    Engaging for success: enhancing performance through employee engagement sets out the evidence that only organisations that truly engage and inspire their employees produce world class levels of innovation, productivity and performance. The lessons that flow from that evidence can and should shape the way leaders and managers in both the private and public sectors think about the people who work for them. They should also shape the way employees approach their jobs and careers. 
  2. Content Article
    A study of police wearing body worn cameras showed a reduction in complaints, and a decrease in occurrences and crimes. Mental health staff working in inpatient settings do not routinely wear cameras. The aim of this project, published in Mental Health in Family Medicine, was to examine the feasibility of using body worn cameras in an inpatient mental health setting. The results found that both staff and patients considered that their use in an inpatient mental health setting was beneficial. Compared to the same period the year before, there was a reduction in complaints and incidents during the duration of the pilot.
  3. Content Article
    The objective of this study, published in the Journal of Clinical Nursing, was to determine the predictive value of individual and combined dutch-early-nurse-worry-indicator-score indicators at various Early Warning Score levels, differentiating between Early Warning Scores reaching the trigger threshold to call a rapid response team and Early Warning Score levels not reaching this point.
  4. Content Article
    BMJ Quality & Safety, was to determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.
  5. Content Article
    Major critical illness events, such as cardiopulmonary arrest and intensive care unit (ICU) transfer, disrupt workflow in a hospital ward. Other patients on the same ward may receive inadequate attention, especially if their care team is distracted by the emergency. Most studies have concentrated on patient-level variables associated with outcomes.This paper, published by JAMA, looks at the risk to ward occupants associated with patients on the same ward experiencing critical illness.
  6. Content Article
    The reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery. The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
  7. Content Article
    This paper, published by the Canadian Journal of Surgery, suggests that the failure to systematically measure patient safety is the reason for limited progress. In addition to defining patient safety outcomes and describing their financial and clinical impact, the authors argue why the failure to implement patient safety measurement systems has compromised the ability to move the agenda forward. They also present an overview of how patient safety can be assessed and the strengths and weaknesses of each method and comment on some of the consequences created by the absence of a systematic measurement system.
  8. Content Article
    Peter Duffy, consultant surgeon writes of his 35 years of experience on the front-line of the NHS. Charting his career pathway from auxiliary nurse and unskilled operating theatre orderly, he takes us through his progress to senior consultant surgeon and head of department. In 2015, and after blowing the whistle on a series of near misses, he reluctantly reported an avoidable death, cover-up and ongoing surgical risk-taking to the Care Quality Commission. Within months he was out of work and unemployed. Via avoidable deaths and errors, cover-ups, misuse of public funds, bullying, abuse and victimisation the author charts out in searing detail his demotion, punishments and exile from both family and NHS and the subsequent brutal legal process that followed his illegal dismissal.
  9. Content Article
    The author of this article, published in The Guardian, argues that centuries of female exclusion has meant women’s diseases are often missed, misdiagnosed or remain a total mystery.
  10. Content Article
    Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. The authors of this study, published in The Lancet, reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes.
  11. Content Article
    One woman's account, published by Care Opinion, of her traumatic experience of having a hysteroscopy. "At no point was any pain relief, sedation or anaesthetic offered to me or discussed at all."
  12. Content Article
    Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review, published in BMJ Open, is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.
  13. Content Article
    SHOT is the United Kingdom independent, professionally led haemovigilance scheme.  Since 1996 SHOT has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. Where risks and problems are identified, SHOT produces recommendations to improve patient safety. The recommendations are put into its annual report which is then circulated to all the relevant organisations including the four UK Blood Services, the Departments of Health in England, Wales, Scotland and Northern Ireland and all the relevant professional bodies as well as circulating it to all of the reporting hospitals.  As haemovigilance is an ongoing exercise, SHOT can also monitor the effect of the implementation of its recommendations.
  14. Content Article
    Patients are not always given a choice between an outpatient hysteroscopy and a general anaesthetic. Radio's 4's Women's Hour discusses the issue of inadequate pain relief for hysteroscopies. The discussion includes one patient's story of the trauma she suffered and a response from a consultant in reproductive health. The interview was published on the Hysteroscopy Action website, please follow the link below to listen. 
  15. Content Article
    This patient story essay was produced by the Campaign against painful hysteroscopy to highlight the extreme levels of pain many women experience when undergoing the procedure. The campaign calls for an end to inadequate pain relief for hysteroscopies.
  16. Content Article
    This leaflet, produced by Kingston Hospital, is designed to prepare women for hysteroscopy procedures that are performed in the gynaecology outpatients department. Join the conversation on the hub about hysteroscopies.
  17. Content Article
    Hysterical Women is a blog inspired by the work of freelance health journalist, Sarah Graham. It was launched in October 2018, after she noticed that a common theme in so much of her work was women not being taken seriously, not being trusted to know their own bodies, and having their concerns dismissed or disbelieved by doctors. This cut right across the health spectrum – whether their concerns were related to mental, physical, sexual, or any other kind of health problem.
  18. Content Article
    For eligible patients, prompt admission to the Intensive Care Unit (ICU) can increase their chance of survival by up to 23%. Yet those that do survive may experience lasting physical and emotional effects, and it is the job of the clinician to carefully weigh up the potential gains and risks of admission in what is often a time-pressured environment. There are currently no national guidelines to help the decision-making process, and evidence suggests it is influenced by a range of factors, with considerable variation between clinicians. In addition, patients and their families are not always fully informed or consulted. This study, published by Health Services and Delivery Research, explored current practice in order to create a decision support tool that could be used to help take some of the uncertainty out of the process, thereby improving decisions and, when possible, also informing the discussions with the patient and their family.
  19. Content Article
    In her blog for the Professional Standards Authority, Sarah Seddon talks about her personal experience as a patient going through the fitness to practise process. She outlines her thoughts on the key considerations that she believes regulators should take into account to help 'humanise' the process.   "I was known as ‘Woman A’. To me, this embodies the entire impersonal, inhumane world of fitness to practise. I wasn’t a person with needs, thoughts and feelings; I wasn’t a bereaved mum; I wasn’t a professional anymore but simply a piece of evidence."
  20. Content Article
    This diagram, published by the Institute for Healthcare Improvement (IHI), is titled A driver diagram to systematically and proactively identify and eliminate non-value-added waste in the US health care system by 2025. Produced by the IHI's Leadership Alliance's Waste Working Group, it sets out a number of drivers for reducing waste in the healthcare system in America. The top driver listed focuses on safety and reducing harm.
  21. Content Article
    A dilemma is a situation in which a difficult choice has to be made between two or more alternatives, especially ones that are equally undesirable. Healthcare is full of dilemmas as a result of the huge number of stakeholders with conflicting goals, multifaceted interactions and constraints, and multiple perspectives, which change daily. Dilemmas are created when safety conflicts with productivity, cost efficiency, and flow. A focus on one patent’s safety may conflict with a focus on all patients’ safety. It is vital that the different stakeholders talk to expose dilemmas and reveal the hidden trade-offs or adjustments that are kept secret because people are fearful of the consequences. Articulating dilemmas helps us to find a way to bring people with different interests and incentives into a conversation that meets everyone’s needs.
  22. Content Article
    The Committee of Inquiry was set up in 1967 by the Welsh Hospital Board at the request of the Minister of Health, to investigate allegations of ill-treatment of patients and of pilfering by staff which had been made by a nursing assistant employed at the hospital. The Committee was also asked to make their own examination of the situation in the hospital at the time of their inquiry.
  23. Content Article
    American women visit more doctors, have more surgery, and fill more prescriptions than men. In Everything Below the Waist, Jennifer Block asks: why is the life expectancy of women today declining relative to women in other high-income countries and even relative to the generation before them? Block examines several staples of modern women's health care, from fertility technology to contraception to pelvic surgery to miscarriage treatment and finds that while over-diagnosis and over-treatment persist in medicine generally, they are particularly acute for women. Further reading: Interview with the author
  24. Content Article
    Fourteen years after being diagnosed with endometriosis, Gabrielle Jackson couldn't believe how little had changed in the treatment and knowledge of the disease. In 2015, her personal story kick-started a worldwide investigation into the disease by the Guardian; thousands of women got in touch to tell their own stories and many more read and shared the material. What began as one issue led Jackson to explore how women, historically and through to the present day, are under-served by the systems that should keep them happy, healthy and informed about their bodies. Further reading: Interview with the author
  25. Content Article
    This is an interview with Gabrielle Jackson, author of Pain and Prejudice: A call to arms for women and their bodies, published by the Hysterical Women website. Jackson talks about her diagnosis of endometriosis, the lack of advanced medical knowledge around women's medical issues and a need for access to better treatments.
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