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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    Editor of the award-winning site Feministing.com, Maya Dusenbery brings together scientific and sociological research, interviews with experts within and outside the medical establishment, and personal stories from women across the country to provide the first comprehensive, accessible look at how sexism in medicine harms women today.
  2. Content Article
    The objective of this paper, published by the BMJ, was to determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England, and to determine the association with the trust’s hospital-wide standardised mortality ratio assessed using the two commonly used methods - the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI).
  3. Content Article
    Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. The authors of this paper, published in BMJ Quality & Safety, performed a systematic review of the literature on in-hospital adverse events.
  4. Community Post
    @Jayne Addison this thread may be of interest to you/ relevant to your role. What are your thoughts?
  5. Content Article
    Patient and family advisory councils (PFAC) are groups of patients, family members, community members, and hospital staff who work together to bring the unique perspectives of patients and families to a hospital’s operations, especially its efforts to improve care. According to one estimate, more than 2,000 hospitals in the United States have PFACs. They are also slowly becoming more common in outpatient settings. Massachusetts is the only state that mandates all hospitals (acute care, rehabilitation, and long-term acute care) to have a PFAC. Five years on, this is a review of how the mandate came about, how the implementation process has gone, what PFACs in Massachusetts are doing now and what other states, healthcare organisations and consumer advocacy groups can learn from the Massachusetts experience.
  6. Content Article
    This article from the British Association of Oral Surgeons (BAOS) highlights that these clinicians perform a high volume of multi-site complex procedures, on anxious patients who are frequently conscious, that have the potential for error to occur.
  7. Content Article
    The report, Improving care by using patient feedback, published by the National Institute for Health Research, features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better.  Here, we highlight one of the examples from the report, showing some correspondence between a patient and a nursing team.
  8. Content Article
    Patients are increasingly being asked for feedback about their healthcare experiences. However, healthcare staff often find it difficult to act on this feedback in order to make improvements to services. This paper, published by Social Science & Medicine, draws upon notions of legitimacy and readiness to develop a conceptual framework (Patient Feedback Response Framework – PFRF) which outlines why staff may find it problematic to respond to patient feedback.
  9. Content Article
    The authors of this paper, published in Clinica Chimica Acta, argue that in the current health care organisational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: We need to move from looking at errors as individual failures to realising they are caused by system failures We must move from a punitive environment to a just culture We move from secrecy to transparency Care changes from being provider (doctors) centred to being patient-centred We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, inter-professional teamwork Accountability is universal and reciprocal, not top-down.
  10. Content Article
    There is little research focusing on how bereaved families experience NHS inquiries and investigations. Despite this gap, there is a consistent assumption that these processes provide families with catharsis. Drawing on her personal experiences of NHS investigations over a five‐year period after the death of her son, Connor Sparrowhawk, the author suggests the assumption of catharsis is misplaced and works to erase the considerable emotional ‘accountability’ labour that families undertake during these processes. She further question whether inquiries or investigations are an effective way of holding stakeholders to account. She concludes with two points: first, qualitative research is needed to better understand bereaved family experiences of inquiries and investigations and second, the ‘lessons learned’ objective underpinning inquiries should be replaced with ‘leading to demonstrable change’, which is what families typically want.
  11. Content Article
    Much policy focus has been afforded to the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), the authors of this paper, published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice. 
  12. Content Article
    This paper, published by BMJ Quality & Safety, argues that discharge handovers are often haphazard. Healthcare professionals do not consider current handover practices safe, with patients expected to transfer information without being empowered to understand and act on it. This can lead to misinformation, omission or duplication of tests or interventions and, potentially, patient harm. Vulnerable patients may be at greater risk given their limited language, cognitive and social resources. Patient safety at discharge could benefit from strategies to enhance patient education and promote empowerment.
  13. Content Article
    With the aim of examining current and potential practice in relation to soft intelligence, the authors conducted and analysed 107 in-depth qualitative interviews with senior leaders, including managers and clinicians, involved in healthcare quality and safety in the English National Health Service. This study, published by Science Direct, found that participants were in little doubt about the value of softer forms of data, especially for their role in revealing troubling issues that might be obscured by conventional metrics.
  14. Content Article
    Several countries have national policies and programmes requiring hospitals to use quality and safety (QS) indicators. To present an overview of these indicators, hospital-wide QS (HWQS) dashboards are designed. There is little evidence how these dashboards are developed. This paper, published by BMJ Quality & Safety, studies the challenges faced developing these dashboards in Dutch hospitals.
  15. Content Article
    For senior managers and safety professionals within organisations wishing to develop performance indicators to give improved assurance of control over major hazard risks. Although primarily addressed to major hazard operators, the generic model for establishing a performance measurement system, as given in this guide, can equally apply to other enterprises requiring similar levels of assurance. Offering a six-stage process to adopt in order to implement a programme of performance monitoring for process safety risks.
  16. Content Article
    This study, published in the BMJ Open, aims to examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives.
  17. Content Article
    The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level across the NHS in England using a standard and transparent methodology. It is produced and published monthly as a National Statistic by NHS Digital. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
  18. Content Article
    Recent years have seen increasing calls for more proactive use of patient complaints to develop effective system-wide changes, analogous to the intended functions of incident reporting and root cause analysis (RCA) to improve patient safety. Given recent questions regarding the impact of RCAs on patient safety, the authors sought to explore the degree to which current patient complaints processes generate solutions to recurring quality problems.
  19. Content Article
    This paper, published by Science Daily, highlights how a multidisciplinary group of leaders established consensus-driven research agenda designed to create a path forward to inform approaches that better support harmed patients and families.
  20. Content Article
    This paper explores how patient-reported experience measures (PREMs) are collected, communicated and used to inform quality improvement (QI) across healthcare settings.
  21. Content Article
    Software is playing an expanding role in modern medical devices, raising the question of how developers, regulators, medical professionals, and patients can be confident in the devices' reliability, safety, and security. Software- related errors in medical equipment have caused people's deaths in the past, so the issue is not simply theoretical. Device manufacturers need to provide safety assurance for complex software that is being developed in a competitive environment where price and time-to-market are critical factors. Further, security issues that previously were not a major concern now need to be anticipated and handled. In this interview, published by Electronic Design, Dr. Benjamin Brosgol, senior member of the technical staff at Adacore, talks about these issues. 
  22. Content Article
    This study, summarising evidence from 55 studies, indicates consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs. It demonstrates positive associations between patient experience and self-rated and objectively measured health outcomes; adherence to recommended clinical practice and medication; preventive care (such as health-promoting behaviour, use of screening services and immunisation); and resource use (such as hospitalisation, length of stay and primary-care visits). There is some evidence of positive associations between patient experience and measures of the technical quality of care and adverse events. Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations.
  23. Content Article
    When it was initiated in 2001, England's national patient survey programme was one of the first in the world and has now been widely emulated in other healthcare systems. The aim of the survey programme was to make the National Health Service (NHS) more 'patient centred' and more responsive to patient feedback. The national inpatient survey has now been running in England annually since 2002 gathering data from over 600,000 patients. The aim of this study is to investigate how the data have been used and to summarise what has been learned about patients' evaluation of care as a result.
  24. Content Article
    Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.
  25. Content Article
    This book is about the value of the customer's service experience in improving the quality of services in all respects, from technical quality to interactive quality.
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