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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    The objective of this Australian paper, published in the International Journal for Quality in Health Care, was to develop, implement and evaluate a system-wide 'challenge' with the aim of improving safety and quality.
  2. Content Article
    The objective of this systematic review, published by JBI database of systematic reviews and implementation reports, is to synthesise the eligible evidence of patients' experience of engaging and interacting with nurses, in the medical-surgical ward setting.
  3. Content Article
    In this US-based article, Christopher Jason discusses recent evidence that highlights how electronic health records (EHRs) have the potential to cause patient harm in various ways.
  4. Content Article
    The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: increase time nurses spend in direct patient care improve safety and reliability of care improve experience for staff and patients make changes to physical environments to improve efficiency. The objective of this paper, published in BMJ Quality & Safety, was to explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale quality improvement intervention.
  5. Content Article
    This White Paper, published by the authors, helps explains the key differences between, and implications of, two ways of thinking about safety (Safety-I and Safety-II).
  6. Content Article
    The current approach to patient safety, labelled Safety-I, is predicated on a ‘find and fix’ model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. This article, published by the International Journal for Quality in Health Care, argues that we need to switch the focus to what we have come to call Safety-II, a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails.
  7. Content Article
    The current crisis of clinician burnout is a complex problem. As rates of burnout (the workplace syndrome consisting of emotional exhaustion, depersonalisation and loss of meaning) reach disturbing levels among clinicians, we continue to struggle to understand how to address workplace suffering. An under-examined area of burnout is how the increasing complexity of healthcare, combined with our tentative recognition of complexity science (the study of systems governed by interactions, dependencies and relationships), impacts the well-being of clinicians.  Please note this article, published in BMJ Quality and Safety, is paywalled.
  8. Content Article
    HSIB has identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding. Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks, risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation.
  9. Community Post
    Hi @Sarah Clerk thank you for sharing the website address. Are you able to give a bit more information around the work of the organisation and why people following this thread may find it useful?
  10. Content Article
    Tackling antimicrobial resistance (AMR) and Healthcare Associated Infection (HAI) are currently a priority within healthcare and antimicrobial stewardship is an essential element of national and local programmes to address AMR. The aim of this webinar is to provide an overview of antimicrobial stewardship (AS), its importance in tackling Healthcare Associated Infection (HAI) and how pharmacists can contribute.
  11. Content Article
    The pharmacy contribution to antimicrobial stewardship document focuses on the pharmacist’s role as part of a multidisciplinary approach in tackling the challenges of inappropriate use of antibiotics. The recommendations in this policy have been produced in order to contribute to wider efforts in meeting the challenge set by the UK Government in 2016 of reducing inappropriate antibiotic prescribing by 50% by 2020.
  12. Content Article
    Second Victim Support looks at the definition of a 'second victim', how they are impacted personally and professionally and what can be done to support them. Second victims are healthcare providers who are involved in an unanticipated adverse patient event, a medical error and/or a patient related injury and become victimised in the sense that the provider is traumatised by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base. (Scott et al, 2009)
  13. Content Article
    The objective of this research paper, published in the Journal of the Royal Society of Medicine, was to investigate doctors’ intentions to raise a patient safety concern by applying the socio-psychological model ‘Theory of Planned Behaviour’.
  14. Content Article
    Commissioning is the continual process of planning, agreeing and monitoring services. Commissioning is not one action but many, ranging from the health-needs assessment for a population, through the clinically based design of patient pathways, to service specification and contract negotiation or procurement, with continuous quality assessment. There is no single geography across which all services should be commissioned: some local services can be designed and secured for a population of a few thousand, while for rare disorders, services need to be considered and secured nationally.
  15. Content Article
    In this US based eMagazine Patient Safety: 20 Years after ‘To Err is Human,’ sees thought leaders from across the healthcare industry examine how shifting to patient-centred care has helped organisations across the country sustain a deeper culture of patient safety. By implementing strategies such as optimising health IT usability, advocating on behalf of patients and supporting healthcare workers, patient safety continues trending upward, leading to better outcomes.
  16. Content Article
    The principles and values of the NHS in England, and information on how to make a complaint about NHS services.
  17. Content Article
    This guidance is for all providers of health and adult social care who are registered with the Care Quality Commission (CQC) under the Health and Social Care Act 2008.
  18. Content Article
    A US based study to determine whether medical errors, family experience and communication processes improved after implementation of an intervention to standardise the structure of healthcare provider-family communication on family centered rounds.
  19. Content Article
    Maternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. To understand how to make maternity care safer, we must first understand what makes a maternity unit safe. Rather than focus on what goes wrong, this study from THIS.Institute focuses on what needs to go right by studying one high-performing maternity unit, located in Southmead Hospital in Bristol, UK.
  20. Content Article
    Analysis of the patient safety incidents reported in England to the National Reporting and Learning System (NRLS) up to June 2019.
  21. Content Article
    Examples and recommendations around how to implement some aspects from the Royal Pharmaceutical Society's report: Getting the medicines right.
  22. Community Post
    If anyone else is interested, the webinar that @Evelyn Prodger mentioned on clinical burnout can be accessed retrospectively. Just register via the link on our events calendar.
  23. Community Post
    A question posed by a delegate at our Patient Safety Learning conference 2019: 'Does your employer praise staff and patients for reporting safety concerns?' Tell us about your experiences of how reported concerns are received. Does it differ depending on whether they are raised by staff or patients? Are there any examples of great practice you can share where people are really praised for raising patient safety concerns?
  24. Content Article
    The Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The Report is an in-depth analysis of the Gosport Independent Panel’s findings. It explains how the information reviewed by the Panel informed those findings and illustrates how the disclosed documents add to public understanding of events at the hospital and their aftermath.
  25. Content Article
    An independent review into the widespread failings by Liverpool Community Health Trust. The review conducted by Dr Bill Kirkup CBE, commissioned by NHS Improvement, looks into the issues at the Trust from November 2010 to December 2014. It also looks at the oversight of the Trust by the NHS Trust Development Authority, NHS England and commissioners.
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