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Found 562 results
  1. Content Article
    Today, Patient Safety Learning stands with others around the world to celebrate International Women’s Day 2021. In light of this year’s campaign theme “choose to challenge” we are raising awareness of some of the ways in which male bias can negatively impact on patient safety. Drawing on case studies and quantitative research, this blog focuses on three key areas: Design – using examples to illustrate how male-centric design of equipment and medical devices affects patient safety. Data – discussing how data which does not account for differences between the sexes impacts on patient safety. Dismissal – considering the recurring theme from personal testimonials, and healthcare scandals in recent years, that women’s voices and patient safety concerns are being ignored or dismissed. We will reflect on the key patient safety issues and inequalities in each of these areas and offer our perspective on what needs to happen moving forward to prevent future avoidable harm.
  2. Content Article
    Help to build an understanding of the diversity of body sizes by taking 10 of your own measurements and recording them online. By providing this data it will enable the Chartered Institute of Ergonomics and Human Factors (CIEHF) to build up a picture of the diversity of measurements within the population.
  3. News Article
    Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to prevent deaths. What we are seeing is the hard edge of underinvestment in the workforce and the under resourcing of the service. “Each of these coroner’s reports are someone’s sorrow. From talking to families, they assume when one of these reports is issued, they are acted on and the system learns from it. But the system doesn’t seem to be learning and people pay for this with their life.” Read full story Source: The Independent, 3 March 2021
  4. Content Article
    The Coroners and Justice Act allows coroners in England or Wales to issue reports after inquest, if they believe that action should be taken to prevent a future death. Coroners are under a statutory duty to issue a Prevention of Future Death (PFD) report to persons or organisations that they believe have the power to act. Cumulatively, these reports may contain useful intelligence for patient safety.
  5. Content Article
    NHSX recently launched a brand new information governance portal providing a 'one-stop shop' for NHS policies and guidance. The new portal covers everything from GDPR in research to record management. But even with the new portal, navigating NHS guidance on data isn't easy. This article in Global Compliance News picks out six essential items to have on your radar if your organisation accesses or uses NHS data.
  6. News Article
    Scientists have warned that emerging data on Long Covid in children should not be ignored given the lack of a vaccine for this age group, but cautioned that the evidence describing these enduring symptoms in the young is so far uncertain. Recently published data from the Office for National Statistics (ONS) suggests that 13% of under 11s and about 15% of 12 to 16 year olds reported at least one symptom five weeks after a confirmed COVID-19 infection. Although children are relatively less likely to become infected, transmit the virus and be hospitalised, the key question is whether even mild or asymptomatic infection can lead to Long Covid in children, said Danny Altmann, professor of immunology at Imperial College London. “The answer is that it certainly can, and the Long Covid support groups contain a not insignificant number of children and teens,” Altmann said. Frances Simpson, a lecturer in psychology at Coventry University and co-founder of the Long Covid Kids group, said she was very worried about the emerging data on Long Covid in children. “We just think that there should be a much more cautious and curious approach to long Covid rather than a kind of a sweeping generalisation that children are OK, and that we should just let them all go back to school without any measures being put in place.” One issue, she said, is the sizeable gap between acute infection and Long Covid kicking off. Some children are initially asymptomatic or have mild symptoms but then it might be six or seven weeks before they start experiencing long Covid symptoms, which can range from standard post-viral fatigue and headaches to neuropsychiatric symptoms such as seizures, or even skin lesions." At the moment there is no consensus on the scale and impact of long Covid in adults, but emerging data is concerning. For children, the data is even more scarce. Recent reports from hospitals in Sweden and Italy have generated concern, but this data is not from national trials – they are single-centre studies – and include relatively small patient numbers, said Sir Terence Stephenson, a Nuffield professor of child health at University College London. Stephenson was awarded £1.36m last month to lead a study investigating Long Covid in 11- to 17-year-olds. “I don’t have a scientific view on what long Covid is in young people is – because frankly, we don’t know,” he said. Preliminary results are expected in three months. Read full story Source: The Guardian, 2 March 2021
  7. Content Article
    On 21 January 2021, the Office of National Statistics (ONS) published its latest experimental estimates of long COVID symptom prevalence in the general population, using data from 9,063 respondents to the UK Coronavirus Infection Survey (CIS) testing positive for COVID-19 to 14 December 2020. The CIS is a survey sample of respondents randomly selected from the UK population (excluding communal establishments) who are followed-up weekly for the first month from enrolment, followed by monthly for a up to a year. At each visit, respondents are swab tested for COVID-19 and describe their current symptoms (from a list of 12 common COVID-19 symptoms) to the interviewer. The ONS estimated time-to-symptom-discontinuation using survival analysis techniques. Discontinuation was defined as the first post-infection occurrence of the respondent not reporting any symptoms for two consecutive visits (that is, the visit defining the date of discontinuation plus the next one). To allow time from infection to symptom onset, the ONS tracked symptoms reported at the visit where the respondent tested positive for COVID-19 or within the next month. 
  8. Content Article
    Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. The Pennsylvania Patient Safety Reporting System (PA-PSRS) was queried and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. 
  9. Content Article
    The world has significantly changed in the past decade and the healthcare sector has changed with it. Many healthcare organisations are now digital and digital tools enable patient safety and care. Electronic health records (EHRs) have replaced paper records. Picture archiving and communication systems have replaced film and light boxes. Computer-implemented or enabled hardware and software have replaced the mechanical systems of yesterday. In some instances, virtual visits have replaced in-person visits. And patients can transmit information about their health status and condition in real time to their clinicians via various software applications and devices. As a result of our digital transformation, electronic data is the lifeblood of the healthcare organisation. Electronic data, in the healthcare context, must be kept confidential, integrity must be preserved, and it must be made available on demand wherever and whenever it is needed. But if electronic data is not appropriately protected, clinical care and the business of healthcare can grind to a halt. This is why ransomware has been a significant concern for many healthcare organisations, as Lee Kim, Director Privacy and Security, HIMSS, explains in this article.
  10. Content Article
    BioPhorum has developed a risk-based deviation management system (DMS). 13 member companies have implemented this approach, and summary data from these companies shows improved quality performance plus an average time saving of 22,200 work hours per site per year, which is equivalent to a $888k cost saving. An effective deviation management process is one that identifies and removes risk from processes using root cause analysis (RCA) principles and a corrective and preventive action (CAPA) programme. The current model used by many biopharmaceutical companies considers all deviations or events are equal and require a 30-day closure, known as the ‘30-day rule’1. Treating all events as equal and following the ‘30-day rule’ drives an inefficient process and wasteful behaviours. This guide outlines the work of the BioPhorum DMS Workstream in defining and creating a simplified and effective risk-based deviation management system with advanced RCA methodologies, and a track-and-trending process of low-risk events. It includes everything required to build a risk-based approach to DMS, including the business case for change, the new process, risk-based tools, and a detailed sharing of post-implementation benefit.
  11. Content Article
    During the first wave of the COVID-19 pandemic in England, several population characteristics were associated with an increased risk of death from the virus, including age, ethnicity, income, deprivation, care home residence and housing conditions. Public health agencies wanted to understand how these vulnerability factors were distributed across their communities.  Daras et al. from the NIHR Applied Research Collaboration North West Coast (NIHR ARC NWC) analysed 6,789 small areas in England and assessed the association between COVID-19 mortality in each area and five vulnerability measures relating to ethnicity, poverty, and prevalence of long-term health conditions, living in care homes and living in overcrowded housing. They developed a Small Area Vulnerability Index (SAVI) modelling tool, which forecasts the vulnerability of the local population to the virus.  The data identified noticeably higher levels of vulnerability to COVID-19 clustered within specific communities in the North West, West Midlands and North East regions.
  12. Content Article
    Vaccination is the single most effective way to reduce deaths and severe illness from COVID-19. A national immunisation campaign has been underway since early December 2020. All vaccines and medicines have some side effects. These side effects need to be continuously balanced against the expected benefits in preventing illness. The Medicines and Healthcare products Regulatory Agency (MHRA)'s role is to continually monitor safety during widespread use of a vaccine. They have in place a proactive strategy to do this. They also work closely with our public health partners in reviewing the effectiveness and impact of the vaccines to ensure the benefits continue to outweigh any possible side effects. Part of their monitoring role includes reviewing reports of suspected side effects. Any member of the public or health professional can submit suspected side effects through the Yellow Card scheme. The nature of Yellow Card reporting means that reported events are not always proven side effects. Some events may have happened anyway, regardless of vaccination. This is particularly the case when millions of people are vaccinated, and especially when most vaccines are being given to the most elderly people and people who have underlying illness.
  13. Content Article
    NHSX has launched a brand new information governance portal providing a 'one-stop shop' for NHS policies and guidance.
  14. Content Article
    In Spring 2021, a new national Patient Safety Incident Management System (PSIMS) will enter its public beta stage. The new system will be phased in to replace the current National Reporting and Learning System (NRLS). Its aim is to maximise the NHS’s ability to learn from when things go wrong. In this, the first in a series of blogs from Lucie Mussett, PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer., PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer.
  15. News Article
    The number of covid positive patients in English hospitals fell by 1,491 yesterday, by far the biggest decline recorded since the start of the pandemic. The previous record was set during the decline of the first wave, when numbers fell 1,055 on 17 April. The largest drop in the third wave before yesterday’s record was the 798 seen last Saturday. The national total of covid positive hospital patients now stands at 30,846, a drop of 9 per cent on the peak set on 18 January, but still 163 per cent of the mid-April peak. All seven English regions are now seeing a week-on-week decline in the number of their covid hospital patients for the first time. All have well established trends in falling admissions, with London and the south east seeing the running seven-day total fall by almost a third since a peak on 9 January. The east and south west have seen their admissions total decline by a fifth, while the midlands total has dropped 16 per cent in just five days and north east and Yorkshire nine in only four. Read full story (paywalled) Source: HSJ, 28 January 2021
  16. Event
    until
    The importance of healthcare data and good data practices continues to grow as the COVID-19 pandemic drives further digitalisation and creates new data streams. This free online event from the King's Fund explores the importance of patients trusting that their health and care data will be safely and responsibly used by the NHS. Now is the time to come together and look at how we can modernise protocols and ensure trust is built with the public. This event is the first in a series exploring how we put trust, transparency and fair value at the centre of digital health and care. Our expert panel will discuss what public institutions, industry and decision-makers that hold, control and use our most personal data are doing to help to maintain and improve trust in England while simultaneously modernising best practice. Register
  17. Content Article
    The Health Foundation policy tracker provides a description and timeline of national policy and health system responses to COVID-19 in England in 2020. The full tracker includes data on what changes have been introduced, when, why, and by whom – as well as how these changes have been communicated by policymakers. We track policy changes in five areas – from health and care system changes to wider social and economic policy.
  18. Content Article
    Patient safety remains one of the most pressing health issues for public awareness and further policy action. Since 2006, OECD’s Health Care Quality and Outcomes (HCQO) Working Party (WP) has developed patient safety indicators (PSIs) based on administrative data sources. These data have been regularly collected and reported with an aim of assessing and comparing cross-country differences in patient safety. However, the international comparability of existing PSIs is challenging due to a number of methodological variations in measure implementation, for example, how countries record diagnoses and procedures, define hospital admissions, processes for reporting safety events. Consequently, in some cases, higher adverse event rates may signal more developed patient safety monitoring systems and a stronger patient safety culture rather than worse care. Current PSIs have limitations in that they fail to adequately capture important aspects of patient safety, such as the extent to which health care practices to prevent and address safety incidents are implemented.  This report summarises activities undertaken to date as part of the international indicator development on patient-reported experiences of safety and also a set of questions to be used for the pilot data collection of patient-reported experience of safety, guidelines for the pilot data collection and ongoing pilot data collection
  19. News Article
    The growth in covid positive hospital patients is rapidly slowing in every English region and appears to have stopped in the south east. The weekly increase in covid inpatients across England fell to 8% yesterday, the first time it had dropped to single figures since 12 December. A week earlier, on 10 January, the growth rate stood at 23%. There are now 33,352 covid hospital patients in English hospitals, an increase of 2,594 in the last seven days. The previous week had seen a rise of 5,801. The weekly growth rate of covid positive hospital patients in the seven English regions currently ranges from 26% in the south west to zero in the south east. In every region, the growth rate is seven to 20 percentage points lower than recorded on 10 January. London’s weekly growth rate is now three per cent and the east’s is 2%. There has been no substantive change in the south east total in the past week. It is likely covid patients will be seen to have peaked in these three regions between 13 to 15 January. The slowing in the growth of national covid patient numbers means the total is likely to peak during the next seven days at a level lower than many had feared and expected. HSJ has seen internal NHS England projections from last week that saw growth continuing into February and total covid patient numbers rising well above 40,000, this now seem very unlikely. Read full story Source: HSJ, 18 January 2021
  20. Content Article
    This report summarises data submitted by NHS hospitals and independent sector (IS) NHS treatment centres in England to the national SSI Surveillance Service (SSISS) at Public Health England (PHE). The aim of the national surveillance programme is to enhance the quality of patient care by encouraging hospitals to use data obtained from surveillance to compare their rates of SSI over time and against a national benchmark, and to use this information to review and guide clinical practice. The SSISS provides an infrastructure for hospitals to collect data on 17 surgical categories spanning general surgery, cardiothoracic, neurosurgery, gynaecology, vascular, gastroenterology and orthopaedics. Surveillance is targeted at open surgical procedures, which carry a higher risk of infection than minimally invasive (‘keyhole’) procedures.
  21. Event
    The New Existence Webinar Series will take an in-depth look at The New Existence framework from The Beryl Institute. Helping to link core ideas and apply practices, each session in the series will focus on a key aim and corresponding actions of The New Existence. This webinar series will help to explore how lead together into the future of healthcare. The full webinar series is listed below. Webinars are scheduled from 2:00-3:00pm ET/1:00-2:00pm CT. Participants are not required to attend each webinar in the series. Click on a title below to register for the individual webinars in the series. Care teams Redefine and advance the integrated nature of and critical role patients and their circle of support play on care teams. January 28: Redefine the care team February 25: Invite and activate partnership March 25: Commit to care team well-being Governance & leadership Reimagine, redefine and reshape the essential role of leadership in driving systematic change. April 22: Create transparency across the healthcare ecosystem May 27: Restore and nurture confidence June 24: Transform healthcare in collaboration with diverse voices Models of care & operations Co-design systems, processes and behaviors to deliver the best human experience. July 22: Co-design intentional, innovative and collaborative systems August 26: Innovate processes of care to transform behavior Policy & systemic issues Advocate for equitable institutional, governmental and payor policies, incentives and funding to drive positive change. September 23: Hardwire human partnership in the healthcare ecosystem October 28: Research, measure and dismantle the structures and systems that lead to disparities November 23: Modernise the surveys and democratise the data
  22. Content Article
    Understanding how and why programmes work—not simply whether they work—is crucial. Good theory is indispensable to advancing the science of improvement. Mary Dixon-Woods and colleagues argue for the ex post theorisation programmes.
  23. Content Article
    The Health Index is a new tool to measure a broad variety of health outcomes and risk factors over time, and for different geographic areas. This methodology article explains how the Health Index has been constructed.
  24. Event
    This webcast provides a tutorial on the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Data Entry and Analysis Tool. Speakers will demonstrate how you can enter your SOPS survey data into the tool and it will automatically create tables and graphs to display your survey results. The tool allows healthcare organisations to compare results to the data in SOPS Databases. Register
  25. Content Article
    Every month, the NHS in England publishes anonymised data about the drugs prescribed by GPs. But the raw data files are large and unwieldy, with more than 700 million rows. OpenPrescribing.net are making it easier for GPs, managers and everyone to explore - supporting safer, more efficient prescribing. Source: OpenPrescribing.net, EBM DataLab, University of Oxford, 2020
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