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Showing results for tags 'Decision making'.
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Content ArticleHow can your team improve decision-making and performance in an unpredictable world? The field of Naturalistic Decision Making (NDM) supports organisations in understanding and leveraging expertise. Over the past 40 years, NDM researchers and practitioners have helped clients achieve higher ROI, improve safety, and increase efficiency. In this presentation series captured from our 2022 NDMA Open House, you'll hear directly from leaders in the NDM field. They'll share a variety of key concepts, case studies, tools, and insights that you can use to improve how your team makes decisions—especially when stakes are high and conditions are uncertain.
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Content ArticleThis report outlines the results of the Patient Information Forum's (PIF's) 2022 survey and sets out progress made in the crucial areas of health and digital literacy since the Covid-19 pandemic.
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Content ArticleTo receive and participate in medical care, patients need high quality information about treatments, tests, and services—including information about the benefits of and risks from prescription drugs. Provision of information can support ethical principles of patient autonomy and informed consent, facilitate shared decision making, and help to ensure that treatment is sensitive to, and meets the needs and priorities of, individuals. Patients value high quality, written information to supplement and reinforce the verbal information given by clinicians. This is the case even for those who do not want to participate in shared decision making. The aim of this study was to evaluate the frequency with which relevant and accurate information about the benefits and related uncertainties of anticancer drugs are communicated to patients and clinicians in regulated information sources in Europe. The findings of this study highlight the need to improve the communication of the benefits and related uncertainties of anticancer drugs in regulated information sources in Europe to support evidence informed decision making by patients and their clinicians.
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Content ArticleA key priority for all involved in the development, manufacture and prescription of medicines is safety. To keep patients safe, regulators and pharmaceutical manufacturers have a statutory obligation to provide product information covering the most important instructions on how to take medicines correctly. This report by Kent Surrey Sussex Academic Health Science Network (AHSN) outlines the findings of a project around the accessibility of medication information. Patients, carers, healthcare professionals (HCPs) and senior healthcare system stakeholders were asked what they think about current medicines product information, and if it could be improved using digital solutions.
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Content ArticleThis long read by the Nuffield Trust looks at priority areas where further development and action could help improve the effectiveness of virtual wards. It outlines different models for virtual wards and looks at how to ensure effective system oversight. It also highlights the need to ensure the workforce is equipped to run virtual wards effectively and safely.
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Content Article
Consent to treatment such as operations and diagnostic procedures can only be truly informed if the patient understands the risks, benefits and alternatives. They also need to have considered what will happen if they choose not to have any treatment at all. A failure to obtain informed consent is not only unlawful, but can contribute to lasting physical and psychological harm. In this blog, hub Topic Leader Julie Smith looks at the different areas to consider when creating written information that is genuinely useful to the patient. Julie’s advice also helps readers understand how they can provide information that is medico-legally sound.- Posted
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Content ArticleThis article in BBC Science Focus looks at the factors driving an increase in testosterone prescribing for women in the UK. The author, Dr Michelle Griffin, highlights the need to ensure that there is a strong evidence base for prescribing testosterone to women. While there have been some clinical trials and studies around testosterone as a treatment for low libido, there is concern that patients, doctors and pharma companies are relying on anecdotal accounts of its effectiveness to treat symptoms such as low mood, poor concentration and tiredness. She also highlights that testosterone prescribing is just one example of the lack of research going into women's health issues and treatments, and argues that this is contributing to health inequity.
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Content ArticleRisk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway. This thematic review draws on findings from the Healthcare Safety Investigation Branch's (HSIB's) maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’). It examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included. The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.
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Content ArticleSlides from the recent Patient Safety Incident Response Framework (PSIRF) governance workshop giving an update and overview from the national team. Presentations were given from the early adopters: Jacquetta Hardacre, Assistant Director Safety and Risk, East Lancashire Hospitals NHS Trust and Kerry Crowther, Patient Safety Specialist, Cornwall Partnership NHS Foundation Trust. The workshop concluded with a Q&A panel with the presenters and Gillian Lewis Head of Patient Safety Strategy Delivery, NHS England.
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Content ArticleThis ethnographic qualitative study in the BMJ aimed to describe how patients are engaged with cancer decisions in the context of multidisciplinary teams (MDT) and how MDT recommendations are carried out in the context of a shared decision. The study was carried out at four head and neck cancer centres in the north of England. The authors found that the current model of MDT decision-making does not support shared decision-making, and may actively undermine it. They recommend the development of a model that allows the individual patient more input into MDT discussions, and where decisions are made on potential treatment options rather than providing a single recommendation for discussion with the patient. Deeper consideration should be given to how the MDT incorporates the patient perspective and/or delivers its discussion of options to the patient.
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Content ArticlePeter Seaby had Down's Syndrome and autism and was cared for at home by members of his family for 62 years. However, in 2017, Peter was removed from the home he shared with his sister Karen, who was his full time carer, and placed in a care home. Karen and Peter's brother Mick were not told by social services why Peter was moved. Within six months of being in the home, Peter choked on a carrot and died. Karen and Mick found the subsequent inquest into Peter's death in July 2021 to be inadequate and launched a Judicial Review challenge which was successful in quashing the findings of the initial inquest. A new inquest was held in February 2023 Journalist George Julian has been following and reporting on Peter's second inquest and has written several blog posts about the case, highlighting serious failings in his care that led to his death: Peter Seaby’s 2nd inquest – how he came to be in the care of the Priory Group Peter Seaby’s 2nd inquest “I have stood on my own in this” Peter Seaby’s 2nd inquest – the SALT plan Peter Seaby’s 2nd inquest – record keeping and decision making Peter Seaby’s 2nd inquest – April 2018 Peter Seaby’s 2nd inquest – May 2018 Peter Seaby’s 2nd Inquest – Conclusion
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Content ArticleThe OptiBreech project is a research study exploring the feasibility of evaluating a new care pathway for women with a breech pregnancy. About 1 in 25 babies are born bottom-down (breech) after 37 weeks of pregnancy. Women who wish to plan a vaginal breech birth have asked for more reliable support from an experienced professional. This aligns with national policy to enable maternal choice. In this video, Dr Shawn Walker explains why the combination of meconium and tachycardia, particularly in the first stage of labour, indicates increased risk in breech births.
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News Article
Michael Watt: Review finds 'significant failures' in patient treatment
Patient Safety Learning posted a news article in News
A review of the clinical records of 44 patients who died under the care of former neurologist Michael Watt has found "significant failures in their treatment" and "poor communication with families". While this review looked at a sample of cases in which people died, potentially thousands more could be affected. The review arises from a 2018 recall of 2,500 outpatients who were in Dr Watt's care at the Belfast Health Trust. About one in five patients had to have their diagnoses changed. This separate review into 44 deaths was conducted by the Royal College of Physicians at the request of the regulator, the Regulation and Quality Improvement Authority (RQIA). It highlighted concerns over clinical decision-making, prescribing and diagnostics. It reveals a misdiagnosis rate of 45% among this group of patients, twice that for living patients. Speaking to BBC News NI, the RQIA's chair, Christine Collins, said the outcome of the review was "shocking and gut-wrenching as so many had experienced unpleasant deaths which they ought not to have done". Read full story Source: BBC News, 29 November 2022 -
News Article
Patient harm versus medical malpractice: What US clinicians fear more
Patient Safety Learning posted a news article in News
Attending physicians and advanced practice clinicians in US emergency departments are more concerned about medical errors resulting in patient harm than in malpractice litigation, according to a study published JAMA Network Open. The findings are based on an online survey of 1,222 ED clinicians across acute care hospitals in Massachusetts from January to September 2020. Respondents used a Likert scale of 1 (strongly disagree) to 6 (strongly agree) to indicate their degree of agreement with statements on how fearful they are of making a mistake that leads to a patient harm in their day-to-day practice, and how fearful they are of an error that results in being sued. The mean score was greater for fear of harm (4.40) than fear of being sued (3.40), the findings showed. Researchers said the mean scores for both fear of harm and fear of suit were similar regardless of whether the survey was completed before or after onset of the COVID-19 pandemic. Although previous studies have associated clinicians' fear of legal concerns with "excessive healthcare use through defensive medicine," the role fear of patient harm may play in clinical decision-making is less documented, researchers said. "Although the study did not delineate the association between this concern and potential overuse of testing, it suggested that fear of harm should be considered with, and may be more consequential, than fear of suit in medical decision-making," researchers said. Read full story Source: Becker's Hospital Review, 21 November 2022 -
News Article
Maternity unit death 'lessons not learned'
Patient Safety Learning posted a news article in News
High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found. A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety. The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019. The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth. During their visit, inspectors found: High-risk women giving birth in a low-risk area. Not enough staff with the right skills and experience. "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported". Concerns over foetal heart monitoring. Women being referred to by room numbers instead of their names. A "lack of response by consultants to emergencies" resulting in delays The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care". Read full story Source: BBC News, 18 August 2020 "This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded." -
News Article
Fast response to terror attacks saves lives. UK medics should not be held back
Patient Safety Learning posted a news article in News
The Streatham terrorist attack has again highlighted one of the most difficult decisions the emergency services face – deciding when it is safe to treat wounded people. In the aftermath of the stabbings by Sudesh Amman, a passer-by who helped a man lying on the pavement bleeding claimed ambulance crews took 30 minutes to arrive. The London Ambulance Service (LAS) said the first medics arrived in four minutes, but waited at the assigned rendezvous point until the Metropolitan police confirmed it was safe to move in. Last summer, the inquest into the London Bridge attack heard it took three hours for paramedics to reach some of the wounded. Prompt treatment might have saved the life of French chef Sebastian Belanger, who received CPR from members of the public and police officers for half an hour. A LAS debriefing revealed paramedics’ frustration at not being deployed sooner. A group of UK and international experts in delivering medical care during terrorist attacks have highlighted alternative approaches in the BMJ. In Paris in 2015, the integration of doctors with specialist police teams enabled about 100 wounded people in the Bataclan concert hall to be triaged and evacuated 30 minutes before the terrorists were killed. The experts writing in the BMJ believe the UK approach would have delayed any medical care reaching these victims for three hours. These are perilously hard judgment calls. Policymakers and commanders on the scene have to balance the likelihood that long delays in intervening will lead to more victims dying from their injuries against the increased risk to the lives of medical staff who are potentially putting themselves in the line of fire by entering the so-called 'hot zone'. First responders themselves need to be at the forefront of this debate. As the people who have the experience, face the risks and want more than anyone to save as many lives as possible, their leadership and insights are vital. In the wake of the Streatham attack the government is looking at everything from sentencing policy to deradicalisation. Deciding how best to save the wounded needs equal priority in the response to terrorism. Read full story Source: The Guardian, 7 February 2020 -
News Article
Earlier recognition of aortic dissection needed to prevent deaths
Patient Safety Learning posted a news article in News
Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report. The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey. The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition. It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years." Read full story Source: HSIB, 23 January 2020 -
News Article
Refusing Scottish help a 'grave error' in blood scandal, letter says
Patient Safety Learning posted a news article in News
Hundreds of people with haemophilia in England and Wales could have avoided infection from HIV and hepatitis if officials had accepted help from Scotland, newly released documents suggest. A letter dated January 1990 said Scotland’s blood transfusion service could have supplied the NHS in England and Wales with the blood product factor VIII, but officials rejected the offer repeatedly. Large volumes of factor VIII were imported from the US instead, but it was far more contaminated with the HIV and hepatitis C viruses because US supplies often came from infected prison inmates, sex workers and drug addicts who were paid to give blood but not screened. The death of scores of people with haemophilia and blood transfusion patients and the infection of thousands of others across the UK in the contaminated blood scandal has been described as the worst health disaster to hit the NHS. The latest document was released under the Freedom of Information Act to campaigner Jason Evans, whose father died in 1993 having contracted hepatitis and HIV. In it, Prof John Cash, a former director of the Scottish Blood Transfusion Service, said the decision not to use Scotland's spare capacity to produce Factor VIII for England was "a grave error of judgement". Read full story Source: The Guardian, 3 January 2020 -
News Article
Women needlessly having their appendix out in almost one in three cases
Patient Safety Learning posted a news article in News
Women are having their appendixes removed wrongly in nearly a third of cases, British research suggests. Researchers said too many female patients were being put under the knife when they should have undergone investigations for period pain, ovarian cysts or urinary tract infections. They said the study, which compared practices in 154 UK hospitals with those of 120 in Europe, suggests that Britain may have the highest rate of needless appendectomies in the world. Surgeons said they were particularly concerned by the high rates among women, with 28% of operations found to be unnecessary. They said the NHS was too quick to book patients in for surgery, when further scans and investigations should have been ordered. Researchers warned that such operations put patients at risk of complications, as well as fuelling NHS costs. Read full story Source: The Telegraph, 4 December 2019 -
Content Article
Hospitals are rejecting GP referrals for investigations and outpatient treatment at an increasing rate. In this blog, Patient Safety Learning looks at the patient safety issues caused by rejected referrals and lack of capacity in outpatient specialities. We call for the government and NHS leaders to investigate the problem and take action to mitigate risks to patient safety. -
Content ArticleProviding high quality care and treatment for patients coming to the end of their lives is likely to involve making difficult and emotionally challenging decisions. This guidance from the General Medical Council provides a framework to support doctors in meeting the needs of each patient as they come towards the end of their life.
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Content ArticleAlthough leaders might say they value inquisitive minds, in reality most stifle curiosity, fearing it will increase risk and inefficiency. Harvard Business School’s Francesca Gino elaborates on the benefits of and common barriers to curiosity in the workplace and offers five strategies for bolstering it.
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Content ArticlePeople affected by health conditions bring insights and wisdom to transform healthcare – ‘jewels from the caves of suffering'. Yet traditional patient and public engagement relies on (child–parent) feedback or (adolescent–parent) ‘representative' approaches that fail to value this expertise and buffers patients' influence. This editorial from David Gilbert outlines the emergence of ‘patient leadership' and work in the Sussex Musculoskeletal Partnership, its patient director (the first such role in the National Health Service) and a group of patient/carer partners, who are becoming equal partners in decision-making helping to reframe problems, generate insight, shift dynamics and change practice within improvement and governance work.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. Pulmonary embolisms can form when clots from the deep veins of the body, usually originating in the legs, travel through the venous system and become lodged in the lungs. A person suffering from a pulmonary embolism requires urgent treatment to reduce the chance of significant harm or death.
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Content ArticleThis article by the National Institute for Health Research (NIHR) summarises recent evidence about the information and support pregnant women need to make decisions about their maternity care, and any interventions they may need. It discusses the following areas: The importance of continuity of carer and personalised care in maternity services Women need clear information and better access to mental health care Helping women with complicated pregnancies make informed decisions about their care Supporting shared decision-making when there are problems with the baby
