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Found 498 results
  1. Content Article
    Elisabeth Poorman argues that becoming a doctor means learning that mistakes are not acceptable. From study through to practice, doctors are told in ways big and small, the only way to be a good doctor is to be a perfect doctor. The pressure only intensifies when real harm is on the line. The encouraged response is to study harder, sleep less, and never admit fear. 
  2. Content Article
    Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the UK and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to GPs as a Q&SI approach, is currently unknown. This study from Stocks et al., published in the Journal of Patient Safety, aimed to estimate the frequency of 10 NEs occurring within GPs' own practices and the extent to which the NE approach is perceived as acceptable for use.
  3. Content Article
    Samantha Batt-Rawden, Co-founder of the The Doctors' Association UK, discusses the struggles of a junior doctor and how changes in the NHS over the last 14 years has made it so much harder to do an already hard job. In this article published in the Metro, she says "that the combination of spiralling workloads and a decimation of morale and camaraderie has been toxic for the profession." Last year, 55% of UK doctors met the criteria for burnout and ‘emotional exhaustion’, with one in five resorting to the use of drugs or alcohol as a ‘coping strategy’. It’s hardly surprising that we are haemorrhaging doctors out of the profession, and it’s only getting worse. So, how do we fix this? Sally suggests that we need to treat staff like human beings if we are going to have any hope of stemming the exodus of clinicians. It’s as simple as restoring some on-call rooms so we can get our heads down, and stop crashing our cars on the way home. Or it’s as basic as ensuring that junior doctors have leave for our own weddings. Honestly, at this stage, just letting us have access to now-outlawed NHS coffee overnight would be a significant morale boost.
  4. Content Article

    Walk on by...

    Anonymous
    This anonymous blog is about a patient with learning disabilities, his treatment and outcome while coming in for a 'routine' procedure. This blog highlights the need for adequate training for all staff around caring for patients with learning disabilities to prevent harm and protracted length of stay.
  5. Content Article
    This anonymous blog high lights the vulnerability of patients, especially when it come to consent. This is a shocking account of events by a well informed patient when they were wrongly consented for a gynaecological procedure.
  6. Content Article
    Promoting patient and occupational safety are two key challenges for hospitals.  Recent studies have shown there are key topics that are interrelated and form a critical foundation for promoting patient and occupational safety in hospitals. So far, these topics have mainly been studied independently from each other. This study did a combined assessment of hospital staffs’ perceptions of four different topics: psychosocial working conditions leadership patient safety climate occupational safety climate.
  7. Content Article
    The aim of this qualitative service evaluation, published by Nursing in Critical Care, was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable. This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re‐escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams.
  8. Content Article
    Harold Shipman was an English doctor who killed approximately 15 patients while working as a junior hospital doctor in the 1970s, and another 235 or so when working subsequently as a general practitioner. Is it possible to learn general lessons to improve patient safety from such extraordinary events? In this paper, published in the US Journal of the Royal Society of Medicine, it is argued that it is not possible fully to understand how Shipman came to be such a successful and prolific serial killer, nor to learn how the safety of healthcare systems can be improved, unless his diabolical activities are studied using approaches developed to investigate patient safety.
  9. Content Article
    Child deterioration: human factors is a presentation by Peter-Marc Fortune, Consultant Paediatric Intensivist, Associate Clinical Head, Royal Manchester Children’s Hospital.
  10. Content Article
    Staff at C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, Michigan are adopting a new approach to safety. By picking up near misses, close calls, deviation off protocol and investigating each one via a daily huddle, they are able to enable change system wide.
  11. Content Article
    Team-targeted rudeness may underlie performance deficiencies, with individuals exposed to rude behaviour being less helpful and cooperative. The objective of this paper, published by The Official Journal of the American Academy of Pediatrics, was to explore the impact of rudeness on the performance of medical teams. In conclusion,  rudeness had adverse consequences on the diagnostic and procedural performance of the neonatal intensive care team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.
  12. Content Article
    Inclusion Healthcare, a social enterprise, provides primary medical services for homeless people in Leicester. It was rated outstanding following its CQC inspection in November 2014. CQC inspectors found strong leadership at its heart and a positive culture that ensures patient safety is paramount. In this short film, we hear from service users and staff and find out how they are promoting patient safety. 
  13. Content Article
    In this video, clinicians from Great Ormond Street Children's Hospital who are involved in the SAFE project talk about how the ‘huddle’ technique – a ten minute free, frank exchange of information between clinical and non-clinical professionals involved in a patient’s care every few hours – is helping them to improve their situation awareness, resolve risks to patient safety more quickly and reduce harm.
  14. Content Article
    Ever wondered what GPs do in a day? Watch this short video to find out.
  15. Content Article
    In Wales, like in England, the government has come under pressure over the poor performance of parts of the service. The Betsi Cadwaladr Health Board is the largest in Wales. It also has the worst A&E waiting times and has been in special measures for three years. Its hospital in Bangor, Ysbyty Gwynedd, serves 193,000 people, from tourists visting Snowdonia to the many retirees who live in North Wales. In this film, Saleyha Ahsan, looks at how the department tries to cope with unrelenting demand for patient space.
  16. Content Article
    Ever wondered what a day in the life of a neurosurgeon on-call is like? Watch this video to follow a neurosurgery resident in a UK major trauma centre as he works a 28 hour shift.
  17. Content Article
    Clinician burnout has been well-documented and is at record highs. The same issues that drive burnout also diminish joy in work for the healthcare workforce. Healthcare leaders need to understand what factors are diminishing joy in work, nurture their workforce, and address the issues that drive burnout and sap joy in work. The most joyful, productive, engaged staff feel both physically and psychologically safe, appreciate the meaning and purpose of their work, have some choice and control over their time, experience camaraderie with others at work, and perceive their work life to be fair and equitable. There are proven methods for creating a positive work environment that creates these conditions and ensures the commitment to deliver high-quality care to patients, even in stressful times.
  18. Content Article
    Patient safety depends on doctors’ well-being. Medicine is a tough job, but it's made it far harder than it should be by neglecting the simple basics in caring for doctors’ well-being. The well-being of doctors is vital because there is abundant evidence that workplace stress in healthcare organisations affects quality of care for patients as well as doctors’ own health. In 2018 the General Medical Council asked Professor Michael West and Dame Denise Coia to carry out a UK-wide review into the factors which impact on the mental health and well-being of medical students and doctors. The detailed practical proposals in this report provide a road map to health service leaders faced with the challenge of developing healthy and sustainable workforces.
  19. Content Article
    When an adverse event occurs in healthcare, the consequences can be catastrophic for patients and their families. In the aftermath of such events there are multiple needs, expectations and demands. This blog from our Patient Safety Learning website, looks at the case in which Dr Hadiza Doctor Bawa-Garba was convicted of manslaughter. 
  20. Content Article
    Locum doctors are often perceived to present greater risks of causing harm to patients than permanent doctors. However, a study from Ferguson and Walshe published in the Journal of the Royal Society of Medicine found that there is little evidence that locum doctors, including GPs, have a 'detrimental' pact on patient care delivery.
  21. Content Article
    Winner of Patient Safety Learning's 'Data and Insight' 2019 award, Neptune is a drug testing monitoring software. Catherine tells the story of Neptune's journey from initial idea to implementation.
  22. Content Article
    Speaking up, raising concerns, whistleblowing. However you describe it, we know it can be daunting. Supporting 'National Speak Up Month' , the General Medical Council (GMC) has provided advice and tools to help you.
  23. Content Article
    In this Editorial published in BMJ Quality & Safety, Major and Aphinyanaphongs discuss the challenges in translating mortality risk to the point of care. Despite advances in medicine, prognostication remains inaccurate for many patients. Physicians tend to overestimate survival, even in advanced cancer and terminal illness groups. Over half of terminally ill patients express they do not want prolonging of life if their quality of life would decline. End-of-life interventions such as advanced care planning have shown improved adherence to patient’s wishes, improvement in satisfaction and reductions in stress, anxiety and depression, but clinicians remain reluctant to initiate end-of-life discussions with terminal patients if they are currently asymptomatic. Automated systems can complement clinician judgement to prompt earlier end-of-life discussions.
  24. Content Article
    "It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
  25. Content Article
    Drug monitoring is a cumbersome, time consuming (expensive) and somewhat inaccurate process. The challenge set to ESC Software by a GP was to make an IT solution that was easy to use, comprehensive and reliable that would monitor patient testing to improve safety.
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