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Found 21 results
  1. Content Article
    The variety of alarms from all types of medical devices has increased from 6 to 40 in the last three decades, with today’s most critically ill patients experiencing as many as 45 alarms per hour. Alarm fatigue has been identified as a critical safety issue for clinical staff that can lead to potentially dangerous delays or non-response to actionable alarms, resulting in serious patient injury and death. To date, most research on medical device alarms has focused on the nonactionable alarms of physiological monitoring devices. While there have been some reports in the literature related to drug library alerts during the infusion pump programming sequence, research related to the types and frequencies of actionable infusion pump alarms remains largely unexplored.
  2. Content Article
    This study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England’s national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used. AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen.
  3. Content Article
    Guy's and St Thomas' NHS Foundation Trust share their Quality Impact Assessment (QIA) policy. The QIA policy has been developed to ensure that the Trust has the appropriate steps in place to safeguard quality whilst delivering changes to service delivery. This process is used to assess the impact that the Cost Improvement Plan (CIP) may have on the quality of care provided to patients at Guys and St Thomas’ NHS Foundation Trust.
  4. Content Article
    One year ago, on 2 October 2019, we officially launched the hub at our annual conference. To celebrate this special occasion, we want to update you on how the hub has grown and the impact it’s having, both on the people using it directly and on patient safety more broadly. To date, the hub has over 1,000 members from 450 organisations and from over 40 countries. It’s home to over 3,000 pieces of content, has had 45,000 unique visitors and has been accessed 70,000 times. Although we are delighted with these numbers and continued growth of the hub, we are most proud of the relationships the hub is facilitating and the good work that is happening as a result. We launched the hub so that all members of the public – from patients to clinicians – could share their insight and experiences of patient safety. By working together with users of the hub, we aim to highlight patient safety concerns and take action so that real change can happen as we journey towards the patient-safe future.   Wonderfully, we are beginning to achieve these aims. Here are some of the ways the hub has been making an impact.
  5. Content Article
    The rate at which nursing and ambulance staff are leaving the NHS is increasing. The number of nurse vacancies has risen to over 40,000 – a record high. The ambulance service has recorded an 80% per cent increase in staff leaving the profession since 2010. These rates are unequally distributed across professions, specialties and geographical regions, introducing inevitable inequalities in patient care. This Efficiency Research project aims to use this variation to detect underlying contributory factors for better or worse nurse and ambulance staff retention, and determine its effect on patient outcomes. A research team from Staffordshire University will use their experience of applying ‘big data’ analytics and unifying large datasets from three previous studies on the effect of nurse staffing on patient safety. Projects began in 2019 and will run until December 2023.
  6. Content Article
    The lack of funding in social care doesn’t only mean that services are unable to meet demand – there is also under-investment in data and analytics. Laura Schlepper explains why social care data matters and what would help to increase its potential.
  7. News Article
    The health service has been promised “whatever it needs” to deal with the coronavirus pandemic, but government spending choices reveal possible long-term changes to funding and policy. Having initially promised the health service “whatever it needs, whatever it costs” on 11th March, the government made this official when Matt Hancock issued a ministerial direction allowing the Department of Health to “spend in excess of formal Departmental Expenditure Limits”—effectively providing a blank cheque. But while the government’s actions are designed for the immediate crisis, they may be difficult to reverse once the peak of coronavirus has passed. Indeed, they could yet change how the health service operates on a permanent basis. Read full story Source: Prospect, 7 April 2020
  8. News Article
    New figures reveal that what we think we know about the Covid-19 death toll in the UK is wrong. Here’s why. Every day we get one big figure for deaths occurring in the UK. Everyone jumps on this number, taking it to be the latest toll. However NHS England figures – which currently make up the bulk of UK deaths – in fact reflect the day on which the death was reported, not the actual date of death, which is usually days, sometimes weeks, before it appears in the figures. The truth is we don’t know how many deaths have taken place the previous day. In fact the headline figure is likely to under-report the number of deaths that actually happened the previous day. The number we hear about usually counts deaths which took place at an earlier date. The difference matters because by undercounting the number of deaths we are skewing the curve. Read full story Source: Guardian, 4 April 2020
  9. News Article
    The Financial Times tracks the countries affected, the number of deaths and the economic impact of the coronavirus. Read full story Source: Financial Times, 25 March 2020
  10. Content Article
    As we study the numbers on the coronavirus cases and the deaths related to COVID-19, a similar question comes up again and again: Why is the coronavirus causing so many more deaths in Italy than in other countries? In this article, published in Medium, Andreas Backhaus, an Economist, discusses the demographics and why they are a warning to other countries.
  11. News Article
    Draper & Dash, a leading predictive patient flow provider, has launched a COVID-19 live hospital planning and demand impact assessment tool. The company said it has been working around the clock to deliver its vital tool to support impact assessment. It allows trusts to view and analyse national Hospital Episode Statistics (HES) data, alongside a number of live data sources on COVID-19 cases by the minute, as they emerge across the globe. The system models the impact of increased volume and complexity at a local and system level, providing visibility of ICU, theatres, and overall bed impact, and connects this live information to each trust’s clinical workforce. The tool shows immediate impacts on beds and staff under a range of selected scenarios. Read full story Source: Health Tech Newspaper, 18 March 2020
  12. Content Article
    Mindful organising is a key integrating concept in resolving the organisational accident. Mindful organising is both the unique source of critical information about the normal operation, as well as the key recipient of intelligence about the operation, ensuring that operational actions are always informed by the most current, relevant information about potential risks no matter how remote.
  13. Content Article
    Anna Erhard, Quality and Outcomes Manager at the Schoen Clinic, presented at the recent Bevan Brittan Patient Safety Seminar. Attached are the presentation slides.
  14. Content Article
    Resilient Health Care (RHC) is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is by Sujan et al., published in Safety Science, was to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout.
  15. Content Article
    The use of artificial intelligence (AI) in patient care currently is one of the most exciting and controversial topics. It is set to become one of the fastest growing industries, and politicians are putting their weight behind this, as much to improve patient care as to exploit new economic opportunities. In 2018, the then UK Prime Minister pledged that the UK would become one of the global leaders in the development of AI in healthcare and its widespread use in the NHS. The Secretary for Health and Social Care, Matt Hancock, is a self-professed patient registered with Babylon Health’s GP at Hand system, which offers an AI-driven symptom checker coupled with online general practice (GP) consultations replacing visits at regular GP clinics.
  16. Content Article
    In 2013, the Centers for Medicare and Medicaid Services announced that it would begin levying penalties against hospitals with the highest rates of hospital-acquired conditions through the Hospital-Acquired Condition Reduction Program. Whether the programme has been successful in improving patient safety has not been independently evaluated. Sheetz et al. used clinical registry data on rates of hospital-acquired conditions in 2010–18 from a large surgical collaborative in Michigan to estimate the impact of the policy. They concluded that the programme did not improve patient safety in Michigan beyond existing trends. These findings, published in Health Affairs, raise questions about whether the program will lead to improvements in patient safety as intended.
  17. Content Article
    Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. This paper from Almaberti et al. Implementation Science published  attempts to reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.
  18. Content Article
    The Health Foundation’s Report, Untapped potential: Investing in health and care data analytics, highlights nine key reasons why there should be more investment in analytical capability.
  19. Content Article
    Reducing emergency admissions from care homes has the potential to reduce pressure on hospitals. This is a significant national policy focus, as demonstrated by a strong commitment to improve support in care homes in the NHS Long Term Plan. 
  20. Content Article
    The University of Missouri Health Care (MUHC), an academic healthcare system located in Columbia, Missouri, USA, deployed an evidence-based emotional support structure for second victims based on research with recovering second victims. MUHC is a six-hospital healthcare system with 52 ambulatory clinics and approximately 6,500 employees. The second victim support structure, known as the forYOU Team, was designed to increase awareness of the second victim phenomenon, “normalise” the psychological and physical impacts, provide real-time surveillance for possible second victims within clinical settings, and render immediate peer-to-peer emotional support when a potential second victim is identified. This article published in Patient Safety & Quality analyses the success of the programme.
  21. Content Article
    In an interesting paper by Brazil and colleagues in the July edition of BMJ Quality and Safety, the authors explore the positioning of simulation-based methods within QI programmes, the role of trained simulation experts as part of QI-focused teams and the directions for future scholarly enquiry that supports integration of these fields.
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