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Showing results for tags 'Information processing'.
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Content ArticleBen Goldacre in his review makes the following recommendations: Use people with technical skills to manage complex technical problems. Build impatiently, but incrementally, accepting that new ways of working are overdue, but cannot replace old methods overnight: we must build skills, and prove the value of modern approaches to data in parallel to maintaining old services and teams. Identify a range of ‘data pioneer’ groups from each key sector. Build Trusted Research Environment (TRE) capacity by taking a hands-on approach to the components of work common to all TREs. Focus on platforms by resourcing teams, services and institutions who are focused solely on facilitating great analytic work by other people, working closely with users. Data curation, secure analytics, TREs, libraries, RAP training, and platforms are the key missing link: they will only be delivered if they become high status, independent activities.
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Content ArticleThe update highlights that: there is no automatic recall for a 3-month booster built into the national digital system for patients who are severely immunosuppressed and would be receiving a fourth dose. at present, patients are unable to book a fourth dose via the national online booking systems, because the patient's data shows that a total of three doses have already been administered. The system classifies these patients as having 'received a booster'. severely immunosuppressed people will not be able to book their booster (fourth dose) three months after their last primary course dose using the NHS online booking system. these patients can present at 91 days post-third dose to GPs, pharmacies and services offering unbooked appointments (‘walk-in’ or ‘drop-in’ centres). Some evidence of need for the booster as a result of their high-risk status will be required. It suggests that secondary care doctors will need to: communicate with their own high-risk specialty patient groups to ensure boosters are being taken up. ensure severely immunosuppressed patients have some ‘evidence of need’ for the fourth dose (previous letters issued on the need for third primary dose could be used).
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News Article
Ministers to legislate for more power over patient data
Patient-Safety-Learning posted a news article in News
Ministers are to legislate more powers over how data on patients is collected and are imposing a 'duty' on the NHS to share patient information when doing so would benefit the system. The Health and Social Care Act 2021 already allows for sharing of data on an individual basis but staff have reported finding it hard to share it when it comes to primary and secondary care and administrative purposes. The new draft strategy produced by NHSX, has suggested it may want to use cloud storage to create a set of “structured data records” with the idea that it would make it easier for patients to access their own data. Read full story. (paywalled) Source: HSJ, 22 June 2021 -
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Q Exchange Project lunchtime webinars: Violations
Patient Safety Learning posted a calendar event in Community Calendar
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News ArticleIn a bid to fight against misinformation about the coronavirus vaccines, a group of scientists from all over the world have created an online guide to building a ‘truth sandwich’. The guide serves to arm people with practical tips, up-to-date information and evidence to talk reliably about the vaccines, and enable them to constructively challenge associated myths. The scientists, led by the University of Bristol, are appealing to everyone to understand the facts set out in the 'COVID-19 Vaccine Communication Handbook', follow the guidance and spread the word. Professor Stephan Lewandowsky, the lead author of the guide, said: “Vaccines are our ticket to freedom and communication about them should be our passport to getting everyone on board." “The way all of us refer to and discuss the COVID-19 vaccines can literally help win the battle against this devastating virus by tackling misinformation and improving uptake, which is crucial." Read full story Source: The Independent, 7 January 2021
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NHS Education for Scotland: Process mapping
Patient Safety Learning posted an article in Quality Improvement
Why use this tool? To capture and visually represent all the steps in an existing process. To show everyone in a team how a process works in practice now, rather than what they think is happening, To help identify change ideas for improvement. To visually represent a new process. To assist team building as it should involve all team members in accurately capturing current process and the design of any new process. -
Content ArticleHaving accurate patient information (for example, age, allergies, laboratory results) helps practitioners select medications, doses and routes of administration. One vital piece of information, the patient's weight, is especially important, because it is used to calculate the appropriate dose of a medication (for example, mg/kg, mcg/kg, mg/m2). A prescribed or dispensed medication dose can differ significantly from the appropriate dose because of missing or inaccurate patient weights. Patients in oncology treatment, patients with renal insufficiency, or who are elderly, paediatric or neonatal are at greater risk for adverse drug events, because they are more vulnerable to the effects of an error, and their weight may change frequently over short periods of time. Formulas such as the Cockcroft-Gault equation, which is used to calculate creatinine clearance to aid in the dosing of medications, and the Harris-Benedict formula, which is used to calculate basal metabolic rate, rely on knowledge of an accurate patient weight. Also, both height and weight are needed to use nomograms to determine body surface area and body mass index, for example, when calculating doses for chemotherapy. In the United States, most patients are weighed in pounds. But weighing and documenting patients' weights in pounds introduces the need to convert the weight into kilograms—an error-prone process—to conduct weight-based and other dosing. Another risk when measuring the patient's weight in pounds is failing to convert the weight into kilograms but recording that weight in kilograms (that is, documenting a weight of 200 lbs. as 200 kg instead of 90.9 kg), resulting in more than two-fold dosing errors. This document recommends a number of procedures to ensure accurate patient weights. Further reading Weight-based medication errors: How to tip the scale in the right direction
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From stargazing to mole-gazing
Patient Safety Learning posted a news article in News
Astrophysics and dermatology are colliding through a new research project led by the University of Southampton – with potentially lifesaving consequences. The project, dubbed MoleGazer, will take algorithms used for detecting exploding stars in astronomical imaging data and develop them to be used to spot changes in skin moles and, therefore, detect skin cancer. MoleGazer, led by Professor Mark Sullivan, Head of the School of Physics and Astronomy at the University, and Postdoctoral Researcher Mathew Smith, has been awarded a Proof of Concept Grant from the European Research Council (ERC). It is the first time the University has won such a grant. Currently, patients at high risk of developing skin cancer are photographed at regular intervals and a consultant visually compares images to detect changes. MoleGazer could automate this process, potentially leading to earlier diagnoses and improved survival rates. “It’s a really exciting project that came along from nowhere,” added Professor Sullivan. “It also highlights the importance of blue sky science – curiosity-driven scientific research will always have a fundamentally important role to play.” Read full story Source: University of Southampton, 10 January 2020 -
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JAMA editorial blasts FDA's reporting of medical device problems
Patient Safety Learning posted a news article in News
The US Food and Drug Administration (FDA) needs to do more to quickly and substantially reform its system for reporting adverse events caused by medical devices, two researchers wrote in an Editorial published in JAMA Internal Medicine. The editorial notes several instances where information on a medical device was withheld from the public or not reported fully. The current adverse events reporting system relies on device makers to voluntarily report adverse events, which the authors say does not place patient safety as a priority. The editorial specifically highlights a study involving Medtronic's Insync III model 8042 heart failure pacemaker, which the authors said caused a "high burden of serious adverse events (including death)." The authors said it took the FDA 19 months to recall the device after the first instance of the device failing was reported. The FDA also decided to classify the recall as Class II, which signifies a low probability of serious adverse events. "This long unexplained delay before the recall and the inappropriate recall classification raise concerns about patient harms that could have been prevented by speedier and stronger regulatory actions," the authors wrote. Read full story Source: Becker's Hospital Review, 10 January 2020 -
Content ArticleThe aim of the Standard is to establish a framework and set a clear direction such that patients and service users (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss receive: ‘Accessible information’ (‘information which is able to be read or received and understood by the individual or group for which it is intended’). ‘Communication support’ (‘support which is needed to enable effective, accurate dialogue between a professional and a service user to take place’). Such that they are not put “at a substantial disadvantage…in comparison with persons who are not disabled” when accessing NHS or adult social services. This includes accessible information and communication support to enable individuals to: Make decisions about their health and wellbeing, and about their care and treatment. Self-manage conditions. Access services appropriately and independently. Make choices about treatments and procedures including the provision or withholding of consent.
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Myla’s mum left with ‘soul‑destroying sadness’
Patient Safety Learning posted a news article in News
Mother Natalie Deviren was concerned when her two-year-old daughter Myla awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless. She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice. She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit. Myla died from an intestinal blockage the next day and could have survived with treatment. The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times. In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.” Read full story Source: The Times, 5 January 2020 -
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Toddlers died after NHS 111 helpline said they were not in danger
Patient Safety Learning posted a news article in News
The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation. Read full story (paywalled) Source: The Times, 5 January 2020- Posted
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Revealed: Dozens of hospitals ignoring NHS safety warnings
Patient Safety Learning posted a news article in News
Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed. Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved. Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospitals ignoring the deadlines. National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes. NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt. Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.” He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.” Read full story Source: The Independent, 30 December 2019 -
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NHS e-health systems 'risk patient safety'
Patient Safety Learning posted a news article in News
Hospitals across England are using 21 separate electronic systems to record patient health care – risking patient safety, researchers suggest. A team at Imperial College say the systems cannot "talk" to each other, making cross-referencing difficult and potentially leading to "errors". Of 121 million patient interactions, there were 11 million where information from a previous visit was inaccessible. The team from London's Imperial College's Institute of Global Health Innovation (IGHI) looked at data from 152 acute hospital trusts in England, focusing on the use of electronic medical records on the ward. Around a quarter were still using paper records. Half of trusts using electronic medical records were using one of three systems: researchers say at least these three should be able to share information. 10% were using multiple systems within the same hospital. Writing in the journal BMJ Open, the researchers say: "We have shown that millions of patients transition between different acute NHS hospitals each year. These hospitals use several different health record systems and there is minimal coordination of health record systems between the hospitals that most commonly share the care of patients." Lord Ara Darzi, lead author and co-director of the IGHI, said: "It is vital that policy-makers act with urgency to unify fragmented systems and promote better data-sharing in areas where it is needed most – or risk the safety of patients." A spokesperson for NHSX, which looks after digital services in the NHS, said: "NHSX is setting standards, so hospital and general practioner IT systems talk to each other and quickly share information, like X-ray results, to improve patient care." Read research article Read full story Souce: BBC News, 5 December 2019 -
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