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Found 57 results
  1. Event
    until
    Q members only Register
  2. Content Article
    This book is a resource for the coaches who provide health IT-related assistance for primary care practices to support their QI and practice transformation efforts. The audience for this handbook includes both the health IT-focused coaches who support QI work as well as the practice facilitators/coaches who have the necessary background, interest, and skills to provide clinical health IT support. Although the handbook is primarily intended for external coaches working with primary care practices, the content could also be useful for practice-based staff responsible for addressing health IT needs related to QI. The handbook assumes readers already have a basic level of comfort with EHR use and with extracting and using electronic data for QI.
  3. Content Article
    In this guest blog for the Professional Records Standards Body (PRSB), Taffy Gatawa, Chief Information and Compliance Officer at everyLIFE Technologies, talks about the importance of ensuring that healthcare technologies comply with recognised standards. She discusses everyLIFE's experience on PRSB’s Standards Partnership Scheme, and their journey to implementing standards in their digital products. Taffy describes a process of learning and feedback, achieved through desktop research, clinical reviews and critical engagement with PRSB and customers.
  4. Content Article
    Health information technology (health IT) has potential to improve patient safety, but its implementation and use has had unintended consequences and has raised new safety concerns. This viewpoint article in BMJ Quality & Safety introduces a new framework—the health IT safety (HITS) framework—to provide a conceptual foundation for health IT-related patient safety measurement, monitoring and improvement.
  5. Content Article
    Health IT (HIT) systems are increasingly becoming a core infrastructural technology in healthcare. However, failures of these systems, under certain conditions, can lead to patient harm and as such the safety case for HIT has to be explicitly made. This study from Habli et al., published in Safety Science, focuses on safety assurance practices of HIT in England and investigates how clinicians and engineers currently analyse, control and justify HIT safety risks. Two areas of strength were identified: establishment of a systematic approach to risk management and close engagement by clinicians; and two areas for improvement: greater depth and clarity in hazard analysis practices and greater organisational support for assuring safety. Overall, the dynamic characteristics of healthcare combined with insufficient funding have made it challenging to generate and explain the safety evidence to the required level of detail and rigour. Improvements in the form of practical HIT-specific safety guidelines and tools are needed. The lack of publicly available examples of credible HIT safety cases is a major deficit. The availability of these examples can help clarify the significance of the HIT risk analysis evidence and identify the necessary expertise and organisational commitments.
  6. Content Article
    This document from the Patient Safety Authority outlines final recommendations to acute care facilities in the USA regarding patient weights. The Patient Safety Authority is responsible for submitting recommendations to the Department of Health (Department) in the US for changes in health care practices and procedures which may be instituted for the purpose of reducing the number and severity of serious events and incidents.
  7. Content Article
    The United States is one of only three countries in the world that does not use the metric system. Yet, every single medication prescribed today is based on it. In addition to dosages based on the metric system, some doses are also very dependent on patient weight. These include blood thinners, certain antibiotics, chemotherapy agents, and many pediatric doses. The very young, very old, and people with certain medical conditions are at the highest risk of experiencing harm because their bodies are more sensitive to the effects of an error. Calculations made with incorrect weights can have devastating, if not fatal, consequences. Further reading Patient Safety Authority Department of Health: Final recommendation to ensure accurate patient weights
  8. Content Article
    The Accessible Information Standard directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting individuals’ information and communication support needs by NHS and adult social care service providers. 
  9. Content Article
    A team of scientific experts has joined forces from across the world to help fight the spread of misinformation about the COVID-19 vaccines. Together they have created a unique online guide, led by the University of Bristol, to arm people with practical tips combined with the very latest information and evidence to talk reliably about the vaccines, constructively challenge associated myths, and allay fears. With the race on to vaccinate as many people as possible soonest in the wake of a more virulent virus strain, they’re appealing to everyone, from doctors to politicians, teachers to journalists and parents to older generations, to understand the facts, follow the guidance, and spread the word.
  10. Content Article
    This article from Perlin et al. discusses how a 173-hospital system used technology as a strategy to reduce sepsis-related mortality system-wide by real-time dissemination of basic laboratory and clinical data to alert teams to patients exhibiting signs of sepsis risk.
  11. Content Article
    A process map is a planning and management tool that visually describes the flow of work. Using process mapping software, process maps show a series of events that produce an end result.
  12. Content Article
    This report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.  The report recommends a number of urgent actions to address these risks to patients.
  13. Content Article
    With the widespread adoption of electronic health records (EHRs), there is an increased focus on addressing the challenges of EHR usability; that is, the extent to which the technology enables users to achieve their goals effectively, efficiently, and satisfactorily. Poor usability is associated with clinician job dissatisfaction and burnout and could have patient safety consequences. Using EHR surveillance data collected by the ONC, researchers from the MedStar Health National Center for Human Factors analysed over 350 reports regarding EHR issues that violated the federal certification programme. They found that roughly 40% of ONC-certified EHRs had the potential for patient harm.
  14. Content Article
    This article, published by Forbes, looks at the airline industry and discusses the value in not only studying what pilots do wrong, but also what they do right. This can be translated into healthcare, we know lots about what has gone wrong in healthcare but not so much about the small, quiet things that go right. 'In aviation safety, it’s like we’ve been trying to learn about marriage by only studying divorce.' Written by Kirsty Kiernan a professor at Embry-Riddle Aeronautical University who teaches and conducts research in unmanned systems and aviation safety.
  15. Content Article
    Warren et al. 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. They found 117 (77.0%) hospital trusts were using electronic health records (EHR), but there was limited regional alignment of EHR systems. On 11,017,767 (9.1%) occasions, patients attended a hospital using a different health record system to their previous hospital attendance. Most of the pairs of trusts that commonly share patients do not use the same record systems. This research published in BMJ Open highlights significant barriers to inter-hospital data sharing and interoperability. Findings from this study can be used to improve EHR system coordination and develop targeted approaches to improve interoperability. The methods used in this study could be used in other healthcare systems that face the same interoperability challenges.
  16. Content Article
    Ever wondered what GPs do in a day? Watch this short video to find out.
  17. Content Article
    To ensure consistency and effectiveness of responses to health information under threat, Alberta Health has instituted the Provincial Reportable Incident Response Process (PRIRP) for all health stakeholders managing or accessing Alberta’s provincial Electronic Health Record (EHR), including its subsystems and repositories. This process covers incidents of data confidentiality, data integrity, and data availability and is divided into five phases. PRIRP is applicable to all health stakeholders managing, accessing, or regulating Alberta’s EHR, including its subsystems and repositories. • Health stakeholders use PRIRP to report a suspected or known security incident to Alberta Health. Alberta Health will assess the threat from the incident, and if valid will assemble an Incident Response Team (IRT). The IRT will be led by the Alberta Health Security team and include the reporting health stakeholder(s) and other applicable resources for any particular incident. The IRT will communicate as needed with other stakeholders impacted by the incident.
  18. Content Article
    The Information Commissioner’s Office (ICO) has ruled the Royal Free NHS Foundation Trust failed to comply with the Data Protection Act when it provided patient details to Google DeepMind. The Trust provided personal data of around 1.6 million patients as part of a trial to test an alert, diagnosis and detection system for acute kidney injury. An ICO investigation found several shortcomings in how the data was handled, including that patients were not adequately informed that their data would be used as part of the test. The Trust has been asked to commit to changes ensuring it is acting in line with the law by signing an undertaking.
  19. Content Article
    Published in the Journal of Clinical Nursing this paper explores the experiences of the families of young adults with intellectual disabilities at the point of transition from child to adult health services.
  20. Content Article
    Researchers have shown that people often miss the occurrence of an unexpected yet salient event if they are engaged in a different task, a phenomenon known as inattentional blindness. However, demonstrations of inattentional blindness have typically involved naive observers engaged in an unfamiliar task. What about expert searchers who have spent years honing their ability to detect small abnormalities in specific types of images? In this research paper published in Physiological Science, Wolfe et al. asked 24 radiologists to perform a familiar lung-nodule detection task. A gorilla, 48 times the size of the average nodule, was inserted in the last case that was presented. Eighty-three percent of the radiologists did not see the gorilla. Eye tracking revealed that the majority of those who missed the gorilla looked directly at its location. Thus, even expert searchers, operating in their domain of expertise, are vulnerable to inattentional blindness.
  21. Content Article
    This commentary, published in the Journal of the American Medical Informatics Association (JAMIA), highlights the value of explicit inclusion of context in Electronic Health Records (EHRs). The author highlights how discussions of why decisions were made illustrate important relationships in elements of patient care than can often get lost in clinical notes.
  22. Content Article
    Many studies have investigated the presence of a ‘weekend effect’ in mortality following hospital admission, and these frequently use diagnostic codes from administrative data for information on co-morbidities for risk adjustment. However, it is possible that coding practice differs between week and weekend. This paper assess patients with a confirmed history of certain long-term health conditions and investigate how well these are recorded in subsequent week and weekend admissions.
  23. Content Article
    Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. The term 'human factor' is rarely defined, but people often refer to reducing it. In this blog, Steven asks what are we actually reducing?
  24. Content Article
    The phrase “lessons learned” is such a common one, yet people struggle with developing effective lessons learned approaches. The Lessons Learned Handbook is written for the project manager, quality manager or senior manager trying to put in place a system for learning from experience, or looking to improve the system they have. Based on experience of successful and unsuccessful systems, the author recognises the need to convert learning into action. For this to happen, there needs to be a series of key steps, which the book guides the reader through. The book provides practical guidance to learning from experience, illustrated with case histories from the author, and from contributors from industry and the public sector.
  25. Content Article
    The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.  When CQC inspects health and care services they assess how well these services meet people’s needs. As part of this, they look at how people’s medicines are optimised. Medicines optimisation is the safe and effective use of medicines to enable the best possible outcomes for people. It also looks at the value that medicines deliver, making sure that they are both clinically and cost effective, and that people get the right choice of medicines, at the right time, with clinicians engaging them in the process. 
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