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News ArticleToday, four leading global organisations dedicated to fighting preventable deaths due to medical errors announced their partnership to co-convene the #uniteforsafecare programme on World Patient Safety Day (September 17, 2020). In June, the Patient Safety Movement Foundation announced the wide-ranging campaign to bring attention to system-wide improvements that will ensure better health worker and patient safety outcomes, called #uniteforsafecare. Now, the organisation will be joined by the American Society of Anesthesiologists (ASA), The Leapfrog Group, and International Society for Quality in Health Care (ISQua) in co-convening the slate of programming, which includes a virtual physical challenge to raise awareness of the issue; collaboration with the National Association for Healthcare Quality’s annual conference, NEXT; an in-person demonstration in Washington, D.C. and a free virtual event for the public and those who have experienced errors, harms, or death to themselves or loved ones. “As the first medical specialty to advocate for patient safety, and as physicians on the front lines treating COVID-19 patients, we know firsthand how critical ensuring health worker safety is,” said ASA President Mary Dale Peterson. “The issue is especially timely. From having the appropriate PPE to strategies for stress management and wellness – ensuring health worker safety is patient safety and improves outcomes. We are happy to participate in this effort to advance safety in health care.” Read press release
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News ArticleAcross the country there have been reports of “do not resuscitate” (DNR) orders being imposed on patients with no consultation, as is their legal right, or after a few minutes on the phone as part of a blanket process. Laurence Carr, a former detective chief superintendent for Merseyside Police, is still angry over the actions of doctors at Warrington Hospital who imposed an unlawful “do not resuscitate” order on his sister, Maria, aged 64. She has mental health problems and lacks the capacity to be consulted or make decisions and has been living in a care home for 20 years. As her main relative, Mr Carr found out about the notice on her records only when she was discharged to a different hospital a week later. Maria had been admitted for a urinary tract infection at the end of March. Although she has diabetes and an infection on her leg her condition was not life threatening. Mr Carr said: “My sister has no capacity to effectively be consulted due to her mental illness and would not understand if they did try to explain, so I was furious that I had not been consulted." He later learnt that the reason given by the hospital for imposing the DNR was "multiple comorbitidies". In a statement, Warrington and Halton Teaching Hospitals Foundation Trust said it was fully aware of the law, which was reflected in its policies and regular training. It said: “We did not follow our own policy in this case and have the requisite discussions with the family. The template form which was completed in this case indicates that discussion with the family was ‘awaiting’. Regretfully due to human error this did not occur." Mr Carr and his sister are not alone. National charity Turning Point said it had learnt of 19 inappropriate DNARs from families, while Learning Disability England said almost one-fifth of its members had reported DNARs placed in people’s medical records without consultation during March and April. Read full story Source: The Independent, 14 July 2020
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News Article
"They don’t hide from the coronavirus, they confront it"
Patient Safety Learning posted a news article in News
As the world writhes in the grip of Covid-19, the epidemic has revealed something majestic and inspiring: millions of health care workers running to where they are needed, on duty, sometimes risking their own lives. In his article in the New York Times, Don Berwick says he has never before seen such an extensive, voluntary outpouring of medical help at such a global scale. Millions of health care workers are running to where they are needed, sometimes risking their lives. Intensive care doctors in Seattle connect with intensive care doctors in Wuhan to gather specific intelligence on what the Chinese have learned: details of diagnostic strategies, the physiology of the disease, approaches to managing lung failure, and more. City by city, hospitals mobilise creatively to get ready for the possible deluge: bring in retired staff members, train nurses and doctors in real time, share data on supplies around the region, set up special isolation units and scale up capacity by a factor of 100 or 1000. "We are witnessing professionalism in its highest form, skilled people putting the interests of those they serve above their own interests." Read full article Source: New York Times, 23 March 2020 -
News Article
Patient Safety Awareness Week
Patient Safety Learning posted a news article in News
This week is Patient Safety Awareness Week, an annual recognition event intended to encourage everyone to learn more about healthcare safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done. Although there has been real progress made in patient safety over the past two decades, current estimates cite medical harm as a leading cause of death worldwide. The World Health Organization estimates that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries, resulting in some 2.6 million deaths. Additionally, some 40 percent of patients experience harm in ambulatory and primary care settings with an estimated 80 percent of these harms being preventable, according to WHO. Some studies suggest that as many as 400,000 deaths occur in the United States each year as a result of errors or preventable harm. Not every case of harm results in death, yet they can cause long-term impact on the patient's physical health, emotional health, financial well-being, or family relationships. Preventing harm in healthcare settings is a public health concern. Everyone interacts with the health care system at some point in life. And everyone has a role to play in advancing safe healthcare. Learn more about IHI's work to advance patient safety. -
News Article
New pharmacy referral service to help patients avoid hospital readmission
Patient Safety Learning posted a news article in News
From July, hospitals will be able to refer patients who would benefit from extra guidance around new prescribed medicines to their community pharmacy. Patients will be digitally referred to their pharmacy after discharge from hospital. The NHS Discharge Medicines Service will help patients get the maximum benefits from new medicines they’ve been prescribed by giving them the opportunity to ask questions to pharmacists and ensuring any concerns are identified as early as possible. This is part of the Health Secretary’s ‘Pharmacy First’ approach to ease wider pressures on A&Es and general practice. Read full story Source: Department of Health and Social Care, 23 February 2020 -
News ArticleNHS Digital and the Private Healthcare Information Network (PHIN) have launched a consultation as part of the next phase of a programme to align private healthcare data with NHS recorded activity. The consultation sets out a series of changes to how data is recorded and managed across private and NHS care, along with a series of pilot projects, based upon feedback from a variety of stakeholders. It aims to seek the views of private and NHS providers, clinicians, the public and other organisations with an interest in private healthcare and will be used to help shape the future changes. The consultation, which has been launched following the publication of the Paterson Inquiry, will be hosted on the NHS Digital Consultation Hub. Under the changes proposed in the Acute Data Alignment Programme (ADAPt), PHIN will share the national dataset of private admitted patient care in England with NHS Digital, creating a single source of healthcare data in England. This recommendation has been supported by recommendations in the Paterson Inquiry to create a single repository for practice of consultants in private and public healthcare across England. Health Secretary Matt Hancock said: “Regardless of where you’re treated or how your care is funded, everybody deserves safe, compassionate care. The recent Paterson Inquiry highlighted the shocking failures that can occur when information is not shared and acted upon in both the NHS and independent sector. We are working tirelessly across the health system to deliver the highest standards of care for patients. Trusted data is absolutely critical to this mission and the ADAPt programme will help improve transparency and raise standards for all.” Read full story Source: NHS Digital, 19 February 2020
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News Article
Not enough pharmacists are aware of the yellow card scheme
Clive Flashman posted a news article in News
Every pharmacist must report adverse drug reactions using the yellow card scheme, says chair of the Community Pharmacy Patient Safety Group, Janice Perkins Polypharmacy, when different medications are used by an individual at the same time, is becoming increasingly common because people are living for longer and with multiple different illnesses. One study, published in 2018 by the Oxford University Press, found that over half (54%) of those aged 65 years and above who took part in the study had two or more long-term conditions, for which they could have been taking a range of medicines. Read full story Source: Community Pharmacy News, 17 February 2020 -
News Article
The cost of patient safety inaction: Why doing more of the same is unsustainable
Patient Safety Learning posted a news article in News
On January 2020, Patient Safety will be on the G20 agenda (among other five health key priorities), but Abdulelah M. Alhawsawi, Saudi Patient Safety Center, asks "what is patient safety doing on an economic forum like the G20?" Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both US and Canada, patient safety adverse events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the US alone, 440,000 patients die annually from healthcare associated infections. In Canada, there are more than 28,000 deaths a year due to patient safety adverse events. In low-middle income countries, 134 million adverse events take place every year, resulting in 2.6 million deaths annually. In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development countries is attributed to patient safety failures each year, but if we add the indirect and opportunity cost (economic and social), the cost of harm could amount to trillions of dollars globally. When a patient is harmed, the country loses twice. The individual will be lost as a revenue generating source for society and the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. Alhawsaw proposed establishing a G20 Patient Safety Network (Group) that will combine Safety experts from healthcare and other leading industries (like aviation, nuclear, oil and gas, other), and economy and fFinancial experts This will function as a platform to prioritise and come up with innovative patient safety solutions to solve global challenges while highlighting the return on investment (ROI) aspects. This multidisciplinary group of experts can work with each state that adopts the addressed global challenge to ensure correct implementation of proposed solution. Read full story Source: The G20 Health & Development Partnersip, 10 February 2020- Posted
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News Article
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 -
News Article
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 -
Content ArticleAn increasing number of cancer patients are using the internet to better understand their disease and connect with others facing the same challenges. Online cancer communities have developed into resources that highlight new research and evolving treatments. Combined with increasing health literacy and social media, they have enabled some patients to become experts in their cancer. This article in the journal JCO Oncology Practice examines the role of expert patients (e-patients) in advancing cancer medicine, and looks at opportunities available to those who wish to become more involved in research advocacy. The authors found that e-patients play a greater role in their own care and in larger conversations regarding practice, research, and policy. They highlight that clinicians can engage e-patients as partners in cancer care to work together towards improving healthcare access and outcomes for people with cancer.
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Content Article
WHO - Announcing World Patient Safety Day 2022 (4 March 2022)
Patient-Safety-Learning posted an article in WHO
The theme for World Patient Safety Day 2022 is Medication Safety. It will take place on 17 September 2022. Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare across the world. Medication errors occur when weak medication systems, and human factors such as fatigue, poor environmental conditions or staff shortages, affect prescribing, transcribing, dispensing, administration and monitoring practices. This can result in severe patient harm, disability and even death. The ongoing Covid-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm. The theme builds on the ongoing WHO Global Patient Safety Challenge: Medication Without Harm. It also provides much-needed impetus to take urgent action for reducing medication-related harm through strengthening systems and practices of medication use. -
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
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Content Article
This is the first of a short series of blogs in which we take a look back at our work in five areas of patient safety during 2021. This blog explores how the hub has encouraged collaboration, connection and the sharing of patient safety solutions. Through our work, Patient Safety Learning seeks to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable. -
Content ArticleThis patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help family members and carers of severe stroke patients under 60 understand the risks and benefits of decompressive hemicraniectomy, so that they can make an informed decision about treatment.
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Content ArticleThis patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help patients with high blood pressure understand the risks and benefits of different treatment options so that they can make an informed decision about their care.
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Content ArticleThese free e-learning courses about communicating the potential harms and benefits of treatment to patients have been produced by the Winton Centre for Risk & Evidence Communication, the Academy of Medical Royal Colleges in the UK and the Australian Commission on Safety & Quality in Healthcare.
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Content Article
Positive patient safety: how Mustard can help
HelenH posted an article in Improving patient safety
In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on her recent experience attending a meeting of the Patient Safety Management Network and hearing about the work of the Quality and Safety Department at the Sussex Community NHS Foundation Trust. -
Content ArticleThis is a presentation given by the Quality and Safety Department at the Sussex Community NHS Foundation Trust to the Patient Safety Management Network on 22 October 2021. It provides an overview of how they have been developing the Trust’s approach to patient safety, focusing on safety culture, learning for improvement and aiming to raise the profile of patient safety within their organisation.
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Content Article
In this blog, Claire Cox, Quality Improvement and Patient Safety Manager at Guys and St Thomas' Hospital NHS Foundation Trust, explains why and how she developed the Patient Safety Management Network. She looks at why the network is needed, what it has achieved so far, its aims for the future and how patient safety managers can get involved. -
Content ArticleThis systematic review in The Journal of Advanced Nursing aimed to synthesise current knowledge about the impact of safety briefings on improving patient safety. The authors found that safety briefings achieved beneficial outcomes and can improve safety culture. Beneficial outcomes included: improved risk identification. reduced falls. enhanced relationships. increased incident reporting. ability to voice concerns. reduced length of stay.
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Content ArticleA Patient Safety Huddle is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. This evaluation of The Huddle Up for Safer Healthcare (HUSH) project in BMC Health Services Research aims to assess the impact on teamwork and safety culture of the project, which implemented PSHs in 92 wards at five hospitals, across three NHS Trusts. This paper also seeks to add to the evidence-base around huddles as a mechanism for improving safety.
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Content ArticleThis blog by consultancy firm Gallup highlights seven questions leaders should ask to about their huddles, to ensure they are effective in improving patient safety and preventing staff burnout.
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Content ArticleThis short article describes how maternity and neonatal teams across Herefordshire and Worcestershire Local Maternity and Neonatal System (LMNS) have been using video conferencing technology to drive safety improvements for mothers and babies, thanks to the launch of their new daily digital safety huddles.
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Content ArticleThis systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
