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Showing results for tags 'Organisation / service factors'.
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News Article
Prisoners suffer cancelled appointments and poorer healthcare
Patient Safety Learning posted a news article in News
Prisoners in Britain frequently have hospital appointments cancelled and receive less healthcare than the general public, a new study has found. As many as 4 in 10 hospital appointments made for a prisoner were cancelled or missed in 2017–18, with missed appointments costing the NHS £2 million. The in-depth analysis of prison healthcare by the Nuffield Trust think tank examined 110,000 hospital records from 112 prisons in England. It revealed 56 prisoners gave birth during their prison stay, with six prisoners giving birth either in prison or on their way to hospital. The Nuffield Trust said its findings raised concerns about how prisoners are able to access hospital care after a cut in the number of frontline prison staff and a rising prison population. Lead author Dr Miranda Davies, a senior fellow at the Nuffield Trust, said: “The punishment of being in prison should not extend to curbing people’s rights to healthcare. Yet our analysis suggests that prisoners are missing out on potentially vital treatment and are experiencing many more cancelled appointments than non-prisoners.” Read full story Source: The Independent, 26 February 2020 -
Content ArticleIt is widely known that prisons in England and Wales are crowded and facing severe difficulties, but the health and health care use of the prisoners within has received little attention. Drawing on over 110,000 patient hospital records for prisoners at 112 prisons, this study from the Nuffield Trust provides the most in-depth look to date at how prisoners’ health needs are being met in hospital.
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Content ArticleThis report from the King's Fund looks at the reality of caring for acutely ill medical patients at the NHS front line and asks how care in hospitals can be improved. It comprises a series of essays by frontline clinicians, managers, quality improvement champions and patients, and provides vivid and frank detail about how clinical care is currently provided and how it could be improved. The essays are introduced and summarised by Chris Ham and Don Berwick and the report serves as the starting point of an ongoing appreciative inquiry into improving care processes, particularly for acutely ill medical patients.
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Content ArticleMany clinicians and managers struggle with the concept of waste in clinical processes. After hearing and reading about the transformation of healthcare at Virginia Mason Medical Center in Seattle, the Gordon Caldwell read Toyota Culture the Heart and Soul of the Toyota Way. This article discusses some of the concepts of waste in clinical processes, concentrating particularly on the waste and costs of over-investigation.
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Content Article
James Titcombe: The complexity of failure (2 October 2018)
PatientSafetyLearning Team posted an article in Culture
When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organisation that robbed them of their child. The ‘complexity of failure’ video documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever. -
News Article
Prime Minister urged to give NHS 100 new hospitals plus an extra £7bn a year
Patient Safety Learning posted a news article in News
NHS leaders have urged Boris Johnson’s government to build 100 new hospitals and give the service an extra £7bn a year for new facilities and equipment. They want the Prime Minister to commit to far more than the 40 new hospitals over the next decade that the Conservatives pledged during the general election. So many hospitals, clinics and mental health units are dilapidated after years of underinvestment in the NHS’s capital budget that a spending splurge on new buildings is needed, bosses say. Too many facilities are cramped and growing numbers are unsafe for patients and staff, they claim. Johnson has promised £2.7bn to rebuild six existing hospitals and pledged to build 40 in total and upgrade 20 others, although has been criticised for a lack of detail on the latter two pledges. The call has come from NHS Providers, which represents the bosses of the 240 NHS trusts in England that provide acute, mental health, ambulance and community-based services. Read full story Source: The Guardian, 3 February 2020 -
News ArticleHeart attack, stroke and burns victims are among the seriously ill and injured patients waiting over an hour for an ambulance to arrive in England and Wales, a BBC investigation shows. The delays for these 999 calls - meant to be reached in 18 minutes on average - put lives at risk, experts say. The problems affect one in 16 "emergency" cases in England - with significant delays reported in Wales. NHS bosses blamed rising demand and delays handing over patients at A&E. Rachel Power, Chief Executive of the Patients Association, said patients were being "let down badly at their moment of greatest need" and getting a quick response could be "a matter of life or death". She said the delays were "undoubtedly" related to the sustained underfunding of the NHS. Read full story Source: BBC News, 29 January 2020
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Content ArticleRecording of Ted Baker's presentation at The Royal Society of Medicine's Improving Patient Safety & Care Conference.
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Content ArticleThis 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.
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News Article
England's poorest 'get worse NHS care' than wealthiest citizens
Patient Safety Learning posted a news article in News
England’s poorest people get worse NHS care than its wealthiest citizens, including longer waiting for A&E treatment and worse experience of GP services, a new study has shown. Those from the most deprived areas have fewer hip replacements and are admitted to hospital with bed sores more often than people from the least deprived areas. With regard to emergency care, 14.3% of the most deprived had to wait more than the supposed maximum of four hours to be dealt with in A&E in 2017-18, compared with 12.8% of the wealthiest. Similarly, just 64% of the former had a good experience making a GP appointment, compared with 72% of those from the richest areas. Research by the Nuffield Trust and Health Foundation thinktanks found that the poorest people were less likely to recover from mental ill-health after receiving psychological therapy and be readmitted to hospital as a medical emergency soon after undergoing treatment. The findings sparked concern because they show that poorer people’s health risks being compounded by poorer access to NHS care. Read full story Source: The Guardian, 23 January 2020 -
Content Article'Hospitals should remove any barriers to doctors eating and drinking during the working day'. As healthcare providers, it’s easy to forget to look after ourselves at work. We know that taking breaks and eating and drinking regularly is a critical component of being “optimised,” helping to sustain our energy, concentration and performance, and reduce the risk of human error. Yet, for many, the realities of working in busy, modern hospitals get in the way. Medicine is a demanding profession, with days often starting early and finishing late and many fall into the habit of forgetting to take regular breaks, not drinking enough fluids, or missing meals. If we want to improve staff wellbeing and reduce the risk of errors, we need to change this.
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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 -
News ArticleAn 88-year-old woman with a broken neck died after being transferred three times between two hospitals in the space of just 48 hours, The Independent has reveal. The death of Jean Waghorn, who died after contracting pneumonia in hospital, sparked criticism from a coroner who said the NHS trust had ignored earlier warnings over moving patients between hospitals. Senior coroner Veronica Deeley had issued two official alerts to Brighton and Sussex Hospitals Trust last year after the deaths of frail elderly patients who were wrongly shuttled between hospitals. But despite this, in June this year Ms Waghorn, who broke her neck after falling at home, was repeatedly transferred between the Princess Royal Hospital in Sussex and Brighton’s Royal Sussex County Hospital. She caught pneumonia and died two days later. The hospital, which is rated good by the CQC, has now apologised and said it has learned lessons from the case. A spokesperson said it did take action following the previous warnings and added that work was ongoing to ensure the changes were consistently applied. Read full story Source: The Independent, 17 December 2019
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Content ArticleIn this blog published in the New York Times, Theresa Brown explains why American healthcare has become one giant workaround. "The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait." These 'work arounds ' pose a significant patient safety risk. What work around problems do you have in your department? Theresa Brown is a clinical faculty member at the University of Pittsburgh School of Nursing.
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Content ArticleECRI Institute's mission is to protect patients from unsafe and ineffective medical technologies and practices. More than 5,000 healthcare institutions and systems worldwide, including four out of every five U.S. hospitals, rely on ECRI Institute to guide their operational and strategic decisions.
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Content ArticleThere are a number of fundamental weaknesses in governance around patient safety and the quality of care at Cwm Taf Morgannwg University Health Board, a joint review by Healthcare Inspectorate Wales (HIW) and the Wales Audit Office found. Following well-publicised concerns about maternity services at the Health Board, the joint review examined the organisation’s overall approach to quality governance. It found that whilst there has been a strong focus on financial balance and meeting key targets, less attention has been paid to the overall quality and safety of its services. The report highlights the need for stronger and broader leadership in respect of quality and patient safety and worryingly, points to a culture of fear and blame in some parts of the organisation that has prevented staff from speaking out and raising concerns.
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Content ArticleIncreased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues.
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Content ArticleIn recent years, there has been an increasing focus on the role of safety culture in preventing incidents such as medication errors and falls. However, research and developments in safety culture has predominantly taken place in hospital settings, with relatively less attention given to establishing a safety culture in care homes. Despite safety culture being accepted as an important quality indicator across all health and social care settings, the understanding of culture within social care settings remains far less developed than within hospitals. It is therefore important that the existing evidence base is gathered and reviewed in order to understand safety culture in care homes.
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Content Article
Creating a safety culture
Claire Cox posted an article in Other countries and national agencies
A safety culture is built on trust. It empowers staff to report errors, near misses, and recognise unsafe behaviours and conditions that can put patients at risk, all of which drive improvement. This video by the Joint Commission Centre for Transforming Healthcare explains how they are engaging staff and the importance of speaking up. -
Content Article
Museum of failure
Claire Cox posted an article in Miscellaneous
Museum of Failure is a collection of failed products and services from around the world. The majority of all innovation projects fail and the museum showcases these failures to provide visitors a fascinating learning experience. Every item provides unique insight into the risky business of innovation.The idea for the museum was born out of frustration. ‘I was so tired of reading and hearing the same boring success stories, they are all alike’ says the museum’s curator, Samuel West. ‘It is in the failures we find the interesting stories that we can learn from.’ Innovation and progress require an acceptance of failure. The museum aims to stimulate discussion about failure and inspire us to have the courage to take meaningful risks.Could we learn from our 'failures' in healthcare in the same way? -
Content Article
The ‘C’ word (May 2017)
Claire Cox posted an article in Other countries and national agencies
The ‘c’ word, 'cost' is often used to defend the status quo in patent safety. This article, published by PatientSafe Network, highlights the importance of assessing the financial loss in not introducing the safety intervention. It includes examples on how to overcome barriers like 'we don't have the money for that' when it comes to delivering safer care. After all, the price of safer care is priceless -
Content ArticleThis 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.
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Content ArticleThis infographic, by patient Jennifer Gilroy, demonstrates what makes patients feel safe and what contributes to them feeling unsafe in a hospital environment.
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Content ArticleHealthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper published in BMJ Quality & Safety, Amalberti and Vincent discuss the strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.
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Content Article
CQC case study: outstanding, safe care for all (May 2017)
Claire Cox posted an article in GP and primary care
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.
