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Found 207 results
  1. Content Article
    Each year in March, Patient Safety Awareness Week (PSAW) serves as a spark for increasing safety. Initiated in 2002, the concept of PSAW was formed by New York State-based founder of the Pulse Center for Patient Safety Education and Advocacy, Ilene Corina. In 2003, Ilene then collaborated with the Society to Improve Diagnosis in Medicine founder Dr. Mark L. Graber and the National Patient Safety Foundation to establish the annual event. PSAW triggers the sharing of resources and experiences to initiate partnerships that propel patient safety work forward. Many in the field take advantage of the opportunity to build awareness of their inventiveness and motivate collective action toward enhancing patient safety. PSAW uses a wide range of communication methods to create energy and rejuvenate effort through the sharing of lessons learned and common goals. Buttons, posters, in-house newsletter articles, blogs, webinars, employee recognition awards, and poster presentations are all used to increase awareness. Earlier this month, The Institute for Healthcare Improvement (IHI) partnered with the Agency for Healthcare Research and Quality (AHRQ) to host a Twitter chat that surveyed the experiences of participants on transitions, challenges and successes. Programmes highlighted during the discussion include the bundled handoff method I-PASS developed by a team at Boston Children's Hospital and Harvard Medical School to enhance team communication. Twitter chat participants noted the importance of being able to adapt transitions tool to their environments. I-PASS leaders noted efforts to develop local champions to assist with the application of the bundle for use in the variety of situations patients and providers encounter throughout the care journey. The California Patient Safety Organization (CHPSO) hosted five free webinars during PSAW on a range of topics. One webinar focused on mitigating unconscious influences, or cognitive biases, that degrade relationships, decision making and care delivery. The speaker, Michelle van Ryn, President and Founder of the Institute for Equity & Inclusion Science, highlighted specific tactics, tools and educational programming to combat unconscious biases generated by gender and racial differences. She reviewed organisational conditions that facilitate biased interaction such as unsafe psychological culture and overwork. Dr van Ryn discussed valuable skill development tactics for increasing an individual’s management of their potential for implicit bias that focused on mindfulness, empathy, inclusion and partnership-building behaviours. Another high point of the week was the release of AHRQ’s Making Health Care Safer III report. This publication summarises the current evidence base on 47 patient safety practices targeting 17 areas of concern. For example, the chapter on sepsis discusses the evidence on manual or electronic screening tools for sepsis. The authors discuss the performance of currently used methods to determine patient susceptibility to sepsis to help ensure timely treatment initiation. While they concluded more evidence is required to determine outcome measures associated with screening methods, the authors shared links to examples of robust tools currently being used in US hospitals. Another focuses on infections due to multi-drug resistant organisms. One distinct practice review discusses hand hygiene, of particular relevance due to the COVID-19 outbreak. The authors discuss the persistent weakness in hand-hygiene practice due to workload, lack of education and easily accessible supplies. The World Health Organization’s My Five Moments for Hand Hygiene programme is highlighted in this evidence covered as an important approach for implementing hand hygiene completeness into frontline care. Thirdly, patient and family engagement is covered as a patient safety practice relevant across the spectrum of care delivery. The authors discuss difficulties in tracking the evidence on engagement as a distinct element of patient safety. They highlight several studies on the topic and share resources to encourage adoption of activities that encourage patient involvement in their care. hub members should refer to the search strategies in the report (included as an appendix in each chapter) designed to review each discussed best practice. Leaders can use these vetted search strategies to keep current on the emerging evidence related to the initiatives they are implementing in their own organisations, targeting the specific challenges they are confronting in their own improvement work. Connecting with experts and recognising their contribution to change can motivate action. By providing stimuli, Patient Safety Awareness Week re-energises those on the front-line of safety. It facilitates expert conversation, knowledge sharing and evidence identification to keep our patient safety efforts and our patient safety leaders moving forward.
  2. News Article
    National NHS leaders are to take action over growing fears that the “unintended consequences” of focusing so heavily on tackling covid-19 could do more harm than the virus, HSJ has learned. NHS England analysts have been tasked with the challenging task of identifying patients who may not have the virus but may be at risk of significant harm or death because they are missing vital appointments or not attending emergency departments, with both the service and public so focused on covid-19. A senior NHS source familiar with the programme told HSJ: “There could be some very serious unintended consequences [to all the resource going into fighting coronavirus]. While there will be a lot of covid-19 fatalities, we could end up losing more ‘years of life’ because of fatalities relating to non-covid-19 health complications. “What we don’t want to do is take our eye off the ball in terms of all the core business and all the other healthcare issues the NHS normally attends to." “People will be developing symptoms of serious but treatable diseases, babies will be born which need immunising, and people will be developing breast lumps and need mammograms.” HSJ understands system leaders are hopeful that in the coming days they will be able to assess the scale of the problem, and the key patient groups, and then begin planning the right interventions and communications programme to tackle it. Read full story Source: HSJ, 5 April 2020
  3. News Article
    Doctors have been reminded not to prioritise coronavirus patients at the expense of others in new ethical guidance backed by royal colleges. There are increasing concerns that patients are not getting treatment for serious problems, including strokes or heart attacks, because they are afraid to go to hospitals. The guidelines were drawn up by the Royal College of Physicians (RCP) amid worries that a shortage of ventilators and beds could force doctors to make difficult decisions on which patients get lifesaving treatment. Read full story (paywalled) Source: The Times, 2 April 2020
  4. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
  5. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  6. News Article
    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
  7. Content Article
    On January 2020, Patient Safety will be on the G20 agenda (amongst other five health key priorities). One would ask: What is Patient Safety doing on an economic forum like the G20? Another cynic might even add: What is Healthcare doing on the G20? The G20 was established in the late 1990s with the objective of its members working together to achieve economic and financial stability. It is comprised of 19 countries and the European Union (EU). The G20 collectively represent more than 85 % of the world’s Gross Domestic Product (GDP), and more than two- thirds of the world’s population. Healthcare was only introduced in 2017 during the German presidency. Why put patient safety on the G20 agenda? 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 U.S. and Canada, Patient Safety Adverse Events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the U.S. alone: 440 thousand patients die annually from healthcare associated infections (HAIS). In Canada: there are more than 28 thousand deaths a year due to Patient Safety Adverse Events. In Low – Middle Income Countries (LMIC), every year 134 million adverse events take place resulting in 2.6 million deaths annually. Having said all that, up to 70 % of harm is . (OECD, 2017) 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 (OECD) countries is attributed to patient safety failures each year (OECD 2017) But if we add the indirect and opportunity cost Economic & Social), the cost of harm could amount to trillions of dollars globally (OECD 2017). According to a report by Frost & Sullivan in 2018, Patient Safety Adverse Events cost the US alone 146.1 billion dollars annually. When you compare the cost of prevention to the cost of harm, the return on investment (ROI) becomes a “no brainer”. In a study that looked at patient safety ROI for Pressure Injuries, the cost of prevention was € 291.33 million compared to the cost of harm of € 2.59 billion (almost 1,000 times higher). (Demmarre et al 2015) Over the past 20 years, numerous efforts were made to improve patient safety in individual G20 countries as well as globally under the World Health Organization leadership. Despite all those efforts, the level of harm to patients persists and 20-40% of health resources are being wasted (WHO). Many healthcare structural causes are responsible for the ongoing harm: Healthcare Workforce Factors: In addition to the quality and quantity, the wellbeing and safety of health workforce are foundational to patient safety. A substantial body of research now points to link nurse staffing with patient outcomes. A business case by Needleman (2006) demonstrated cost saving from reduced complications and shorter length of stay associated with higher nurse staffing levels. This relationship is articulated clearly in the Jeddah Declaration on Patient Safety in 2019. Dall (2009) estimated the impact of increased nurse staffing on medical cost, lives saved and national productivity. Their research suggests that adding 133,000 nurses to U.S. hospitals would save 5900 lives per year, increase productivity by $1.3 billion, or about $9900 per year per additional nurse. Decrease in length of stay resulting from this additional nurse staffing would translate into medical savings of $6.1 billion and increased in productivity attributed to decreased length of stay was estimated at $231 million per year. Addressing and ensuring guidelines that are consistent with research findings for nursing staffing in acute settings is a viable key solution to prevent medical errors, improve patient safety and decrease cost of healthcare delivery. Healthcare Education Causes: Even though healthcare is provided by multi-disciplinary teams, healthcare education (undergraduate – postgraduate) continues to be conducted in separate settings. This siloed approach results in many of the communication failures / safety failures that are experienced on a regular basis. According to Joint Commission communication failures were the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 2004. Healthcare education requires a serious reevaluation of its current curricula and practices. Furthermore, the lack of patient safety components to the medical and allied health sciences curriculum does a disservice to have safe medical practices imbedded within the day-to-day implementation of the healthcare workforce. Patient – Provider Information Asymmetry: The information and communication gap between the healthcare providers and their patients has caused ongoing harm. With the information abundance, patients turned to the internet as a source of guidance, regardless of its accuracy, which is minimally provided by Healthcare teams. Healthcare providers need to be the trusted guidance for information and the empowering force for patients to make informed decisions. Unempowered patients may result in lack of transparence and noncompliance to the care plans that contribute patient harm. Major movement for patient empowerment and community engagement is warranted. In addition, engaging patients can reduce the burden of harm by about 15%, saving billions of dollars each year. (WHO) Poor Safety Culture: The Hospital Survey on patient safety culture has been implemented in many countries to gain insight on the employees’ perception of the hospital patient safety culture. It has been consistently found that employees perceive hospital cultures lack transparency and results in punitive consequences when adverse events are reported. ‘Shame and Blame’ culture is one of the major barriers to improving safety. It is imperative that healthcare systems adopt strategies enabling Just Culture. Lack of consideration of Human Factors: In the healthcare sector, and since the Institute of Medicine (IOM) report “To Err is Human”, have come a long way in improving our services with elimination of potential harm in mind. However, healthcare can learn much more from other industries that have improved safety through use of HFE in redesigning work process and flow to ensure they are error-proof. HFE is an important discipline that can embed resilience to healthcare systems and could, potentially, transform patient safety. Lack of sufficient sharing and learning: The different sectors within the healthcare industry have created silos based on profession, departments, type of organization and many more subcultures and entities within a facility and at the national levels. This results in fragmented systems working in isolation, creating piece meal solutions and multi-levels of communication gaps, let alone the opportunity to share and learn in a manner that prevents harm from being repeated. Learning (from within healthcare), through Reporting & Learning Systems, and (from other industries), e.g. aviation, nuclear, oil & gas, is essential to healthcare safety innovation and transformation. Furthermore, population ageing has significant implications for patient safety as older adults are at higher risk for medical errors and the rate of adverse events due to increases in frailty, comorbidities, and incidences of chronic conditions, falls, and dementia makes providing health care more complex and increases costs. Individuals 65 years and older are at a two-fold risk for developing adverse events when compared with individuals between the ages of 16 and 44 years. (Brennan TA, Leape LL, Laird N, et al.) Nations across the G20 will face this challenge, which necessities innovate safety interventions and new approaches in health care to design a safer health care system. When it comes to patient safety, doing more of the same will result in: More lives will be lost More preventable harm will take place like Healthcare Associated Infections, medication errors, Anti-microbial Resistance (AMR) …etc. More money will be wasted (not to mention indirect cost and opportunity cost). When a patient is harmed, the COUNTRY LOSES TWICE: The individual will be lost as a revenue generating source for society+ 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. Our G20 proposal for patient safety Establishing a G20 Patient Safety Network (Group) that will combine two types of expertise: Safety experts from healthcare and other leading industries (like Aviation, Nuclear, Oil & Gas, other) Economy and Financial Experts This will function as a platform to prioritize 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. Benefit Investment in Patient Safety – – > sustainability of healthcare systems – – > and overall economies. In conclusion, patient safety is a global priority that goes beyond healthcare. It is a challenge that requires the collective wisdom of the G20 and the overall global community. It is not just an issue for health ministers, but it is an important issue that requires the attention of finance ministers and heads of states. The economic cost of failing patient safety could be risking the sustainability of healthcare systems and the overall global economies. WE NEED TO ACT NOW!
  8. News Article
    Mike Ramsay has been appointed new Chairman of the Patient Safety Movement Foundation, taking over from Joe Kiani. The Patient Safety Movement's goal is to get to ZERO preventable deaths. In their latest newsletter, Mike discusses how he intends to build on the tremendous momentum gained so far. "We are not competing with any organization but strongly support entities with the patient safety goal and hope that we can all pull together and use all our resources to reach zero preventable deaths and zero harm. Zero is our target and we can get there!" Read Mike's Letter in the March Patient Safety Movement Foundation newsletter
  9. Content Article
    Implications While this study shows that those referring patients to ICU could benefit from greater support, the decision support tool trialled in this study would need some adaptation to fit the time-pressured realities of the users. The process did seem to help clinicians articulate and communicate their reasoning for admission. Perhaps, as the authors say, if the tool were to be integrated into existing systems the perceived additional workload may be diminished. Another not insignificant finding is that although clinicians stated they valued patient’s wishes, in some cases there was a lack of patient and family involvement.
  10. News Article
    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.
  11. Content Article
    Key take-away messages The healthcare organisation you work in is a system of interacting human elements, roles, responsibilities and relationships. Quality and patient safety are performed by your human-designed organisational structures, processes, leadership styles, people's professional and cultural backgrounds, and organizational policies and practices. The level of interconnection of all these aspects will impact the distribution of perception, cognition, emotion and consciousness with the organisation you work for. What goes on between people defines what your health system is and what it can become.
  12. News Article
    A new poll has found only 8 out of the 1,618 respondents believed the health service was ready to deal with an outbreak when asked by The Doctors’ Association UK (DAUK), despite the prime minister’s insistence that the NHS will cope if it is hit by a surge in the number of people falling ill. Common concerns included difficulties coping with increased demand, a shortage of beds and poor staffing levels, according to the group who led the poll. Some doctors asked said they were worried that there could be not enough laboratory space to do testing in the case of a pandemic. Others claimed that NHS 111 had been giving out “inappropriate advice” to go to A&E and GP practices, according to DAUK. “The NHS has already been brought to its knees and many frontline doctors fear that our health system simply will not cope in the event of a Coronavirus (Covid-19) outbreak,” Dr Rinesh Parmar, the DAUK chair, said. “Many hoped the threat of Covid-19 would prompt an honest conversation to address the issue of critical care capacity and our ability to look after our sickest patients. By simply saying ‘the NHS is well prepared to deal with coronovirus’ it seems that yet again doctors’ concerns have been brushed under the carpet.” The findings come after the number of people infected with the coronavirus which rose to 39 in the UK on Monday. Read full story Source: The Independent, 3 March 2020
  13. Content Article
    In my current role I oversee the therapy programme for the Eating Disorders Unit (EDU) and see in-patients, day-patients and out-patients for individual and group therapy. I work with both adults and children with eating disorders, depression and anxiety, and use evidence-based therapies including cognitive behavioural therapy (CBT). A case study Lucy* is a 25-year-old interior designer who is seeking treatment for anorexia. She was an inpatient on our EDU. Throughout the whole admission there is a strong focus on patient safety. One of Lucy’s goals was to gain weight to a safer weight, but the increases were very gradual to avoid refeeding syndrome. At the beginning of her stay and all throughout we carried out regular risk assessments to check her risk to herself and also to others. Lucy had her bloods monitored throughout and was regularly observed for physical symptoms. In terms of the therapy, our focus was looking at the role that anorexia played in Lucy’s life. To do this we did a collaborative formulation which was continually evolving. This helped Lucy to make more sense of her illness and understand what it meant to her. Lucy was able to articulate that her anorexia made her feel ‘special’ and also was a way of managing difficult feelings such as feeling upset and angry by her parents’ divorce. Lucy was also able to identify that feelings were not spoken about in her family, so she did not have the ability to identify and name feelings. Lucy did very well in therapy managing both the physical and mental challenge of gaining weight. Over time, Lucy found different ways of managing her feelings such as talking to others, distracting herself and writing a journal. An essential part of our work is relapse management and ensuring that patients learn from their ‘blips’ instead of viewing them as failings. Key learning points I am flexible in tailoring treatment to patients’ needs and it is important to build a warm and trusting therapeutic relationship with patients. As part of my role I work closely with the multidisciplinary team and regularly present to other healthcare professionals about the complexities of treating people with eating disorders and related conditions and to ensure the patient's safety is always met. Here are some of my suggestions when treating children and adults with eating disorders: It is important to remember that whilst sometimes people with eating disorders can look very emaciated and frail, at other times they can be a normal weight and look well. It is therefore vital that health professionals do not solely use weight to diagnose an eating disorder. People with eating disorders often have a great deal of shame and so may not readily disclose their symptoms and instead may present with physical problems such as bowel problems. It is helpful if health professionals ask question such as "do you ever restrict your food" or "do you ever experience guilt after eating". Treatment for an eating disorder involves monitoring both the physical and psychological health of the patient. In order to ensure the physical safety of patients, tasks include monitoring electrolyte levels, assessing for risk and assessing patients nutritional and fluid levels. Eating disorders are complex mental illnesses in which patients use food in different ways to cope with difficult feelings. Health professionals should aim to build a positive therapeutic relationship with patients and should have a non-judgmental and accepting attitude towards them. *Name and details of patient have been changed to preserve confidentiality.
  14. Content Article
    The WHO Flagship Initiative “A Decade of Patient Safety 2020-2030” will: Respond to global movement and latest developments in the area of patient safety. Give due prominence to the concept “First do not harm” and patient safety area of work. Call for political commitment and immediate action at country level. Leverage resources (internal and external/financial and human). Ensure institutional mechanisms within the organisation for coordinated work across departments/divisions, especially with disease-specific programmes.
  15. Content Article
    Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!