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Found 121 results
  1. News Article
    The NHS in London is planning to “fundamentally shift the way we deliver health and care” in the wake of coronavirus, according to documents obtained by HSJ. The plans from NHS England and Improvement’s London office say leaders should: Plan for elective waiting times to be measured at integrated care system level, rather than trust level. Accept “a different kind of risk appetite than the one we are used to”. Expect decisions from the centre on the location of cancer, paediatric, renal, cardiac, and neurosurgical services. Plan for a permanent increase in critical care capacity. Transform to a “provider system able to be commissioned and funded on a population health basis”. Work towards “a radical shift away from hospital care”. Expect “governance and regulatory landscape implications” plus “streamlined decision-making”. The document, titled Journey to a New Health and Care System, says there are three “likely” phases, with the final new system in place “from November 2021”. The preceding two phases are “action programmes” over the next 12 to 15 months which will be about reconfiguring services to deal with “immediate covid, non-covid and elective need”, and “transition” when the move to new configurations is evaluated and “public consent” sought. Read full story Source: HSJ, 11 May 2020
  2. News Article
    St Bartholomew’s Hospital is to be the emergency electives centre for the London region as part of a major reorganisation to cope with the coronavirus outbreak. Senior sources told HSJ the London tertiary hospital, which is run by Barts Health Trust, will be a “clean” site providing emergency elective care as part of the capital’s covid-19 plan. It is understood the specialist Royal Brompton and Harefield Foundation Trust will also be taking some emergency cardiac patients. The news follows NHS England chief executive Sir Simon Stevens telling MPs on Tuesday that all systems were working out how best to optimise resources and some hospitals could be used to exclusively treat coronavirus patients in the coming months. Read full story (paywalled) Source: HSJ, 18 March 2020
  3. News Article
    Children’s cancer services in south London are to be reconfigured after a new review confirmed they represented an “inherent geographical risk to patient safety” — following HSJ revelations last year of how serious concerns had been “buried” by senior leaders. Sir Mike Richards’ independent review was commissioned after HSJ revealed a 2015 report linking fragmented London services to poor quality care had not been addressed, and clinicians were facing pressure to soften recommendations which would have required them to change. The review, published in conjunction with Thursday’s NHS England board meeting, recommended services at two sites should be redesigned as soon as possible to improve patient experience. Read full story (paywalled) Source: HSJ, 31 January 2020
  4. News Article
    UK women face widespread barriers to essential healthcare services. A survey of over 3,000 women in the UK shows many are struggling to access basic healthcare services including contraception, abortion care and menopause support . The Royal College of Obstetricians and Gynaecologists (RCOG) calls for one-stop women’s health clinics to provide healthcare needs for women in one location and at one time. The RCOG launched a landmark report “Better for Women” – to improve the health and wellbeing of girls and women across their life course – in The House of Commons. The RCOG is calling for better joined up services, as part of its 'Better for Women' report. It emphasises the need for national strategies to meet the needs of girls and women across their life course – from adolescence, to the middle years and later life. Read full report
  5. Content Article
    Preventable harm continues to occur to critically ill premature babies, despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. This article in the Journal for Healthcare Quality describes the introduction of a robust process improvement (RPI) program at a NICU in a US children's hospital. Leaders, staff, and parents were trained in RPI concepts and tools and given regular mentoring for their improvement initiatives, which focused on central line blood stream infections, very low birth weight infant nutrition and unplanned extubations. The authors conclude that implementing the RPI program resulted in significant and sustainable improvements to reduce harm in the NICU.
  6. Content Article
    Traditional efforts to detect adverse events have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10-20% of errors are ever reported and, of those, 90-95% cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients in order to quantify the degree and severity of harm, and to select and test changes to reduce harm. The IHI Global Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The Trigger Tool methodology includes a retrospective review of a random sample of patient records using “triggers” (or clues) to identify possible adverse events. Many hospitals have used this tool to identify adverse events, to measure the level of harm from each adverse event, and to identify areas for improvement in their organizations. It is important to note, however, that the IHI Global Trigger Tool is not meant to identify every single adverse event in a patient record. The recommended time limitation for review and the random selection of records are designed to produce a sampling approach that is sufficient for the design of safety work in the hospital.
  7. Content Article
    A strong focus on systems thinking and an encouragement to apply insights and expertise from human factors and ergonomics is paramount in how we plan, design and deliver healthcare safely. It’s central to the WHO Global Patient Safety Action Plan, the NHS Patient Safety Strategy, new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care and the National Patient Safety Syllabus.[1-3] It’s something Patient Safety Learning emphasise in our report A Blueprint for Action and is central to the organisational standards for patient safety that we’ve developed.[4] But how should we ‘do’ human factors? How do we apply the concepts, methodologies, tools and techniques in healthcare? What training do we need? How can patient safety managers embed human factors in all of their work, not just a reactive response to incidents of harm? These are some of the questions that patient safety managers have been asking and discussing in the recent Patient Safety Manager Network (PSMN) meetings. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance, providing information, peer support and safe space for discussion. You can find out more about the network here.
  8. Content Article
    This webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch  Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust
  9. Content Article
    In this video of a plenary session from the Guidelines International Network (GIN) Conference on 26 October 2021, James McCormack, Professor at the Faculty of Pharmaceutical Science, University of British Columbia, discusses issues with clinical practice guidelines and ways to overcome them.
  10. Content Article
    This paper reviews recent research literature reporting the effects of hospital design on patient safety.
  11. Content Article
    The direction of hospital design is taking a turn for the practical as a surge of institutions are updating their infrastructure and responding to demands for more outpatient facilities. Beyond aesthetics, hospitals are seeking architectural updates that improve safety, patient and staff satisfaction, and friendliness to the environment. Infection control, lighting conditions, noise level, air quality, and patient room design are just some of the factors that are considered. 
  12. Content Article
    In 2002 the UK Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the National Health Service (NHS). The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries in order to ascertain how the design of systems—equipment and other physical artefacts, working practices and information—could contribute to patient safety. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the healthcare system, including the users of that system, as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.
  13. Content Article
    WireSafe® is an innovative solution designed to prevent retained guidewires during central venous catheter (CVC) insertion. Retained guidewires are never events that require urgent removal if accidentally left in. They occur in about 1 in 300,000 procedures. We interviewed Maryanne, who developed the WireSafe®, on the innovation, the human factor considerations in designing it and the difficulties she faced getting a new product into the NHS.
  14. Content Article
    NHS healthcare providers are under constant pressure to make costs savings. There does not appear to be a way to account for the costs of errors, harms and inefficiencies in patient care. If we could account for these costs, then medium to long term plans could be created in order to reduce the costs lost in the consequences of errors, harm and delayed or low-quality care of patients. If we get ‘Care Correct First Time’ then these wasted costs will fall, which could well achieve the 5% savings target within 5 years. Dr Gordon Caldwell proposes a conceptual framework, which would account for these costs wasted on the consequences of error, harm or delays caused by opportunity costs in the inefficient way that frontline staff have to provide patient care.
  15. Content Article
    Many diagnostic mistakes are caused by reasoning errors, but lack of feedback makes it difficult for healthcare providers to make improvements in this area. This paper, published in BMJ Quality & Safety, describes the reason for and process of developing 'The Diagnosis Learning Cycle', a new model for feedback and improvement in diagnosis. The model is based on theory and knowledge from both outside and within the field of healthcare. It proposes a standardised feedback mechanism that includes concrete measures of factors such as reasoning and confidence.
  16. Content Article
    Presentation from Terry Wilcutt Chief, Safety and Mission Assurance, and Hal Bell Deputy Chief, Safety and Mission Assurance at NASA.
  17. Content Article
    This is the Chartered Institute of Ergonomics and Human Factors (CIEHF)'s second guide in response to issues concerning vaccination and COVID-19. It documents the key learnings gained from the human factors assessment of the vaccination system implemented by NHS Ayrshire & Arran (NHSAA). Its purpose is to share success, recommend design and safety improvements and offer a universal template for future safe and effective rollouts of time-critical vaccination programmes. The guidance will also be useful for the design and delivery of any public health vaccination programmes post COVID-19. Further reading CIEHF: COVID-19 human factor response
  18. Community Post
    I was just listening to a podcast interview between Dr Rangan Chatterjee and Matthew McConaughey (In the series 'Feel better, live more'). Matthew M. mentioned that he came from a highly resilient family. If someone fell over, his mother would tell them to get right back up straight away and carry on. He added that he thought that while this resilience was generally a good thing, there should be (what he called) a 'loophole' in it so that there was time to learn why they have fallen over to begin with. Was there a crack in the pavement that needed to be avoided? That way, it wouldn't happen again in the future. This made me think about whether there really was a conflict between resilience in organisations and the need to learn from failure. What do you think??
  19. Community Post
    See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
  20. Community Post
    Healthcare staff have had to adapt their way of working as a result of the pandemic, which has made pre-Covid guidance obsolete. Different Trusts are doing different things. What’s the solution?
  21. Content Article
    On Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar.
  22. Content Article
     The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries. 
  23. Content Article
    Central line–associated bloodstream infections (CLABSI) account for many harms suffered in healthcare and are associated with increased costs and disease burden. Central line rounds, like medical rounds, are a multidisciplinary bedside assessment strategy for all active central lines on a unit. The project team designed a HIPAA-protected, text-based process for assessing central lines for risk factors contributing to infection. Staff initiated a consultation via a virtual platform with an interdisciplinary team composed of oncology and infectious disease experts. The virtual discussion included recommendations for a line-related plan of care.
  24. News Article
    No single solution will stop the virus’s spread, but combining different layers of public measures and personal actions can make a big difference. It’s im­por­tant to un­der­stand that a vac­cine, on its own, won’t be enough to rapidly ex­tin­guish a pan­demic as per­ni­cious as Covid-19. The pan­demic can­not be stopped through just one in­ter­ven­tion, be­cause even vac­cines are im­per­fect. Once in­tro­duced into the hu­man pop­u­la­tion, viruses con­tinue to cir­cu­late among us for a long time. Fur­ther­more, it’s likely to be as long as a year be­fore a Covid-19 vac­cine is in wide-spread use, given in­evitable dif­fi­cul­ties with man­u­fac­tur­ing, dis­tri­b­u­tion and pub­lic ac­ceptance. Con­trol­ling Covid-19 will take a good deal more than a vac­cine. For at least an­other year, the world will have to rely on a mul­ti­pronged ap­proach, one that goes be­yond sim­plis­tic bro­mides and all-or-noth­ing re­sponses. In­di­vid­u­als, work-places and gov­ern­ments will need to con­sider a di­verse and some­times dis­rup­tive range of in­ter­ven­tions. It helps to think of these in terms of lay­ers of de­fence, with each layer pro­vid­ing a bar­rier that isn’t fully im­per­vi­ous, like slices of Swiss cheese in a stack. The ‘Swiss cheese model’ is a clas­sic way to con­cep­tu­al­ize deal­ing with a haz­ard that in­volves a mix­ture of hu­man, tech­no­log­i­cal and nat­ural el­e­ments. This article can be read in full on the WSJ website, but is paywalled. The illustration showing the swiss cheese pandemic model is hyperlinked to this hub Learn post.
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