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Found 949 results
  1. Content Article
    Amiri et al. analysed the role of nurse staffing in improving patient safety due to reducing surgical complications in member countries of Organization for Economic Co-operation and Development (OECD). They found that a higher proportion of nurses is associated with higher patient safety resulting from lower surgical complications and adverse clinical outcomes in OECD countries.
  2. Content Article
    This policy paper, published by the Department of Health and Social Care, sets out a UK vision to unleash the full potential of clinical research delivery to tackle health inequalities, bolster economic recovery and to improve the lives of people across the UK.
  3. Content Article
    Few empirical studies have directly examined the relationship between staff experiences of providing healthcare and patient experience. Present concerns over the care of older people in UK acute hospitals – and the reported attitudes of staff in such settings – highlight an important area of study. Maben et al. examine the links between staff experience of work and patient experience of care in a ‘Medicine for Older People’ (MfOP) service in England.
  4. Content Article
    This work from Nurek et al. aims to provide a rapid expert guide for post Covid-19 condition ('long covid') clinical services. In the absence of research into mechanisms, therapies and care pathways, yet faced with an urgent need, guidance based on “emerging experience” is required.
  5. Content Article
    Risk management has a number of accident causation models that have been used for a number of years. Dr Nancy Leveson has developed a new model of accidents using a systems approach. The new model is called Systems Theoretic Accident Modeling and Processes (STAMP). It incorporates three basic components: constraints, hierarchical levels of control, and process loops. In this model, accidents are examined in terms of why the controls that were in place did not prevent or detect the hazard(s) and why these controls were not adequate to enforcing the system safety constraints. Altabbakh et al. present STAMP accident analysis and its usefulness in evaluating system safety is compared to more traditional risk models. STAMP is applied to a case study in the oil and gas industry to demonstrate both practicality and validity of the model. The model successfully identified both direct and indirect violations against existing safety constraints that resulted in the accident at each level of the organisation.
  6. Content Article
    In this blog, Julie Rehmeyer discusses the impact that flawed research results had on patients with chronic fatigue syndrome.
  7. Content Article
    Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV). Early recognition and treatment has been shown to significantly improve babies' chances of making a full recovery. In the first of a series of blogs, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, explains why they are joint-funding new research into neonatal herpes, and how the findings could help save many lives. 
  8. Content Article
    In 2009, the World Health Organization (WHO) published the WHO Surgical Safety Checklist, and 3 years later, the Swiss Patient Safety Foundation adapted it for Switzerland. Several meta-analyses and systematic reviews showed ambiguous results on the effectiveness of surgical checklists. Most of them assume that the study checklists are almost identical, but in fact they are quite heterogeneous due to adaptations to local settings. In this study, Fridrich et al. aims to investigate the extent to which the checklists currently used in Switzerland differ and to discuss the consequences of local adaptations.
  9. Content Article
    This study from the COVIDSurg Collaborative and the GlobalSurg Collaborative found that preoperative covid vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritsation by modelling. The authors concluded that as the global roll out of the covid vaccination proceeds, patients needing elective surgery should be prioritised ahead of the general population.
  10. Content Article
    “Sunshine” policy, aimed at making financial ties between health professionals and industry publicly transparent, has gone global. Given that transparency is not the sole means of managing conflict of interest, and is unlikely to be effective on its own, it is important to understand why disclosure has emerged as a predominant public policy solution, and what the effects of this focus on transparency might be.
  11. Content Article
    We need less research, better research, and research done for the right reasons says D G Altman in this BMJ editorial.
  12. Content Article
    Guest blogger for PLOS Blogs 'Speaking of Medicine', Trish Greenhalgh, suggests its time for less research and more thinking.
  13. Content Article
    Telemetry monitoring of heart rates and rhythms was introduced in intensive care units in the 1960s, and since then it has expanded into patient rooms and units in noncritical care settings. It allows healthcare workers to watch the condition of many patients all at once and intervene quickly when their condition changes; however, if the technology is not used appropriately or the equipment malfunctions, relying on telemetry monitoring also risks patient harm. This study from Kukielka et al. looked at real-life cases of breakdowns in the processes and procedures regarding telemetry monitoring, such as user errors and miscommunication, and equipment failures, including broken transmitters and dead batteries. The lessons learned can help improve training and best practices to improve the safety of patients being monitored.
  14. Content Article
    Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these two methods might not overlap. This is a retrospective observational study from Anderson et al. of all hospitalisations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event identified by surgery faculty and residents for review by departmental M&M conference or administrative data. The authors analysed the degree to which these two processes captured PSI-defined events and reasons for exclusion by each process. The study found that surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.
  15. Content Article
    This international review from the Health Information and Quality Authority highlights the considerable variation in place across countries in relation to patient safety reporting. It is clear however, that the coordination and triangulation of patient safety intelligence for risk profiling is extremely important. Incidents need to be combined with other quality and patient safety sources of information.
  16. Content Article
    Preventable adverse events are an ongoing challenge in healthcare. International studies demonstrate that 3%–17% of admissions are associated with an adverse event (defined as an injury caused by healthcare management resulting in prolonged hospitalisation, disability on discharge or death). Approximately half of the adverse events are preventable. Little is known about adverse events in the Irish healthcare system.Therefore, recommendations on improving patient safety at a national level are being made on limited information. The aim of the Irish National Adverse Events Study (INAES) from Rafter et al. was to quantify the frequency and nature of adverse events in acute hospitals in the Republic of Ireland for the first time using an internationally recognised retrospective patient chart review methodology.
  17. Content Article
    This report from Long Covid Support summarises patient's experiences of Long Covid.
  18. Content Article
    Help to build an understanding of the diversity of body sizes by taking 10 of your own measurements and recording them online. By providing this data it will enable the Chartered Institute of Ergonomics and Human Factors (CIEHF) to build up a picture of the diversity of measurements within the population.
  19. Content Article
    In this blog, pain researcher, Richard Harrison, reflects on the presentation he recently made to the Royal College of Obstetricians and Gynaecologists, based on his research into pain during hysteroscopy. Follow the link below to read Richard's blog, or you can watch the RCOG presentation here. 
  20. Content Article
    Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. Alidina et al. explored the factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings. They found that performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum. The authors conclude that future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.
  21. Content Article
    A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. 
  22. Content Article
    Haugen et al. studied the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. They found that the National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.
  23. Content Article
    Despite the effectiveness of total knee arthroplasty (TKA; knee replacement surgery), patients often have lingering pain and dysfunction. Recent studies have raised concerns that preoperative mental health may negatively affect outcomes after TKA. The primary aim of this study from Melnic et al. investigates the relationship between patient-reported mental health and postoperative physical function following TKA. The study found that poor mental health should not be a contraindication for performing TKA. For patients with the lowest mental health scores, physicians should account for the possibility that physical function scores may deteriorate a year after surgery. Tighter follow-up guidelines, more frequent physical therapy visits, or treatment for mental health issues may be considered to counter such deterioration.
  24. Content Article
    The use of graded exercise therapy and cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome has attracted considerable controversy. This controversy relates not only to the disputed evidence for treatment efficacy but also to widespread reports from patients that graded exercise therapy, in particular, has caused them harm. The authors of this study surveyed the NHS–affiliated myalgic encephalomyelitis/chronic fatigue syndrome specialist clinics in England to assess how harms following treatment are detected and to examine how patients are warned about the potential for harms. The study found that clinics were highly inconsistent in their approaches to the issue of treatment-related harm. They placed little or no focus on the potential for treatment-related harm in their written information for patients and for staff. Furthermore, no clinic reported any cases of treatment-related harm, despite acknowledging that many patients dropped out of treatment. The authors recommend that clinics develop standardised protocols for anticipating, recording, and remedying harms, and that these protocols allow for therapies to be discontinued immediately whenever harm is identified.
  25. Content Article
    Ethics in medical science have been borne out of practices that occurred during the second world war, with the Nuremberg code being set up to prevent unethical experimentation on humans from being carried out.  This was further supported by the Declaration of Helsinki that strengthened the protection of participants within medical research by setting out the stipulations that informed consent should be obtained before research. It ensured that data should be kept confidential so that medical research that ultimately requires input from human participants would be able to be carried out with minimal risk to the individual.  Lara Carballo continues the 'Why investigate' blog series with a cautionary tale of why within Human Factors it is necessary to ensure that ethics are in place before embarking on research.
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