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Found 81 results
  1. Content Article
    Providing patients with access to electronic health records (EHRs) may improve quality of care by providing patients with their personal health information and involving them as key stakeholders in the self-management of their health and disease. With the widespread use of these digital solutions, there is a growing need to evaluate their impact, in order to better understand their risks and benefits and to inform health policies that are both patient-centred and evidence-based. The objective of this paper, published by BMJ Quality & Safety, was to evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care: patient-centredness effectiveness efficiency timeliness equity safety.
  2. Content Article
    Telemedicine and telephone-triage may compromise patient safety, particularly if urgency is underestimated. This paper from Haimi et al., published in BMC Medical Informatics and Decision Making, aimed to explore the level of safety of a paediatric telemedicine service, with particular reference to the appropriateness of the medical diagnoses made by the online physicians and the reasonableness of their decisions.
  3. Content Article
    This is issue 30 of HindSight magazine (a publication about the safety of air traffic management). The theme of this Issue is ‘wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about. This issue coincides with the COVID-19 pandemic. The authors of the articles were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
  4. Content Article
    On 30 March, in response to the UK Government asking for business to provide thousands of ventilators to help tackle the Covid-19 pandemic, Patient Safety Learning published a blog with recommendations to ensure that ventilators are ‘safe in use’ (this means making sure they are as intuitive and easy to use for frontline staff as possible, reducing the potential for error).[1] In that blog, we outlined how we had brought together human factors/ergonomics and clinical experts to discuss the design, development and use of the equipment.
  5. Content Article
    In response to the ongoing coronavirus situation, the Government has put a call out for businesses who can provide support in the supply of ventilators and ventilator components for the healthcare system.[1] This has been met with a positive reaction from industry, with firms such as Dyson, Smiths Group and an industrial consortium (including Rolls-Royce, Airbus, McLaren, Thales, BAE Systems and Ford) responding to this.[2] Patient Safety Learning has been engaging with key leaders in Parliament, the healthcare system and international colleagues on matters in relation to patient safety during the pandemic. With forthcoming introduction of thousands of new ventilators, we have been collaborating with human factors/ergonomics experts and colleagues regarding the design and development of these.  It’s important that we have ventilators. It’s important that they’re safe. 
  6. News Article
    An advanced nurse practitioner working in primary care services at Grimsby Hospital has called on the hospital senior leadership to ‘see for themselves how unsafe it is’. The nurse, who has penned a letter to bosses at Northern Lincolnshire and Goole NHS Foundation Trust says they are having “worst experience to date” in their career and fears somebody will die unnecessarily unless something is urgently done. “I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having ECGs down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately," says the nurse. Hospital bosses say they are taking the letter seriously and are investigating. Earlier this month it was revealed that some hospitals were being forced to deploy ‘corridor nurses’ in a bid to maintain patient safety while dealing with unprecedented demand. Dr Peter Reading, Chief Executive, said: “I can confirm we have received this email and that the hospital and North East Lincolnshire CCG are taking these concerns seriously. The person who raised the concerns with us has been contacted and informed that we are jointly investigating what they have told us. Read full story Source: Nursing Notes, 22 January 2020
  7. Content Article
    Mark Chassin, M.D., president and CEO of The Joint Commission, sat on the Institute of Medicine committee that authored the landmark 1999 report, To Err is Human. In this podcast, he speaks to Nancy Foster, AHA vice president for quality and patient safety, about its impact on health care safety. He speaks about the need to reflect more on the type of culture that exists within zero harm organisations. He also argues that we need to ensure people feel free to speak up and ensure that everyone is accountable for consistently upholding safety processes and standards.
  8. Content Article
    Patient Safety and Healthcare Improvement at a Glance is an overview of healthcare quality written specifically for students and junior doctors and healthcare professionals. It bridges the gap between the practical and the theoretical to ensure the safety and well-being of patients. Featuring essential step-by-step guides to interpreting and managing risk, quality improvement within clinical specialties, and practice development, this highly visual textbook offers preparation for the increased emphasis on patient safety and quality-driven focus in today's healthcare environment. 
  9. Content Article
    Ageing populations have greater incidences of dementia. People with dementia present for emergency and, increasingly, elective surgery, but are poorly served by the lack of available guidance on their peri-operative management, particularly relating to pharmacological, medico-legal, environmental and attitudinal considerations. These guidelines seek to provide information for peri-operative care providers about dementia pathophysiology, specific difficulties anaesthetising patients with dementia, medication interactions, organisational and medico-legal factors, pre-, intra- and postoperative care considerations, training, sources of further information and care quality improvement tools.
  10. Content Article
    The safe management of a patient’s airway is one of the most challenging and complex tasks undertaken by a health professional - complications can result in devastating outcomes. How can anaesthetists improve safety, prevent complications, and be prepared to manage difficulties when they arise? How, in a crisis, can we ensure that human and technical resources are best utilised? This free course from Future Learn, endorsed by the Difficult Airway Society, will provide answers to these key questions and help you develop strategies to improve patient safety in your area of practice, discussing safe airway management in patient groups and multidisciplinary clinical settings.
  11. Content Article
    Medication errors may cause harm, including death, and increase use of health care services. This project aims to summarise the evidence on the burden of medication error, namely the number of errors occurring in the NHS in England, the costs of those errors to the NHS and the health losses due to medication error. This involves two systematic reviews, one on the incidence and prevalence of medication errors, and the other on the costs of health burden associated with errors. Additionally, economic modelling estimates the number of errors occurring in the NHS in England each year, their costs and health consequences.
  12. Content Article
    White paper on nurse staffing levels for patient safety and workforce safety was produced in 2019 by the Saudi Patient Safety Center and the International Council of Nurses. The paper brings together evidence from a wide range of sources, covering different countries and contexts, showing that having the right numbers of nurses, in the right place and at the right time, delivers quality and safety for the populations they serve, and will help to retain nurses.
  13. Content Article
    Major critical illness events, such as cardiopulmonary arrest and intensive care unit (ICU) transfer, disrupt workflow in a hospital ward. Other patients on the same ward may receive inadequate attention, especially if their care team is distracted by the emergency. Most studies have concentrated on patient-level variables associated with outcomes.This paper, published by JAMA, looks at the risk to ward occupants associated with patients on the same ward experiencing critical illness.
  14. Content Article
    Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. The authors of this study, published in The Lancet, reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes.
  15. Content Article
    Although not formally recognised in the Diagnostic and Statistical Manual, awareness about orthorexia is on the rise. The term ‘orthorexia’ was coined in 1998 and means an obsession with proper or ‘healthful’ eating. Although being aware of and concerned with the nutritional quality of the food you eat isn’t a problem in and of itself, people with orthorexia become so fixated on so-called ‘healthy eating’ that they actually damage their own well-being. Without formal diagnostic criteria, it’s difficult to get an estimate on precisely how many people have orthorexia, and whether it’s a stand-alone eating disorder, a type of existing eating disorder like anorexia, or a form of obsessive-compulsive disorder. Studies have shown that many individuals with orthorexia also have obsessive-compulsive disorder. This web page describes: The signs and symptoms of orthorexia Health implications Treatment
  16. Content Article
    Much policy focus has been afforded to the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), the authors of this paper, published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice. 
  17. Content Article
    The Patients Association welcomed our publication of ‘A Patient-Safe Future’, which provides a well-founded critique of the shortcomings in safety in our NHS. This is their full response.
  18. Content Article
    This evidence scan provides a brief overview of some of the tools available to measure safety culture and climate in healthcare. Safety culture refers to the way patient safety is thought about and implemented within an organisation and the structures and processes in place to support this. Safety climate is a subset of broader culture and refers to staff attitudes about patient safety within the organisation. Measuring safety culture or climate is important because the culture of an organisation and the attitudes of teams have been found to influence patient safety outcomes and these measures can be used to monitor change over time. It may be easier to measure safety climate than safety culture.
  19. Content Article
    This paper, published by the Scandinavian Journal, Acta Odontologica Scandinavica, assesses current patient safety incident (PSI) prevention measures and risk management practices among Finnish dentists. 
  20. Content Article
    This study, published in Risk Management and Healthcare Policy, analyses staffs perception of a safety culture and their knowledge of safety measures in the hospitals of Saudi Arabia.
  21. News Article
    All healthcare leaders, providers, patients and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?” “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.” Read full story Source: Hospital News, 3 December 2019
  22. Content Article
    AQuA are an NHS health and care quality improvement organisation at the forefront of transforming the safety and quality of healthcare. They are based in the North West and work with over 70 member organisations. They also undertake a number of consultancy based projects across the UK with both health and care organisations.
  23. Content Article
    For over three decades, patients, consultants and perioperative staff have been exposed to diathermy tissue smoke in all operating hospital theatres. This smoke is called plaque and, when inhaled, is the same as smoking cigarettes. Research shows that inhalation of smoke from one gram of cauterised tissue is equal to smoking six cigarettes. This smoke is also cancerous and can mutate to other organs of the body just like cigarettes. Read my personal view of the harmful effects of diathermy smoke published in the Journal of Perioperative Practice, and also  watch the short video kindly made for me by Knowlex UK.
  24. Content Article
    Published by the American Association of Medical Colleges (AAMC), Quality improvement and patient safety competencies across the learning continuum is designed for: faculty medical education curricula developers residents medical school administration Designated Institutional Officials (DIOs) clinical leaders at teaching hospitals  and others interested in undergraduate, graduate, and continuing medical education.
  25. Content Article
    What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did! 
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