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Showing results for tags 'Safety process'.
Found 208 results
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EventuntilInfection is a leading cause of childhood deaths, but many of these deaths are avoidable with timely treatment. The national Before Arrival at Hospital Project (BeArH), funded by the National Institute for Health Research (NIHR), explored what happens to children under five years of age with serious infections before they are admitted to hospital. The aim of this research was to explore what helps children get help quickly and what might slow this process down, so that lessons could be learned for the care of this group of children in the future. This forum will be led by Professor Sarah Neill, Dr Damian Roland and Natasha Bayes. To join the research forum and hear the findings of this important research project from the study team, email lpt.research@nhs.net for the Microsoft Teams link.
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Content ArticleThis study in the British Journal of Clinical Pharmacology involved searching electronic health records to uncover how many people in prisons have been affected by a potential problem related to their prescribed medication. Researchers looked at published studies and worked with prison healthcare staff to develop and implement prescribing safety indicators (PSIs) for prison electronic health records. The authors found that PSIs provide a significant opportunity to measure and improve medication safety for people in prisons and that more patients were affected by some PSIs than others. The study also investigated how the searches could be used more widely in prisons and interviewed 20 prison health care staff to explore this topic. The staff they spoke to said that it was important to have people who can take on leadership of the searches and to promote team-based responses to them.
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Content ArticleThis qualitative study in Patient Education and Counseling collected narrative accounts from doctors, nurses and patients to determine whether their perspectives can add new content to quality of care frameworks. The three groups raised the following 'quality of care' aspects: Successful communication among staff, with patients and care companions Staff motivation Frequency of knowledge errors Prioritisation of patient-preferred outcomes Institutional emphasis on building “quality cultures” Organisational implementation of fluid system procedures The study found that respondents primarily referred to care processes, rather than structure or outcomes, in their descriptions of 'quality of care'. 'Hippocratic pride' (in response to care successes) and 'rapid reactivity' (in response to (near) failures) emerged as two new outcome indicators of high-quality care.
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Content ArticleThis article in Studies in Health Technology and Informatics looks at how patient-peer support can be a valuable resource for patients in the context of hospital safety. Hospitalised patients often lack access to safety systems and face difficulties in having a proactive role in their safety. The authors of this study conducted semi-structured interviews with 30 patients and caregivers at a paediatric and an adult hospital. They highlight the potential benefits of incorporating patient-peer support into patient-facing technologies and argue that helping patients access such support can help them engage with and improve the quality and safety of their hospital care.
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Content ArticleThis new book by Professor Harold Thimbleby of Swansea University tells stories of widespread problems with digital healthcare and explores how they can be overcome. "The stories and their resolutions will empower patients, clinical staff and digital developers to help transform digital healthcare to make it safer and more effective."
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Content ArticleSerious Hazards of Transfusion (SHOT) introduced a new Human Factors Investigation Tool (HFIT) in 2021. The tool can be used to investigate and capture systemic as well as individual factors where there has been an error. This case study uses the updated Human Factors Investigation Tool and Systems Engineering Initiative for Patient Safety (SEIPS) framework to work through an ABO incompatible red cell transfusion case reported to SHOT.
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Content ArticleThis article in Patient Safety looks at a new approach to identifying and monitoring patients with sepsis developed by a team of nurses at WellSpan Health in the USA. The Central Alert Team (CAT) works remotely, looking for indicators of sepsis in patient charts and vital signs. They relay information and treatment advice to nurses working at the bedside and take an adaptive approach to find the best ways of working. This focused approach means the CAT nurses are able to quickly identify patients who are deteriorating and ensure treatment is administered at the right time.
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Content ArticleDouble-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors. The authors found that: most nurses complied with mandated double-checking, but the process was rarely independent when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious. They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.
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Content ArticleDeveloped by David Havard, this poster shows a number of ways in which reasonable adjustments can easily be made for patients with a learning disability.
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Content ArticleThis report produced by the American Medical Association details action steps that can be taken by an organisation before, during and after a crisis to reduce psychosocial trauma among healthcare workers.
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Content ArticleThis paper in BMJ Quality & Safety brings together the two trends of increasing focus on reducing diagnostic error, and involving patients in their care. The authors analyse strategies for patient involvement: in reducing diagnostic errors in an individual’s own care. in improving the healthcare delivery system’s diagnostic safety. in contributing to research and policy development on diagnosis-related issues.
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Content ArticleThere is an overall dearth of information on implementation and compliance with patient safety standards in developing countries. In recognition of this, the World Bank Group’s Health in Africa Initiative, WHO and the PharmAccess Foundation came together with the ministries of health to conduct an assessment of patient safety at Kenyan health facilities. The study is the first nationwide assessment of patient safety levels based on documented processes and levels of risk, and is meant to serve as a baseline against which future interventions can be measured.
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Content ArticleIn this reflection, published in the BMJ's Post Graduate Medical Journal, Dr John Launer talks about an exercise to help people to become better supervisors, to use peer supervision as a safe space for people to develop better interactional skills generally – and particularly to cultivate their curiosity.
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Content ArticleDr Helen Simpson, Lisa Shepherd and Dr Steve Kell summarise the guidance and implementation of the steroid emergency card in primary care.
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Content ArticleAs part of the NHS family, NHS Supply Chain is prioritising patient and user safety as a core part of their approach to supplying clinical products to the NHS by raising standards and effective partnership working. Jonathan Devereux, Head of Safety and Innovation, heads up a small team focused on driving proactive action on safety complaints, building an innovation pathway and ensuring they drive safety into the agenda for future procurement. In this article for the National Health Executive he explains the work the clinical and product assurance team are doing.
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Content ArticleIn my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed.
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Content ArticleThe Essentials of Safe Care is a practical package of evidence-based guidance and support that enables Scotland’s health and social care system to deliver safe care.
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Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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News Article
NHS staff fear speaking out over crisis in English hospitals
Patient Safety Learning posted a news article in News
Nine months ago, Boris Johnson praised staff at St Thomas’ for saving his life. Now, a senior intensive care nurse at the London hospital has warned that patient care is being compromised because of staff shortages and a failure to plan for the second Covid wave. Dave Carr, an intensive care charge nurse, is one of many NHS workers desperate for the public to know what is going on inside their hospitals at a time when misinformation and scepticism about the virus are rife. “The public needs to be aware of what’s happening. This is worse than the first wave; we have more patients than we had in the first wave and these patients are as sick as they were in the first wave. Obviously, we’ve got additional treatments that we can use now, but patients are still dying, and they will die,” said Carr. As a representative for the union Unite, Carr feels emboldened to speak out. But across the NHS, many more staff claim they have been threatened with disciplinary action or even dismissal if they put their head above the parapet. In Devon, one nurse working on a Covid ward said safety standards had slipped at her hospital, but she feared for her job if she was identified by name. “The infection control restrictions are more relaxed. Before, we had to use a separate entrance but now we don’t, and some doctors feel they don’t have to obey the infection control protocols and are still unsure of how to properly remove the PPE,” she said. Read full story Source: The Guardian, 1 January 2021 -
Content ArticleThis paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
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Content Article
Implementation Approaches for Closing the Loop (2019)
Patient-Safety-Learning posted an article in Diagnostic error
Delayed, missed and incorrect diagnoses are common causes of errors that result in patient harm and inappropriate care. However, some diagnostic errors may be avoided by effectively using health information technology. These resources from the Emergency Care Research Institute provide information on how to implement IT processes to close the loop on diagnostic evaluations. -
Content ArticleDr Gordon Caldwell shares his hospital ward round sheet attached which follows a standard process, including quality and safety checking. Feel free to adapt.
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Content ArticleRyan's Rule is a three step process to support patients of any age, their families and carers, to raise concerns if a patient’s health condition is getting worse or not improving as well as expected. Ryan’s Rule applies to all patients admitted to any Queensland Health public hospital including the emergency department, and in some Hospital in the Home (HITH) services.Ryan’s Rule has been developed in response to the tragic death of Ryan Saunders, who died in 2007 from an undiagnosed Streptococcal infection, which led to Toxic Shock Syndrome. When Ryan’s parents were worried he was getting worse they did not feel their concerns were acted on in time. In light of his death, the Department of Health made a commitment to introduce a patient, family, carer escalation process (Ryan’s Rule), to minimise the possibility of a similar event occurring.Follow the link below to the Queensland Government website to find out more about Ryan's Rule and how it works in practice.
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Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
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Content ArticleThis systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
