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Showing results for tags 'Safety process'.
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Content ArticleUp to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. This study in the Journal of Patient Safety surveyed healthcare staff in the UK and Australia to identify safety practices perceived to be of low value. Staff who took part in a survey as part of the study frequently identified the following categories of practices as being low-value: paperwork, duplication and intentional rounding. Five cross-cutting themes (for example, 'covering ourselves') offered an underpinning rationale for why staff perceived these practices to be of low value. The authors conclude that in healthcare systems under strain, removing existing low-value practices should be a priority.
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Content Article
IHI: Quality Improvement essentials toolkit
Patient-Safety-Learning posted an article in Quality Improvement
This toolkit from the Institute for Healthcare Improvement (IHI) includes the tools and templates you need to launch a successful Quality Improvement (QI) project and manage performance improvement. The QI tools include: Cause and effect diagram: Also known as the Ishikawa or fishbone diagram, this tool helps you analyse the root causes contributing to an outcome. Failure modes and effects analysis: Also used in Lean management and Six Sigma, FMEA is a systematic, proactive method for identifying potential risks and their impact. Run charts: These charts help you monitor performance over time. PDSA worksheet: Plan-Do-Study-Act rapid-cycle testing helps teams assess whether a change leads to improvement using a methodical learning process. You will need to create an IHI account in order to download the toolkit. You can then download the complete toolkit with all ten tools, or download individual tools as you need them to guide your continuous improvement work. -
Content ArticleThis paper in the Journal of Patient Safety and Risk Management addresses the issue of untested products being used on the basis of 'equivalent' products having undergone regulatory testing. Manufacturers of competing products often use each other’s evidence, arguing that the published evidence is generally applicable even if the original tests and trials were performed on only one specific product. In this study, the authors looked at prophylactic dressings for pressure injury prevention to demonstrate how patient safety may be compromised if study conclusions are projected onto unstudied products.
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Content ArticleEarlier this month, 13 leaders shared thoughts in NEJM Catalyst on how healthcare organisations can get more strategic around patient safety and quality improvement - an area that has seen renewed attention after COVID-19-related setbacks. Several themes emerged across leaders' responses, namely the need for more proactive approaches to mitigate risk and intervene, rather than reviewing and assessing harms after they occur. University Hospitals nurses are leading the charge to do just that by embracing the adoption of artificial intelligence to make daily safety huddles more actionable. Read the full article, published by Becker's Hospital Review via the link below.
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Content ArticleEach year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs.
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Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
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Content ArticleThis long read by the Nuffield Trust looks at priority areas where further development and action could help improve the effectiveness of virtual wards. It outlines different models for virtual wards and looks at how to ensure effective system oversight. It also highlights the need to ensure the workforce is equipped to run virtual wards effectively and safely.
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Content ArticleThis document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
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Content ArticleIn this blog, Sonia Barnfield, Clinical Adviser for Maternity Investigations at the Healthcare Safety Investigation Branch (HSIB), looks at risk assessments during the maternity care pathway, following HSIB's recent national learning report on the same subject. Sonia outlines the need for change in the way that risk during pregnancy is assessed and managed, highlighting that there is currently no single national guidance and that HSIB identified repeated examples of insufficiently robust, continuous risk assessment in the maternity pathway. She lays out six key themes highlighted in HSIB's report and looks at how risk assessments should change to improve safety for pregnant women and their babies.
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Content Article
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Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.- Posted
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Content Article
Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety. -
Content ArticleMany people see their GP with symptoms that could either get better without treatment, or be a sign of serious illness; their diagnosis is uncertain. This article from the National Institute of Health and Care Research (NIHR) summarises recent research looking at how GPs and patients can work together to develop follow-up plans (a process known as safety-netting). The study highlights the importance of patients understanding: why they are receiving this advice what actions are required, and by whom.
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News Article
Health systems must tackle workplace, patient safety in tandem, IHI says
Patient Safety Learning posted a news article in News
A nationwide effort in the US to improve and coordinate patient safety measures will strive to make a connection between workplace and patient safety. The Institute for Healthcare Improvement (IHI) gave an update during its National Forum this week on the creation of a national patient safety plan intended to encourage better coordination of safety efforts. A key goal of the plan, expected to be released next year, was to emphasise the role of improving workforce safety. “In our view, too many systems have a separation between workforce safety and patient safety and yet we know the two are connected,” said Derek Feeley, President and CEO of IHI, in a briefing with reporters Monday before the start of the forum in Orlando, Florida. “Patient safety incidents are much less likely to occur when workers feel safe.” The steering committee developing the plan includes 27 organizations that range from patient advocates and professional societies to provider organizations and government representatives. The committee's plan hopes to target healthcare leaders and policymakers. Read full story Source: Fierce Healthcare, 10 December 2019 -
Content Article
At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. This week is World Immunisation Week so our Content and Engagement Manager, Lotty, has picked five resources full of practical advice about vaccination in a range of settings. -
Content ArticleThese resources by the Royal College of Nursing provide practical and clinical guidance for vaccine administration. All information supports guidance in The Green Book - Immunisation against infectious disease published by the UK Health Security Agency.
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Content ArticleThis blog provides an overview of a roundtable webinar organised by the European Biosafety Network (EBN), which focused on the need to prevent exposure to hazardous medicinal products (HMPs) and other substances. It was chaired by Gitta Vanpeborgh, Belgian Federal Deputy, and included attendees from across Europe.
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Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Roohil talks to us about the vital role of pharmacists in making sure medications help patients, rather than causing harm. She highlights the global threat of substandard and counterfeit medicines, the need to improve access to medicines and the importance of having pharmacists 'on the ground' to help patients understand how to take them. -
Content ArticleAlthough research has focused on safe disposal of sharps in healthcare settings, the issue of disposal by patients in the home setting has not often been addressed. This US study in the journal Diabetes Spectrum aimed to evaluate methods of disposal and patient demographic factors associated with correct disposal of diabetes-related sharps in the community.
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Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
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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 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 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 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 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.
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