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Found 794 results
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Content ArticlePresentation slides for topic 5 of the WHO Multi-professional Patient Safety Curriculum Guide. The learning objective from this topic is to understand the nature of error and how healthcare providers can learn from errors to improve patient safety.
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Content ArticleDue to the concerns around ambulance waiting times, the Healthcare Inspectorate Wales undertook a local review of the Welsh Ambulance Service Trust (WAST). The review explored how the risks to patients’ health, safety and wellbeing are managed whilst they are waiting for an ambulance. It assessed how patients are being managed by WAST’s three Clinical Contact Centres across Wales, from when a request for an ambulance is received to the point the ambulance arrives at the scene.
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Content Article
Patient safety: this is public health (2014)
Patient Safety Learning posted an article in Improving patient safety
Avoidable patient harm is a major public health concern. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalised in recent years, but specialist degree programmes in the field remain scarce. Healthcare organisations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement. Alan J Card discusses this further in his article in the Journal of Healthcare Risk Management. -
Content ArticleThe Safe Airway Society is the interprofessional airway society for Australia and New Zealand. Its members represent a wide range of health professions including Anaesthetists, Intensivists, Anaesthetic technicians, Emergency Physicians, Nurses, Rural Doctors, Surgeons and Paramedics. Through innovative collaboration, the Safe Airway Society aims to create resources, including consensus guidelines, promote education and training with an emphasis on human factors and team performance, and improve systems through research and standardisation of practice. The Safe Airway Society aims to build an environment where safe and effective airway management prevails across all professions and for all patients. This video explains more.
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Content Article
NHS: Extraordinary You
Patient Safety Learning posted an article in Workforce and resources
The 55,000 strong healthcare science workforce of the NHS and its related bodies, the Health Protection Agency and NHS Blood and Transplant, represent the largest group of scientists in a single employment sector in the UK. Their vast scientific knowledge and skill base stretches across some 45 scientific specialisms encompassing biology, genetics, physiology, physics and bioengineering. This knowledge lies at the foundation of the profession’s crucial and often unique role in: providing complex and specialist diagnostic services, analysis and clinical interpretation offering direct therapeutic service provision and support introducing technological and scientific advances into healthcare, and undertaking research, development and innovation providing performance and quality assurance, risk management and clinical safety design and management teaching, training and providing a specialist consultancy and clinical advice service to other clinicians with respect to all of the key functions above. The healthcare science workforce plays a critical part in delivering healthcare. More than 80% of all diagnoses are reached with a contribution from healthcare scientists. This document highlights some of these roles. -
Content ArticleOxSTaR (Oxford Simulation, Teaching and Research) is based at the John Radcliffe Hospital. The centre provides a state of the art environment where medical students and multidisciplinary healthcare professionals can use adult and paediatric high fidelity patient simulators to rehearse a wide variety of medical scenarios. The information in the link below is designed for healthcare professionals caring for patients with COVID-19 and has been developed in collaboration with Oxford University Hospitals Foundation Trust (OUH FT). Contents of the OxSTaR website such as text, graphics, images, videos and other material contained in the webinars and online lectures are for educational purposes and information only. The content is not intended to be a substitute for face-to-face training. Whilst great care has been taken to ensure the accuracy of the information provided on this website, please be advised that the contributors to the OxSTaR website are not responsible for the continued currency of the information, or any errors or omissions on the website that result from this rapidly evolving field.
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Content ArticleThe General Medical Council views resilience as a critical part of becoming a “professional”. All graduating medical students should have proved that they are resilient, and NHS job specifications expect it. They define resilience as “the capacity to recover quickly from difficulties.” It implies “toughness”, and an untiring effort to do more, to work faster, and to be better. The Medical Schools Council suggests screening for resilience in interviews, and now once admitted, medical students receive formal resilience training as part of the curriculum. The GMC’s “Professional Behaviour and Fitness to Practise” guidance underlines the importance of emotional resilience, which it defines as an “ability to adapt and be resourceful, mindful, and effective in complex, uncertain, or stressful situations.” This sounds impressive, but is resilience a trainable skill? Katherine Ripullone and Kate Womersley discuss this in this BMJ Opinion article.
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Content Article
Why learn from everyday work? (Steven Shorrock, 2020)
Sam posted an article in Improving patient safety
For a few reasons – especially regulatory requirements – the majority of effort when it comes to safety management concerns abnormal and unwanted outcomes, and the work and processes in the run up to these. We need to learn from incidents – for moral, regulatory and practical reasons. But incidents alone don’t tell us enough about the system as a whole. If we view incidents as the tip of the iceberg in terms of total hours of work or total outcomes, then what lies beneath? Steven Shorrock explores this in an article for HindSight. -
Content ArticleFollowing the publication of Donna Ockenden’s first report: Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust on 11 December 2020, the NHS has issued this latest update. Read previous letter update
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Content ArticleA blog published in Safety & Health on how you can leverage shift supervisors to ensure consistent safety knowledge among frontline workers. Although not specific to healthcare the examples can be applied to frontline healthcare workers.
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Content ArticleInadequate access to anaesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anaesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. In this report, Orser et al. summarises the challenges facing the provision of anaesthesia services in rural and remote regions
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Content Article
Quality improvement from the dining room table
Claire Cox posted an article in Blogs and vlogs
Since her last blog for the hub, Claire has moved away from clinical practice as a critical care outreach nurse and has entered the world of patient safety management in a new Trust. Coming out of a second lockdown, Claire reflects on how her experiences working in the NHS are very different from the first lockdown back in March 2020 and the difficulties she's facing doing quality improvement from home. -
Content ArticleSupport in clinical decision making is recognised as an educational development need for pharmacists. The health policy landscape puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. This is compounded by the COVID-19 pandemic, where healthcare environments have become more complex and challenging to navigate. In this environment, foundation pharmacists were unable to sit the GPhC registration assessment during the summer of 2020 but provisionally the registration assessment is due to take place online during the first quarter of 2021. In response to this, a suite of resources has been developed with collaboration between Chartered Institute of Ergonomics and Human Factors (CIEHF) and Health Education England (HEE). These resources are aimed in particular at early career pharmacists and their supervisors, especially those in foundation pharmacist positions managing the transition from education to the workplace environment.
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Content ArticleHealthcare professionals are experiencing unprecedented levels of occupational stress and burnout. Higher stress and burnout in health professionals is linked with the delivery of poorer quality, less safe patient care across healthcare settings. In order to understand how we can better support healthcare professionals in the workplace, this study from Johnson et al. evaluated a tailored resilience coaching intervention comprising a workshop and one-to-one coaching session addressing the intrinsic challenges of healthcare work in health professionals and students. The authors found preliminary evidence that the intervention was well received and effective, but further research using a randomised controlled design will be necessary to confirm this.
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Content ArticleIn this 30 minute video presentation, we hear from Dr Victoria Brazil, Professor of Emergency Medicine and Director of Simulation, Gold Coast Health Service. Dr Brazil talks through the benefits and complexities of simulation training using real life footage to illustrate key points. She suggests there are three ways healthcare can be improved using simulation: Simulation to explore Simulation to test Simulation to embed.
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Content ArticleThis accredited programme, approved by the Nursing and Midwifery Board of Ireland, is the first of its kind to be offered in Ireland. It aims to support learners in the development of an appropriate level of knowledge, skill and understanding to enable them to appropriately recognise and respond to domestic abuse. This course will be of particular interest to those individuals whose work may bring them into contact with victims of domestic abuse. Follow the link below to find out more.
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Content ArticleUsing a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Patel et al., following a near-miss and subsequent educational and training efforts at their institution, they conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. They found only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.
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Content ArticleIn medical schools, students seek robust and mandatory anti-racist training. Activists especially want to see their institutions recognise their own missteps, as well as the racism that has accompanied past medical achievements. Read Elizabeth Lawrence's article in the Washington Post.
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Content ArticleThe COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? Steven Shorrock asked a variety of practitioners to give a short answer – whatever came to mind. The themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisational hierarchy, problem solving and innovation, and – generally – change. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
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Content ArticleTools and resources to support the implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes.
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Content ArticleThe Health Service Executive (HSE) Dublin North East’s Patient Safety Tool Box Talks have been developed to assist with the delivery of key patient safety messages within the workplace. Patient Safety Tool Box Talks© are not a substitute for formal training but rather recognises the need to embed patient safety into the workplace and as such are a support to formal more detailed training programmes. This approach allows the delivery of consistent short customised patient safety messages to staff in a brief intervention as part of a team meeting or at a shift change. The talks are designed to take no more that 5-10 minutes to deliver are capable of being delivered by a non-specialist. If questions however arise beyond the scope of the talk these should be referred to a specialist for clarification. This Tool Box also contains Guidance on Delivering a Patient Safety Tool Box Talk© and a number of talks on a variety of safety topics.
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Content ArticleThis education and training guide is a resource for every Guardian’s self-development, whatever their experience in the role. Commissioned by the National Guardian’s Office and Health Education England in August 2017, the Guide was compiled by Louisa Hardman from the NHS Leadership Academy with invaluable contributions and guidance from an Advisory Group comprising Freedom to Speak Up Guardians and members of the National Guardian’s Office.
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Content ArticleMind the Gap is a Handbook to raise awareness of how symptoms and signs can present differently on darker skin as well as highlighting the different language that needs to be used in descriptors.The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. This is something which is not commonly practised in medical textbooks. It is important that healthcare professionals are aware of these differences so that care of certain groups is not compromised.
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Content ArticleBy understanding how physicians make clinical decisions, and examining how errors due to cognitive biases occur, cognitive bias awareness training and debiasing strategies may be developed to decrease diagnostic errors and patient harm. Studies of the impact of teaching critical thinking skills have mixed results but are limited by methodological problems. The authors of this paper, published in Academic Medicine, argue that explicit instruction in metacognition in medical education, including awareness of cognitive biases, has the potential to reduce diagnostic errors and thus improve patient safety.
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
