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Content ArticleThis study by Charles Vincent and colleagues, published in the Archives of Disease in Childhood, looked at the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety. Common problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment. This study has identified a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.
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- Paediatrics
- Medical device / equipment
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Content ArticleMedical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human factors, electronic health records, and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.
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- Quality improvement
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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 the knee-jerk blame and shame approach of old.
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- Near miss
- Skills gap
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Content ArticleThe South Thames Paediatric Network's aim is to enable children within the South Thames region (South London, Kent, Surrey and Sussex) to have access to high-quality specialist paediatric care in the place most suitable to their needs, at the appropriate time with a focus on surgery in children, critical care, long term ventilation and gastroenterology.
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- Treatment
- Paediatrics
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Content Article
Consent: Maternity
Claire Cox posted an article in Consent issues
This area of the Royal College of Obstetricians and Gynaecologists website provides guidance for healthcare professionals on obtaining consent from women within obstetrics and gynaecology services. It provides easy access to all procedure-specific consent documentation and gives advice on how best to support women’s decision-making about their care.- Posted
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Content Article
RCOG: Video briefing on human factors and situational awareness
Claire Cox posted an article in Maternity
Each baby counts is the Royal College of Obstetricians and Gynaecologist's national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. Watch the Each baby counts human factors video for information on how to address issues within your unit. -
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Connor Sparrowhawk: The tale of laughing boy (2015)
Claire Cox posted an article in Patient stories
Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.- Posted
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- Patient
- Patient death
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Content ArticleImperial College Hospital NHS Trust have launched their new falls safety improvement video to highlight the importance of safe mobility in hospital. Watch the video and join the conversation on Twitter.
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Put an end to cannula site infections!
Claire Cox posted an article in Other hospital-based clinical areas
This presentation written by Dr Gordon Caldwell, a Consultant Physician at Lorn and Islands Hospital, Oban, Argyll, Scotland, highlights the importance of surveillance and actions to be taken around prevention of infection of cannlula sites.- Posted
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- Patient
- Healthcare associated infection
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Content ArticleChances are, you’ve heard of an electronic health record, or EHR. Over the past 10 years, the vast majority of healthcare providers in the United States have implemented this technology to use in caring for their patients. EHRs have benefited us in many ways and hold tremendous promise. Given their widespread use, this technology now plays a significant role in the routine delivery of health care. Less understood outside the healthcare profession, however, is that EHRs have introduced new kinds of risks to the safety and quality of care, due to serious challenges with EHR usability, or the effectiveness and efficiency of using the technology. These well documented issues can lead to clinician burnout and errors that directly impact patient safety. In response, the MedStar Health National Center for Human Factors in Healthcare teamed up with the American Medical Association to show what they mean by sharing rare videos of real and simulated EHR usability challenges. They believe improving EHR design, development, and implementation to eliminate known patient safety risks and make them easier to use is the responsibility of healthcare providers, EHR vendors, policymakers, and patients, all working together.
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- Interoperability
- Digital health
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Content ArticleGrowing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult. In this observational study published in BMC Health Services Research, Haegdorens et al. analysed retrospectively the control group of a stepped wedge randomised controlled trial of 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. The records showed that, on average, three out of every thousand patients in the hospital died ‘unexpectedly’. A death is considered as unexpected when a patient suddenly dies during active treatment, with no care plan for the end of their life having been started. Their results are in accordance with previous research and confirm the association between higher nurse staffing levels and lower patient mortality. Furthermore, they also found that a higher proportion of bachelor’s degree nurses is related to a reduction in patient mortality. They proposed a new method to estimate optimal staffing levels using ward level data.
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Content ArticleThe number of doctors entering GP training is higher than ever, yet the overall number of full-time equivalent GPs keeps decreasing. This is one of the reasons that patients report increasing dissatisfaction with their ability to access general practice, although they are satisfied with their care once they are seen. In this blog for the King's Fund, Abigail Heller, a current GP trainee discusses the results of a recent survey of 840 trainees about their career intentions. Abigail and many of the respondents hope to pursue other clinical or non-clinical interests alongside general practice, with interests ranging from expedition medicine to medico-legal work to give them the opportunity to broaden their skills However, despite this desire for a more flexible career, the trainees have concerns about an unmanageable workload. The intensity of the working day remains the leading factor in not wishing to undertake full-time GP work.
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Content ArticleLearning from deaths of people in their care can help providers improve the quality of the care they provide to patients and their families, and identify where they could do more. A CQC review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England' found some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care. This video from the NHS Improvement national patient safety team is a guide for NHS trusts in England on developing and implementing learning from deaths policies within their organisations.
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- Post mortem
- Patient death
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Content Article
Making schools safer project
Claire Cox posted an article in Allergies
The Anaphylaxis Campaign is the only UK wide charity solely focused on supporting people at risk of severe allergic reactions.- Posted
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- Teacher / lecturer
- Training
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Content ArticlePhysicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts. In a study published in NEJM, Hu et al. carried out a cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. They found mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.
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- Fatigue / exhaustion
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Remove central lines supine - animation (2017)
Claire Cox posted an article in Implementation of improvements
The PatientSafe Network is a registered non for profit charity in Australia. It has been developed by front line healthcare staff and is for anyone who wants to improve patient safety. Their combined commitment is to improve patient safety through the transparent review of medical mistakes and the generation of transparent networked projects. Hundreds of patients die every year from avoidable central line related air emboli. This animation explains what air emboli are and how they may be avoided.- Posted
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- Hospital ward
- Accident and Emergency
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Health Education England: Human Factors Toolkit
Patient Safety Learning posted an article in Techniques
Health Education England have produced a toolkit on human factors in healthcare looking at example of training, simulation and speaking up. -
Content ArticleEast Kent Hospitals University NHS Foundation Trust is delighted to have been the recipients of the Patient Safety Learning Award 2019 for ‘Professionalising Patient Safety’ for our FallStop programme.
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Content ArticleThis is the fourth annual NHS workforce trends report published by the Health Foundation. In it, they analyse the changes in the size and composition of the NHS workforce in England in the context of long-term trends, policy priorities and future projected need.
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Content ArticleDesigned 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. There have been many advancements in medical education over the past 20 years, including how outcomes such as competencies are defined and used to guide teaching and learning. To support this positive change, the Association of American Medical Colleges (AAMC) has launched the New and Emerging Areas in Medicine series. This first report in the series focuses on quality improvement and patient safety competencies across the continuum of medical education. It presents a roadmap for curricular and professional development, performance assessment, and improvement of health care services and outcomes. The competencies can help educators design and deliver curricula and help learners develop professionally.
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Content ArticleA whole-system approach to nasogastric tubes led by nurses is improving patient safety at Lancashire Teaching Hospitals NHS Foundation Trust. This initiative won the patient safety improvement category in the 2018 Nursing Times Awards.
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- Medical device / equipment
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Content ArticleDr Helen Higham, Co-Director of the Patient Safety Academy, presented at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference on how we can effectively learn from serious incidents.
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- Investigation
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Royal Pharmaceutical Society: Antimicrobial stewardship portal
Claire Cox posted an article in Medicine management
The AMS Portal signposts resources and information to promote learning about antimicrobial stewardship (AMS) and antibiotic resistance. The Portal focuses on resources in the UK for pharmacists and pharmacy teams and within each section they have identified key resources to support pharmacy practice within the UK. They recognise, however, the need to signpost worldwide information and resources from outside the UK and these are also included as additional links. The aim is to continuously develop the AMS Portal to be accessible across all healthcare professions, encouraging a multidisciplinary and collaborative approach for improvement of antimicrobial use. The AMS Portal is intended as a dynamic ‘living’ resource which is constantly revised and updated.- Posted
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Content ArticleMaternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. To understand how to make maternity care safer, we must first understand what makes a maternity unit safe. Rather than focus on what goes wrong, this study from THIS.Institute focuses on what needs to go right by studying one high-performing maternity unit, located in Southmead Hospital in Bristol, UK.
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- Obstetrics and gynaecology/ Maternity
- Baby
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Content ArticleAntibiotic resistance is increasing worldwide due to overuse and misuse of antibiotics. Newborn baby Amala has a life-threatening infection called septicemia. Will her antibiotic treatment work? This video from the World Health Organization (WHO) explains what people can do to prevent the spread of antibiotic resistance.
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- Patient
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