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Found 786 results
  1. Content Article
    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.
  2. Content Article
    Following 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
  3. Content Article
    A 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.
  4. Content Article
    Inadequate 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
  5. Content Article
    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.
  6. Content Article
    Support 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.
  7. Content Article
    Healthcare 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.
  8. Content Article
    In 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.
  9. Content Article
    This 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.
  10. Content Article
    Using 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.
  11. Content Article
    In 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.
  12. Content Article
    The 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.
  13. Content Article
    Tools and resources to support the implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes.
  14. Content Article
    The 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.
  15. Content Article
    This 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.
  16. Content Article
    Mind 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.
  17. Content Article
    By 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.
  18. Content Article
    Dr 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.
  19. Content Article
    Shanté Turay-Thomas, a young woman who had a nut allergy, died of an acute anaphylaxis after eating hazelnuts on 18 Spetember 2018. In this report, senior coroner ME Hassell, highlights 20 'matters of concern' surrounding her death and calls for action to be taken for future deaths to be prevented.
  20. Content Article
    In this webinar, Dr Matt Inada-Kim, Consultant Acute Physician, presents his idea for a COVID-19 virtual ward. Matt talks about using tools and information to empower people to monitor themselves at home so that they know when to ask for help. Early recognition would improve the chances of survival, particularly where symptoms are less obvious but very serious with the potential for rapid deterioration, for example low oxygen levels. Matt uses a Remote Community Oximetry Care (RECOxCARE) model to frame his thinking.
  21. Content Article
    National Healthcare Safety Network (NHSN) subject matter experts provide updates on NHSN Analysis for 2020. Topics include: Changes to NHSN Dataset Generation (DSG) Adjusted Ranking Metric (ARM) & the Reliability-Adjusted Rankings Dashboard MDRO/CDI Module analysis updates, 2020 CLABSI analysis changes and introduction to SIR/SUR percentile distribution 2020 changes to the HAI-AR analysis reports Recently published NHSN surveillance reports Patient Safety Portal.
  22. Content Article
    Survive the wards with key information at your fingertips with this top rated app. It provides clear and succinct information to help UK Foundation doctors navigate some of the common clinical scenarios that they'll face on the wards.
  23. Content Article
    Recently there have been several incidents relating to allergens in hospital food reported. The consistent themes are lack of information and/or communication regarding food allergens present in the food and/or details of the patient’s known food allergy. This alert contains actions for providers to take.
  24. Content Article
    This report from the Parliamentary and Health Service Ombudsman, follows an invitation from the House of Commons Select Committee on Public Administration and Constitutional Affairs to explore the state of local complaints handling across the NHS and UK Government departments. It draws upon significant evidence taken from interviews carried out with a wide range of individuals and organisations who have first-hand experience of how the NHS and UK Government departments approach complaints. It also incorporates a review of a wide range of other research reports and over 300 of our own investigation reports documenting complainant experience. The report highlights three areas that need to change: There is no consistent way in which staff are expected to handle and resolve complaints. Staff do not get consistent access to training to support them in their complex role - complaint handling should be recognised as a professional skill. Public bodies too often see complaints negatively, not as a learning opportunity that can be used to improve their service.
  25. Content Article
    SLIPPS (Shared LearnIng from Practice to improve Patient Safety) is a 3 year Erasmus+ funded Patient Safety education project. The project will: draw on the real experiences of health/social care students in practice placements  utilise these experiences as the basis for a range of educational resources set up an international patient safety education network build an international open access virtual learning centre for international, multi-professional learning about patient safety Who is involved? 7 Higher Education institutions 5 Health and/or social care providers 5 European countries (UK, Finland, Spain, Italy and Norway)
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