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EventuntilJoin the National Academies of Sciences, Engineering, and Medicine’s Committee on Improving the Representation of Women and Underrepresented Minorities in Clinical Trials and Research as it discusses its newly released report Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups. This new report makes a compelling case for why we need more equitable participation in clinical trials and clinical research, including an economic analysis on the cost of health disparities in the United States. It provides a review of the barriers to having more equitable participation in clinical trials, describes strategies to overcome those barriers, and provides actionable recommendations to drive lasting change on this issue. The webinar will take place at 11:00-13:00 EST (16:00-18:00 GMT+1) Register for the webinar
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EventSensemaking, according to Karl Weick, is the process through which the complex and unpredictable world is given order, within which people can orient themselves, find purpose, and take effective action. Organisations unravel when sensemaking collapses, when they no longer supply meaning, and when they cling to interpretations that no longer work. As we enter the third year of a global COVID-19 pandemic, when nearly every aspect of our care and caring has faced disruption, how do we make sense of and take action to prevent the unraveling of organisations and sustainably reverse setbacks in patient and workforce safety? Join IHI’s annual Patient Safety Awareness Week webinar on March 16, 2022 from 11:00 AM to 11:50 AM ET with speakers Don Berwick, MD, MPP, and Jessica Berwick, MD, MPH, for a conversation on sensemaking during times of uncertainty, complexity, and chaos. This session will provide insights and perspective to foster sensemaking and action to reinforce patient and workforce safety in your organisation. Register
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EventuntilIt’s time to register for the 2022 World Patient Safety, Science & Technology Summit, hosted by Patient Safety Movement in the USA. The 2022 World Patient Safety, Science & Technology Summit (WPSSTS) is co-convened by the American Society of Anesthesiologists, the European Society of Anaesthesiology and Intensive Care and the International Society for Quality in Health Care, and will celebrate the Patient Safety Movement Foundation’s first 10 years of achievements. The 2022 WPSSTS will confront leading patient safety issues with actionable ideas and innovations to transform the continuum of care by dramatically improving patient safety and eliminating preventable patient harm and death. The WPSSTS brings together all stakeholders; we need everyone to step up and be part of the solution. We invite international hospital leaders, patient and family member advocates who have experienced harm, public policymakers and government officials, other non-profits working toward zero harm, healthcare technologists, engineers, and the future of healthcare – students and residents. All stakeholders are invited to actively and intimately plan solutions around the leading patient safety challenges that cause preventable patient deaths in hospitals and healthcare organizations worldwide. The WPSSTS will also feature keynote addresses from public figures, patient safety experts, and plenary sessions with healthcare luminaries, patient advocates, as well as announcements from organizations who have made their own commitments to reach the Patient Safety Movement Foundation’s vision of ZERO preventable harm and death across the globe by 2030. Event timings: 4 March 2022 8.00 am PST (4.00pm GMT) - 5 March 2022 5.00 pm PST (6 March 1.00am GMT) Buy tickets
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EventuntilThis webinar by the Institute for Safe Medication Practices in the US is aimed at: Pharmacists, physicians, nurses Medication safety officers Quality professionals Risk managers Leaders in pharmacy and nursing Pharmacy and anaesthesia technicians Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Numerous organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions against serious patient harm. Join the ISMP faculty as we focus particular attention on the potential safe use risks with heparin, concentrated electrolytes, and magnesium using the results from ISMP’s National Medication Safety Self Assessment® for High-Alert Medications. Faculty will review specific safety characteristics of each these important drug classes, describe self-assessment findings related to the use of these medications, and discuss the necessary practice strategies for harm prevention when using these high-alert medications. Register for the webinar 3.00pm Eastern Time (US and Canada), 8.00pm GMT
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EventuntilThis webinar by the Institute for Safe Medication Practices in the US is aimed at: Pharmacists, physicians, nurses Medication safety officers Quality professionals Risk managers Leaders in pharmacy and nursing Pharmacy and anaesthesia technicians Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Many organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions with high-alert drugs against serious patient harm. Join the ISMP faculty as we examine and define the importance of high alert medications as part of routine patient care and review the results of ISMP’s National Medication Safety Self Assessment® for High-Alert Medications with particular attention to vasopressors and insulin. Faculty will review specific safety characteristics of each these important drug classes, describe self assessment findings related to the use of these medications and discuss the necessary strategies for harm prevention when using these medications. Register for the webinar 3.00pm Eastern Time (US and Canada), 8.00pm GMT
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EventuntilThis free webinar from the Patient Safety Movement Foundation in the US is at 7.30am PST (3.30pm GMT). It takes a significant amount of work to implement a performance improvement initiative. However, typical approaches to sustainment are insufficient and lead to drift. Panellists will propose actionable recommendations to set up effective models for sustainment and systems to identify early indicators of drift. Moderator: Chrissie Nadzam Blackburn, MHA, Principal Advisor, Patient and Family Engagement, University Hospitals Health System, Cleveland, Ohio Panellists: Kristen Miller DrPH, MSPH, MSL, CPPS, Senior Scientific Director, MedStar Health National Center for Human Factors in Healthcare Joyce Alumno, President & CEO, HealthCore, President, Health Retirement & Tourism (HeaRT) Alliance of the Philippines Cristine Lacerna DNP, MPH, RN, CIC, CPH, Regional Director, Infection Prevention & Control and HEROES Program, Kaiser Permanente Sign up for the webinar
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EventuntilThis free webinar from the Patient Safety Movement Foundation in the US takes place at 8.30am PT (4.30pm GMT). Every single person has an essential role in the movement to achieve zero preventable harm and death in medical care. Globally, there are significant legislative efforts to improve the quality of care. Regulatory oversight is important, but actions from patients, family members, and members of the general public will be essential. Panellists will discuss actions each group can take to get involved in policy work. Moderator: Yvonne Gardner, Patient Advocate Panellists: Athar Ali Tajik, MD, MSc, MBA, Associate Director, MSD Beth Daley Ullem, MBA, Governance Expert and Advocate for Safety and Quality in Health Care Ty Moss, Founder, Nile’s Project MRSA, Nilesproject.com This webinar is approved for 1 CE credit. This CE satisfies the requirements for Board Certified Patient Advocates (BCPA). Register for this webinar
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Event
Leveraging PFACS for patient safety
Patient Safety Learning posted an event in Community Calendar
There are so many organisations that are doing great work related to Patient and Family Advisory Councils (PFACs) but an astounding number are not and this work is crucial to performance improvement. Meaningful and sustainable incorporation of the patient and family perspective is no longer optional for organisations that strive for high reliability. In this Patient Safety Movement webinar, the panelists will discuss the background of person-centred care, the history of its incorporation in the clinical setting, and the introduction of PFACs, current organisational barriers to implementing and sustaining PFACs, recommendations to nurture involvement in and meaningful use of PFACs, and strategies for participant onboarding into PFACs on the journey towards high reliability. Register -
EventThe physical and psychological safety and well-being of the healthcare workforce is essential for safe, high-quality care, yet the rates and nature of harm to the workforce, including physical and nonphysical forms of violence, is well documented and remains a challenge across all settings. Join IHI’s Annual Patient Safety Awareness Week Virtual Learning Hour to hear from leaders who are successfully applying principles of improvement, healthy work environments and learning systems to advance the will and capabilities of their organisations and communities to prevent and reduce workplace violence. This session, which includes shared experiences and conversations with diverse experts, is relevant to all audiences, and will provide practical and proven tools and approaches to harness action and solutions for executives, safety and quality leaders, and those who provide direct care. Register
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Content ArticleSome patients are unable to tolerate imaging procedures such as MRIs due to pain or anxiety. In these cases, a variety of medications are routinely used prior to imaging to allow the procedure to be carried out successfully. Varying levels of sedation before imaging can be appropriate given the need for patients to remain still during the imaging process, but the minimal amount of sedation should be used to mitigate unwanted side effects and reduce the risk of adverse events. This article examines two cases that highlight the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required and when monitoring is limited or inadequate.
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Content Article
Blog - When diabetes devices fail (8 December 2020)
Patient-Safety-Learning posted an article in Diabetes
In this article for US magazine Consumer Reports, Rachel Rabkin Peachman looks at the incidence and impact of malfunctions and design flaws in continuous blood glucose monitors, insulin pumps and other diabetes equipment. She highlights the case of Pamela, a 64-year-old with diabetes who died when her insulin pump unintentionally gave her a massive dose of insulin overnight. The numbers of adverse events and deaths reported to the FDA regarding diabetes devices is far greater than for any other type of medical device—between January 2019 and July 2020, almost 400 deaths and 66,000 injuries in the US were linked to commonly used diabetes devices. Reports are spread across the different device manufacturers and demonstrate the complexities of trying to determine the exact cause of each adverse event. The article also includes information on how people with diabetes can protect themselves from device malfunctions and errors. -
Content ArticleIt is important that patients understand the risks, benefits and alternatives associated with their treatment, but there is often a gap in patients' actual understanding of these issues. There is now substantial evidence showing that patient decision aids (PDAs) and shared decision making can bridge the gap between the theory and practice of informed consent. However, in spite of the evidence, PDAs are still rarely used in clinical settings. This article in the journal Maine Law Review looks at how the monetary incentive of a professional liability insurance premium reduction could encourage doctors in the USA to increase the use of PDAs.
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Content ArticleHealthcare is traditionally a hierarchical industry. This structure can foster a culture of division amongst staff that is sometimes made worse by significant differences in background and training. However, in order to make sure care is safe and of a high quality, healthcare teams must develop good teamwork and communication. This is only possible if every member of the team feels respected and is free to speak up when they think something is wrong. In this podcast, host David Feldman speaks to Michael Brodman, Professor and Chair Emeritus in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai in the US. They discuss how mutual respect is essential for any institution developing a culture of safety and how the problems presented by medical hierarchy can be overcome.
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Content ArticleFrail older adults are often at increased risk of patient safety incidents including rehospitalisation and overtreatment. In this study, published in BMC Geriatrics, researchers in the United States assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, they found that frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
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Content ArticleThe consultancy firm McKinsey & Company explored the effects of the Covid-19 pandemic on the nursing workforce in a global survey that included nurses from United States, the United Kingdom, Singapore, Japan, Brazil and France. The survey findings show a consistency around how nurses feel in their roles today, despite the different healthcare systems and delivery networks in each of the six countries. A substantial population of nurses are expressing a desire to leave direct patient care, with between 28% and 38% of nurse respondents in the United States, the United Kingdom, Singapore, Japan and France indicating that they were likely to leave their current role in direct patient care in the next year. This article explores in detail some of the reasons why nurses are choosing to leave direct patient care, and highlights approaches that might encourage retention, including positive leadership initiatives.
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Content ArticleIn a 2021 survey conducted by the Federal Aviation Administration (FAA), 35% of engineers working for the aviation company Boeing said they couldn’t raise safety concerns without interference. As a result, US aviation regulators are opening a new review of Boeing. This article in the Irish Times outlines the issues faced by Boeing staff and the reasons for the FAA's concerns.
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Content ArticleThis cross-sectional study in JAMA Network Open looked at patients in the USA with pneumonia who are admitted to hospitals with higher risk-standardised readmission rates. It aimed to assess whether these patients have higher rates of adverse events. The authors found that patients with pneumonia admitted to hospitals with high all-cause readmission rates were more likely to develop adverse events during hospitalisation. This strengthens the evidence that readmission rates reflect the quality of hospital care for pneumonia.
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Content ArticleThis retrospective cohort study in JAMA Internal Medicine aimed to determine whether there are systematic racial and ethnic biases in pulse oximetry among patients with Covid-19, and whether these biases result in patients not being accurately recognised as candidates for oxygen threshold–specific therapy. The authors found that patients from racial and ethnic minority groups with Covid-19 are often subject to overestimation of arterial oxygen saturation levels. This contributes to them not being recognised, or a delay in them being recognised, as eligible to receive Covid-19 therapies.
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Content ArticleIn this study, Ibrahim et al. evaluated the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. They found that in general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The authors suggest that the Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.
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Content ArticleThis white paper from the Institute for Healthcare Improvement (IHI) describes a framework to guide health care organisations in their efforts to provide safe, equitable, person-centred telemedicine. The framework includes six elements to consider: access, privacy, diagnostic accuracy, communication, psychological and emotional safety, and human factors and system design.
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Content ArticleThe delivery of safe and effective healthcare to paediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events. This review from Elkeshawi et al. will explore the medication-use system for hospitalised children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the paediatric medication-use system.
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Content ArticleEvery year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. The purpose of this study from Bauman et al. was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis.
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Content ArticleKrista Haugen is National Director of Patient Safety for US-based emergency and patient relocation services provider Global Medical Response. In this interview, she describes how her 25-year career as an emergency medicine nurse has influenced her approach to safety and patient care. She discusses her personal experience of being involved in an accident as an air-ambulance flight nurse, and how this caused her to look at safety and risk management from a systems perspective, focussing on building a just culture where safety is optimised through organisational reflection and learning.
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Content ArticleThe realities of our healthcare system are driving many health workers to burnout. They are at an increased risk for mental health challenges and choosing to leave the health workforce early. They work in distressing environments that strain their physical, emotional, and psychological well-being. This will make it harder for patients to get care when they need it. The USA is facing high levels of burnout among health care workers, which could lead to serious shortcomings in patient care, a new report from the U.S. Surgeon General has found.
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Content ArticleIn May 2022, the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety to urge health care leaders across the continuum of care to recommit to advancing patient and workforce safety. The NSC called for immediate action to address safety from a total systems approach, as presented in the National Action Plan to Advance Patient Safety, and implored leaders to adopt safety as a core value and foster collective action to uphold this value.
