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Event
Continuing with the JCI Patient Safety Grand Rounds, the next session of the Grand Round is “Diagnostic Safety: From Error to Excellence in Patient Care. This strengthens the global efforts to improve diagnostic safety, building on the World Patient Safety Day theme of 2024. The upcoming session will feature a compelling conversation between internationally recognised leaders in the field. Dr. Hardeep Singh, Professor of Medicine at Baylor College of Medicine, will be joined by Dr. Laura Zwaan, Associate Professor at the Institute of Medical Education Research Rotterdam, Dr. Elizabeth Liz Mort, Vice President and Chief Medical Officer at The Joint Commission, and Dr. Neelam Dhingra, Vice President and Global Chief Patient Safety Officer at Joint Commission International JCI invites you to register now to be part of this important initiative and share this information with your networks and social media channels. The registration is complimentary. Register -
Content Article
Diagnostic uncertainty was relatively common in critically ill children admitted to the paediatric intensive care unit (PICU), an AHRQ-funded study in Critical Care Medicine concluded. Diagnostic uncertainty is the subjective perception of clinicians of their inability to provide an accurate explanation of a patient’s health problem. Researchers aimed to identify the frequency and factors associated with diagnostic uncertainty among critically ill children admitted to PICU. They reviewed the medical records of 882 patients admitted to one of four PICUs. Diagnostic uncertainty at admission was observed in 228 out of 882 patients. They also found a significant association between diagnostic uncertainty and diagnostic error. Researchers highlighted the need for more research and better strategies to address diagnostic uncertainty.- Posted
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A correct diagnosis is essential to understand a patient’s condition and determine the most beneficial management in partnership with that patient. Despite the simplicity of “a correct diagnosis,” terminology and methods differ when defining success and failure in diagnosis and diagnostic processes. Like a multi-faceted prism, different terms describe varying perspectives, insights, or challenges (Figure). This diversity reflects the inherent complexity of diagnosing, as well as the potential for different stakeholders to have different goals or perspectives for diagnostic improvement. This issue brief explores a variety of terms and perspectives that describe aspects of diagnostic success or consequences of diagnostic failure. It provides historical context, underlying assumptions, implications, limitations, and appropriate use of terms. This summary is directed to clinicians, researchers, and others select the most suitable word or phrase for their purposes and understand the terminology others use. There is no single best term for all circumstances or perspectives, rather many lenses, depending on the paradigm, orientation, and purpose, through which we can view diagnosis and diagnostic improvement.- Posted
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News Article
Cancer screening reporting errors led to mum's death
Patient Safety Learning posted a news article in News
The family of a mother who died from cervical cancer after twice being wrongly told she had negative results have been awarded undisclosed damages. The misreporting of Louise Gleadell's cervical screening results was admitted by University Hospitals of Leicester NHS Trust following her death aged 38 in March 2018. An internal review in 2017 found the samples, taken four years apart, were not good enough to produce reliable results but neither Ms Gleadell - a mum to three boys - nor her relatives were told about the "inadequate" samples while she was still alive. Her family have now been given an undisclosed payout, with the trust apologising for its mistakes that had "devastating consequences". Ms Gleadell, from Cossington in Leicestershire, was diagnosed with cervical cancer two years prior to her death. It was, by that stage, too late to have surgery. Two cervical screening tests, carried out in 2008 and 2012, were misreported to her as negative. It meant that over a four-year period, she had been given false reassurance about her health when she was developing cervical cancer, and the opportunity to treat pre-cancerous cells passed. Ms Gleadell's sisters, Laura and Clare Gleadell, say their grief has been compounded by knowing that their sister's death was avoidable. Laura, 43, said: "Her death was preventable and that for us is ultimately really hard. "It would not have developed into cancer had she been recalled in either 2008 or 2012. "If she had had treatment for cell abnormalities before it even developed into cancer, she would not have died." Read full story Source: BBC News, 6 April 2025 -
Content Article
Diagnosis is complex and iterative, therefore liable to error in accurately and timely identifying underlying health problems, and communicating these to patients. Up to 15% of diagnoses are estimated to be inaccurate, delayed or wrong. Diagnostic errors negatively impact patient outcomes and increase use of healthcare resources. This Health Working Paper from the Organisation for Economic Co-operation and Development (OECD) defines the scope of diagnostic error and illustrates the burden of diagnostic error in commonly diagnosed conditions. It also estimates the direct costs of diagnostic error and provides policy options to improve diagnostic safety. Key findings of this report included: Most people will experience at least one diagnostic error in their lifetime, sometimes resulting in severe patient harm, as it is estimated that 80% of all harm caused by delayed or misdiagnosis may be preventable. Tests, tools, diagnostic procedures and information systems are proliferating across healthcare settings to help patients and providers identify the exact nature of health problems. Despite these technological advances, health systems may still fail to identify and communicate health conditions correctly or in a timely way. Diagnostic errors negatively impact patient outcomes and increase the use of healthcare services, with associated increased costs. An estimated 2.6 million diagnostic errors occur in the United States each year, resulting in approximately 371,000 deaths and 424,000 permanent disabilities due to misdiagnosis. The report estimates that the direct consequences of diagnostic error on healthcare budgets account for 17.5% of total healthcare expenditure. In the United States this would amount to USD 870 billion each year. Deficits in health system design and governance, clinical environments, and individual provider competencies can drive poor diagnostic outcomes. Internationally, guidelines and standards on accurate and timely diagnosis for health conditions can be lacking and not systematically adopted. Even a relatively modest target of halving diagnostic error rates would not only reduce considerable patient suffering and distress but could free up as much as 8% of healthcare expenditure. Across OECD countries, this would equate to USD 676 billion a year. Setting out what policymakers can do to improve diagnostic safety, the paper suggests the following set of actions: Clinical directors should foster changes in medical work culture and clinical environment for peer feedback and multidisciplinary approach to patient diagnosis and review. Patient perspectives and preferences should be taken into account when making and reviewing a diagnosis. Medical specialty associations should set national or international standards and guidelines for ordering diagnostic testing and interpreting results, to minimise diagnostic error, harms and wasteful healthcare expenditure. National patient safety agencies should routinely collect, report and publish quality assurance indicators for error and safety for diagnosis of common conditions such as cancer screening, mental health disorders and sepsis. Health financing should report on regional or institutional variations or anomalies in expenditure and reimbursement for diagnosis rates or diagnostic testing, indicative or poor quality care. Healthcare insurers and providers should review policies for financing and reimbursement of diagnostic practices that do not conform to best international practice or guidelines in order to enable healthcare expenditure savings. Healthcare systems should leverage digital health architecture to prioritise development of integrated health information flows between patients and different healthcare providers, to ensure timely and systematic follow-up and communication of diagnosis. The use of language learning models and AI to analyse multiple clinical, biomedical and radiological patient data sources to achieve a more accurate and timely diagnosis requires clinical validation and ongoing refinement, but may be of use in conditions where clinical diagnosis is currently challenging or reliable diagnostic testing is lacking.- Posted
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News Article
Patients being harmed due to repeated mistakes in reading scans
Patient Safety Learning posted a news article in News
Repeated failings in the way scans are read are leading to delays in cancer diagnosis, unnecessary operations and avoidable deaths, England’s Health Ombudsman has warned. Since publishing a report four years ago which highlighted mistakes in the way digital images are read and used as a diagnostic tool, the Parliamentary and Health Service Ombudsman (PHSO) has upheld or partly upheld more than 40 cases in which similar failings were found. The most common issues are doctors failing to identify an abnormality, scans not being carried out or delayed, and results not being properly followed up. Examples of the impact of these failings include a 10-month delay in cancer being diagnosed which significantly harmed the person’s chance of survival. In another case, serious pelvic sepsis was not identified which led to an avoidable death, and in a separate case, a missed ankle fracture led to an avoidable operation. The Ombudsman is calling for greater learning when things have gone wrong to prevent the same mistake being made. Read full story Source: PHSO, 20 March 2025- Posted
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News Article
My mother was told her tumour was benign – five years later she died
Patient Safety Learning posted a news article in News
A woman whose mother died five years after a cancer misdiagnosis is calling for second opinions on oncology scans to be made mandatory. Louise Hickman, from Ipswich, was told in 2019 that a mass removed from her ovary was benign and that she would not require any further treatment. But in 2022, the “kind and caring mother” was diagnosed with ovarian cancer after she returned to Ipswich Hospital with worsening symptoms. Later tests confirmed her initial cyst found three years earlier had indeed been cancerous and in July 2024, she passed away, aged 47. Her daughter, Chloe, said she believes her mother’s outcome may have been different if she was correctly diagnosed in 2019, and is now campaigning to make it mandatory to have oncology scans checked by two experts. A report issued to Ms Hickman and her family by the East Suffolk and North Essex NHS Foundation Trust following her mum’s death accepted that the 2019 cyst should have been “adequately sampled and referred for an expert opinion” at the time. A clinical opinion included in the report also stated that the “missed diagnosis with delay in treatment caused significant harm”. She has launched a petition calling for the government to implement “Louise’s Law”, which would make it mandatory that benign oncology scans are sent for a second expert opinion. Read full story Source: The Independent, 19 March 2025- Posted
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This study in BMJ Quality and Safety aimed to retrospectively estimate the prevalence of harmful diagnostic errors in a randomly selected sample of 675 patients receiving general medical care in a US hospital between July 2019 and September 2021. The researchers developed and validated a structured case review process to enable clinicians to interrogate the electronic health record (EHR) to evaluate the diagnostic process for hospital patients, assess the likelihood of a diagnostic error and characterise the impact and severity of harm. Their findings estimate that harmful diagnostic errors may be occurring in as many as 1 in every 14 (7%) hospital patients. Read a easy-read press release about the research- Posted
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ECRI: Top 10 patient safety concerns 2025
Patient Safety Learning posted an article in International patient safety
ECRI's Top 10 Patient Safety Concerns 2025 highlights the most pressing safety challenges facing both patients and staff in the coming year. This report not only identifies these critical issues but also provides actionable recommendations to address and mitigate them. The list for 2025: Risks of dismissing patient, family, and caregiver concerns. Insufficient governance of Artificial Intelligence in healthcare The wide availability and viral spread of medical misinformation: Empowering patients through health literacy. Medical error and delay in care resulting from cybersecurity breaches. Unique healthcare challenges in caring for veterans. The growing threat of substandard and falsified drugs. Diagnostic error: The big three—cancers, major vascular events and infections. Persistence of healthcare-associated infections in long-term care facilities. Inadequate communication and coordination during discharge. Deteriorating community pharmacy working conditions contribute to medication errors and compromise patient and staff safety.- Posted
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News Article
A coroner has issued a warning about the role of physician associates in NHS hospitals after a woman with severe abdominal problems was wrongly diagnosed as having a nosebleed and died four days later. The family of Pamela Marking, 77, were under the mistaken impression she had been seen by a doctor when she was examined in an emergency department, rather than a physician associate (PA) with far less training. Surrey assistant coroner Karen Henderson has written to 12 health leaders or bodies including the UK health secretary, Wes Streeting, and NHS England expressing concerns about the “limited training” PAs have and the lack of public understanding about their roles. In a prevention of future deaths report, Henderson said Marking was taken to East Surrey hospital in Redhill on 16 February last year after she vomited blood-stained fluid and had a tender abdomen. The coroner said the PA who saw her had “a lack of understanding of the significance of abdominal pain” and sent her home the same day. Marking deteriorated, returning to the hospital two days later. She underwent surgery for complications arising from a femoral hernia but died on 20 February 2024. Henderson said the PA had acted independently in the diagnosis, treatment, management and discharge of Marking without independent oversight by a medical practitioner. The coroner said: “Given their limited training and in the absence of any national or local recognised hospital training for physician associates once appointed, this gives rise to a concern they are working outside of their capabilities.” Read full story Source: The Guardian, 27 February 2025 Related reading on the hub: Physician associates: What are the patient safety issues? An interview with Asif Qasim Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates Prevention of future deaths report: Susan Pollitt (8 August 2024)- Posted
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News Article
Woman's cancer diagnosis after wrong smear results
Patient Safety Learning posted a news article in News
A woman has expressed her anger after being diagnosed with cervical cancer more than two years after her smear test result was incorrectly recorded as normal. Amie Wood, 39, from Bewdley, Worcestershire, had a smear test that was reported as negative by the Royal Wolverhampton NHS Trust in October 2019. Although negative, it showed high-risk human papillomavirus (HPV), a virus that can lead to cancer, the HPV persisted and she was subsequently diagnosed with cervical cancer in January 2022. The NHS trust said it expressed its regret and apologised to Ms Wood. Following her diagnosis, Ms Wood had a hysterectomy. Ms Wood said she suffered increased anxiety about her health, and felt unable to return to her part-time second job as a personal trainer. "To be diagnosed with cervical cancer and undergo a hysterectomy was heartbreaking enough, but then I found out that my smear results had been misreported and it could have all been avoided," she said. Read full story Source: BBC News, 28 January 2025- Posted
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Content Article
In a dynamic healthcare environment, patient safety is crucial. A "Conscious Actions Reduce Errors" (C.A.R.E) approach is needed to safeguard safety and reduce medical errors. The dual process theory highlights two thinking modes: intuitive (fast, automatic) and analytical (slow, deliberate). Intuitive thinking, though quick and often effective, can lead to cognitive biases like anchoring and availability heuristics. A C.A.R.E approach incorporating tools like the TWED checklist (Threat, What if I'm wrong? What else?, Evidence, Dispositional factors) and Shisa Kanko (Japanese method of pointing and calling) can help to improve decision-making and action precision in clinical settings.- Posted
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Content Article
People with mental health conditions can face significant inequalities in their physical health, including a shorter life expectancy. This inequality impacts on the individual, their families, friends, communities and society in significant ways. They are also more likely to experience conditions like heart disease, stroke, and diabetes than those without mental health conditions. The reasons for this include social and financial challenges, the effects of psychiatric medications on physical health, and poorer care for physical health as a whole. Many studies show that people with mental health conditions are also more likely to experience problems during the diagnostic process, including misdiagnosis or late diagnosis of physical health problems. This study reviewed the evidence, which covers a range of mental and physical health conditions. It found consistent evidence that people with mental health conditions – from serious mental illnesses to more moderate or mild conditions – were at greater risk of exposure to diagnostic problems than people without mental health conditions, including delayed diagnosis, misdiagnosis, and non-diagnosis. Some of the studies included pointed towards issues within the healthcare system itself as underlying these inequalities.- Posted
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- Mental health
- Diagnostic error
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Content Article
Over 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures. This scoping review in the Journal of Patient Safety aimed to identify, summarise and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process. This is the first step in a larger study to co-design a patient-facing question prompt list for patients to use throughout the diagnostic process.- Posted
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- Patient engagement
- Communication
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Content Article
One in 20 outpatients in the United States experiences a diagnostic error each year, but there are no validated methods for collecting feedback from patients on diagnostic safety. This mixed-methods study in the Journal of Patient Safety examined patient experience surveys to determine whether patients’ free text comments indicated diagnostic breakdowns. The study aimed to evaluate associations between patient-perceived diagnostic breakdowns reported in free text comments and patients’ responses to structured survey questions. The authors concluded that patient feedback in routinely collected patient experience surveys is a valuable and actionable information source on diagnostic breakdowns in the ambulatory setting. The more easily monitored structured survey data provide a screening method to identify encounters that may have included a patient-perceived diagnostic breakdown and therefore require further examination.- Posted
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News Article
Eight women developed cancer after smear test misread, says report
Patient Safety Learning posted a news article in News
Eight women whose smear tests were misread by screeners went on to develop cancer, a major review into cervical screening at the Southern Health Trust has found. A further 11 women's slides were found to have pre-cancerous changes in the cells when they were reviewed and had to receive treatment. All these women had either pre-cancerous changes to their cervix or were diagnosed with another significant gynaecological condition when their smears were reviewed. The review was triggered when the diagnoses of three women were investigated as a Serious Adverse Incident. Two of the women, Lynsey Courtney and Erin Harbinson, have since died. More than 17,000 were approached to have their smear tests rechecked. The examination of cancer screening at the Southern Health Trust over 13 years found that many women were failed after some screeners underperformed and went unchecked by management for years. Stella McLoughlin from the campaign group Ladies with Letters described what had happened as unforgivable and called for a public inquiry. "This has been an absolute scandal from start to finish and was allowed to go on for 10 years," she added. "Smears being misread, people not being held to account, screeners not being managed properly - all of this is affecting real people." Read full story Source: BBC News, 11 December 2024- Posted
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- Cancer
- Tests / investigations
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News Article
Trust recalls 1,500 patients over potential misdiagnosis
Patient Safety Learning posted a news article in News
Hundreds of patients are being contacted over potentially incorrect results at a second NHS trust, as more laboratories report concerns over diabetes tests, HSJ understands. Bedfordshire Hospitals Foundation Trust was the first to report an issue over blood tests earlier this year, saying up to 11,000 patients may have received the wrong results – including a misdiagnosis of diabetes. But the Medicines and Healthcare Products Regulatory Agency has confirmed to HSJ that other laboratories across the country have reported concerns over the same device, which measure glucose control. The Hb1AC blood test is used to diagnose diabetes and prediabetes, as well as manage existing conditions. One affected trust is Maidstone and Tunbridge Wells FT, which said around 1,500 patients had been identified for a retest following a technical issue affecting results in July. A spokesman said the problem was escalated to the supplier as soon as possible, and that affected patients would be contacted by GPs. Read full story (paywalled) Source: HSJ, 27 November 2024- Posted
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Content Article
Chloe Bremner describes the pain she experiences from endometriosis as akin to having someone stuck inside you desperately trying to claw their way out. The 24-year-old has contended with pain from the chronic inflammatory condition since she was 14 but it was minimised, downplayed and misdiagnosed for nine years - with doctors mistaking her endometriosis for irritable bowel system and a tummy bug. Ms Bremner, who lives in Scotland, says she would routinely wake up in the middle of the night in excruciating pain. “There were countless nights and days spent in this state,” she tells The Independent. “And then throughout the years, that progressively got worse, and then it started to impact my nerves - down my legs and my hips.” “It's excruciating, and to the point where I was on morphine every day, and it didn't do anything,” Ms Bremner says. “I was still in absolute agony.” She explains that for years, nobody ever explained to her what endometriosis was, not even when she was diagnosed. “Endometriosis is a constant battle for validation and relief in a healthcare system that often fails its patients,” she says.- Posted
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- Womens health
- Health inequalities
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Content Article
Guidelines for blood pressure (BP) measurement recommend arm support on a desk with the midcuff positioned at heart level. Still, nonstandard positions are used in clinical practice (eg, with arm resting on the lap or unsupported on the side). This study looked at the effect of commonly used arm positions on blood pressure (BP) measurements compared to the standard, recommended position. It found that commonly used, nonstandard arm positions during BP measurements substantially overestimate BP, highlighting the need for standardised positioning.- Posted
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In 2012, I could not have imagined that the greatest threat my husband faced in the hospital was not the brain bleed we came in to treat — but one of the most common post-surgical complications, venous thromboembolism (VTE). This deadly blood clot was growing in my husband, and no one on his care team knew it. In a few days, it would travel to his lungs and kill him. Simple steps, like a risk assessment and monitoring, could have been taken. However, these proven preventative measures were not taken. Vonda Vaden Bates, a patient safety advocate, shares her story.- Posted
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Diagnostic safety: Royal College of Surgeons Edinburgh
Patient Safety Learning posted an article in Diagnosis
The Royal College of Surgeons of Edinburgh launched a series of blogs in recognition of the World Patient Safety Day (WPSD) 2024 theme of "Improving Diagnosis for Patient Safety". RCSEd World Patient Safety Day 2024 A Novel Facial Cellulitis Pathway: Improving the Time to Surgery for Facial Necrotising Fasciitis Improving Diagnosis for Safety in Dentistry Using Audit to Improve Outcomes for Patients with Upper Tract Urothelial Cancer Diagnostic Safety in Surgery WHO World Patient Safety Day 2024: Improving Diagnosis for Patient Safety The Importance of Teamwork for Surgical Diagnostic Safety in Outpatients Challenges in the Diagnosis of Twin Silent Killers: Aortic Aneurysm and Acute Aortic Dissection Improving Diagnostic Safety in Orthopaedics NCEPOD: Prioritising Diagnostic Safety for Better Health Outcomes Protecting our Precious Gift of Life World Patient Safety Day 2024 — A View from the Bridge Can My Stool be Tested for Bowel Cancer? Virtual Diagnostics The Potential of AI to Help Reduce Diagnostic Errors Non-Technical Skills for Surgeons (NOTSS). Vignette 3 of 3. Leadership in Surgery: A Case Study Non-Technical Skills for Surgeons (NOTSS). Vignette 2 of 3. Team Communication: The Key to Clarity and Precisio Non-Technical Skills for Surgeons (NOTSS). Vignette 1 of 3. Situation Awareness: Staying Ahead of Potential Issues Enhancing Diagnostic Safety in Surgery Through Non-Technical Skills Diagnosing Acute Aortic Dissection – The Patient Perspective- Posted
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Each year, diagnostic errors account for an estimated 16% of preventable harm in health care. Data suggest that most adults will experience at least one diagnostic error in their lifetime, which can result in prolonged ill health, increased health care costs, or even preventable death. The theme for this year’s World Patient Safety Day (17 September 2024) was focused on improving diagnosis for patient safety, using the slogan “Get it right, make it safe!” Patient advocate, Sue Sheridan talks about how being engaged in the diagnostic journey can ensure timely and correct diagnosis. "It completely fractured my soul." Sue shares her heartbreaking story about her son and her husband.- Posted
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Event
untilJoin Patients for Patient Safety US for 3 days of events centred around World Patient Safety Day (WPSD) 2024. PFPS US urges Americans impacted by missed or delayed diagnoses, bias or medical error to convene in Washington, DC for a Summit held September 15-17, 2024. The World Health Organization designates 17 September 17 as World Patient Safety Day, and WPSD 2024’s theme is Improving Diagnosis for Patient Safety. Find the full Summit event list at https://www.pfps.us/wpsd-2024, including: Sunday 15 September: Welcome reception and dinner at Johns Hopkins University Bloomberg Center to launch Project PIVOT, a national project identifying patient-prioritized outcomes and experiences and collaboration with patient organizations, US Department of Health and Human Services, Johns Hopkins University, Harvard Medical School and others. Monday 16 September: Participants visit Capitol Hill to urge Congressional leaders to ACT Now for patient safety, diagnostic safety and health equity solutions. ACT Now is PFPS US’s urgent request to leaders for Accountability, Coordination, and Transparency in health care. Later, PFPS US and AcademyHealth co-host a film premiere of The Pitch: The Next Generation of Patient Safety. From immersive tech to AI machine learning, innovations are finally making waves in medicine with the goal of safer health care. The Pitch gives a unique look at the American health care system’s ongoing challenge to embrace the next generation of patient safety. Tuesday 17 September, World Patient Safety Day: The March for Patient Safety begins at Freedom Plaza and ends with a ceremony on the US Capitol Lawn, where marchers will remember those whose lives have been lost to or impacted by preventable harm. Afterwards, PFPS US and the Bloomberg Center co-host a World Patient Safety Day Leadership Briefing with government leaders. Further information and to sign up- Posted
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Community Post
World Patient Safety Day 2024: many calls to action
JULES STORR posted a topic in Leadership for patient safety
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Tuesday 17 September 2024. Another year, another World Patient Safety Day. This years theme “Improving diagnosis for patient safety”. Last years' report by the World Health Organization https://www.who.int/publications/i/item/9789240095458 first introduced the theme and talked about the need for multifaceted interventions rooted in systems thinking, human factors and active engagement of patients, their families, health workers and healthcare leaders. Improving healthcare processes that will result in improvements to diagnosis requires action at every level of the health system and looking at this years' calls to action https://www.who.int/campaigns/world-patient-safety-day/world-patient-safety-day-2024/calls-to-action leadership is both implied and front and centre. Focusing on these calls to action, here is what the campaign suggests individuals/entities across a range of settings can do to help improve patient safety in diagnosis. Patients, families and caregivers are - be informed, involved, and proactive in your diagnosis Be actively engaged in the diagnostic process and with your health care team: share accurate and comprehensive information about your symptoms and medical history; make sure you understand the diagnostic process, your illness’ or symptoms expected progression, and next steps; check your information is up-to-date, and keep track of your symptoms, medical visits, tests and treatments. Share your questions and concerns: don’t be afraid to ask questions; speak up, ask about alternative options or seek a second opinion if you need to; share your experiences and contribute to making diagnosis safer for others. Health workers providing clinical care - make diagnostic excellence integral to your daily practice Keep focussed on the person at the centre of the diagnosis: listen to your patient, ask them about their concerns and tailor the interventions to their needs; take a careful and thorough history and physical examination of your patient; talk openly and empathetically with your patients, and encourage them to ask questions. Leverage available technology, tools, and tests to reach a diagnosis. Be a good team player and contribute to a safe and collaborative professional environment, where information is shared in a timely manner. Keep learning: participate in regular training and seek feedback from your peers and patients; contribute a culture of continuous improvement by sharing best practices, and information about errors and near misses with peers. Healthcare facility leaders and managers - implement safer systems to improve diagnosis, support your clinical teams and empower patients Empower the health workforce through policy, culture and practice: ensure adequate staffing, resources and regular capacity development; make sure quality and well-maintained tests and technologies are available; implement and monitor the use of diagnostic safety guidelines, protocols and practices to ensure errors are minimised; promote a culture of continuous learning and safety, and take action to address problem areas; establish a conducive, collaborative and safe work environment free from distractions. Continually seek feedback from patients and their families and reserve space for advocates on advisory bodies. Celebrate diagnostic excellence within your teams. Policy-makers and programme managers - champion diagnostic excellence in health policy Prioritise patient safety in policy, legislation and regulation: ensure that appropriate guidelines and protocols to support diagnostic processes exist at a national level and are implemented; provide the necessary budget, staff, training and access to tools and technologies for national health systems. Establish national collaboration mechanisms to sustainably engage stakeholders. Promote accountability through monitoring and evaluation mechanisms, and ensure health leadership prioritize transparency. Set up national knowledge-sharing systems and encourage continuous learning. Invest in research into diagnostic errors, patient harm and the development of diagnostic tools and technologies. Patient organizations and civil society - advocate for quality and safe diagnosis Champion diagnostic safety in health policy and practice: work with patients, policy-makers and health care leaders to build health systems that deliver correct and timely diagnosis; facilitate patient advocacy and support their role in promoting and improving diagnostic safety; work with policy-makers, academics, health care leaders, health workers and patients to help identify areas for improvement. Contribute to the development of educational and training resources for health workers and patients. Diagnostics and medical devices’ regulators, manufacturers, innovators and managers - innovate for smart solutions and diagnostic excellence Drive research and development for diagnostic tools and technologies. Ensure diagnostic solutions meet the highest standards of safety, quality, and reliability. Create user-friendly products and instructions and provide regular training for health workers and patients. Collaborate with patients, health workers and health care leaders to build products tailored to the needs of end-users. I'm a strong believer in the power of campaigns. They act as a tool to raise awareness on important matters and trigger action that will result in change and improvement and there is evidence that they can have an impact on patient outcome. Before the end of 2024 there will be many more awareness days and weeks all of which will use campaigning to get their messages across in the noisy world of health care. It will be interesting to see the evaluation of WPSD 2024. More on this in due course.- Posted
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Have you or someone you know been affected by a: delayed diagnosis incorrect diagnosis missed diagnosis? Errors can happen at every stage of the diagnostic process and can happen in all healthcare settings. In some circumstances the impact is life-changing. If you have insights to share around diagnostic error and the impact on patient safety, please comment below (sign up first here, for free). Or you can contact us directly at [email protected]. This post has been published as part of our World Patient Safety Day activity, with the 2024 theme of Improving diagnosis for patient safety. #WPSD, #WorldPatientSafetyDay, World Patient Safety Day 2024- Posted
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