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Found 13 results
  1. Content Article
    This national learning report (NLR) draws on findings from investigation reports completed by the Healthcare Safety Investigation Branch (HSIB) that considered the risks associated with patient identification. ‘Positive patient identification’ is correctly identifying a patient to ensure that the right person receives their intended care. To support patient identification in England, the patient’s NHS number should be used alongside other identifiers, such as their name, date of birth and address. Patient misidentification is where a patient is identified as someone else. This may mean that a patient does not receive the care meant for them, or that they receive the care meant for someone else. Patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. Despite the time that has passed, patient misidentification remains a persistent risk to patient safety that can result in significant harm. The aim of this NLR was to combine and analyse HSIB’s previous investigations and relevant international research literature, with the goal of informing national learning and influencing national actions to help reduce the risk of patient misidentification.
  2. Content Article
    This study in JAMA Psychiatry aimed to assess whether multivariate machine learning approaches can identify the neural signature of major depressive disorder in individual patients. The study was conducted as a case-control neuroimaging study that included 1801 patients with depression and healthy controls. The results showed that the best machine learning algorithm only achieved a diagnostic classification accuracy of 62% across major neuroimaging modalities. The authors concluded that although multivariate neuroimaging markers increase predictive power compared with univariate analyses, no depression biomarker could be uncovered that is able to identify individual patients.
  3. News Article
    Hundreds of organisations, including drug companies, private healthcare providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals. “High risk” breaches were revealed to have occurred at healthcare groups, pharmaceutical giants and educational institutions including Virgin Care, GlaxoSmithKline (GSK) and Imperial College London, during audits by NHS Digital, according to an investigation by the BMJ. This means these organisations were handling information outside the remit agreed in data contracts and may be failing to protect confidentiality, the journal said. In one instance, local NHS commissioners allowed sensitive, identifiable patient data to be released to Virgin Care without permission from NHS Digital. When auditors tried to get access to Virgin Care to check their compliance, they were denied access for several weeks and the company refused to delete the patient data, the BMJ reported. Records about mental health, including children and young people, those with learning disabilities, diagnostic imaging and other confidential patient data was being processed outside the scope of objectives agreed with NHS Digital, at an address that had not been agreed, and without a data sharing contract. A spokesperson for Virgin Care said it had “robust data protection in place”. “It is outrageous that private companies and university research teams are failing to comply,” said Kingsley Manning, the former chair of NHS Digital. “How is it that these organisations can be so lax with data?” Read full story Source: The Guardian, 11 May 2022
  4. Content Article
    This paper from Parsons et al. looked at how patients prefer to be addressed by their healthcare providers and assessed their knowledge of their attending medical team's identity. The researchers conducted a survey which included 300 inpatients, with findings showing over 99% of patients prefer informal address and 57% of patients unable to correctly name a single member of their attending medical team.
  5. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  6. Content Article
    The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital.
  7. Content Article
    The Healthcare Safety Investigation Branch's (HSIB's) local investigation pilot aimed to evaluate the organisation's ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning. It differs from HSIB's usual national investigations, which make safety recommendations to organisations that can make changes at a national level across the NHS in England. The pilot published three investigations focused on cross boundary and multi-agency safety events: Investigation 1: incorrect patient identification Investigation 2: incorrect patient details on handover Investigation 3: transfer of a patient with a stroke to emergency care The report summarises how the HSIB local investigation pilot was undertaken, and shares findings applicable to local healthcare systems including healthcare organisations and Integrated Care Systems.
  8. Content Article
    Reliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
  9. Content Article
    The aim of this qualitative service evaluation, published by Nursing in Critical Care, was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable. This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re‐escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams.
  10. Content Article
    The 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.
  11. Content Article
    Frimley Health NHS Foundation Trust have devised a patient leaflet to help patients play a role in their safety while at the hospital. 
  12. Content Article
    In this blog, Jayne Flood, Falls Prevention Practitioner at East Kent Hospitals NHS Foundation Trust, describes how her team introduced ‘yellow kits’* to assist patients at high risk of falls in A&E, and evaluated their impact. *Developed in partnership with Medline Industries Ltd.
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