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Showing results for tags 'Retrospective'.
Found 13 results
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Content ArticlePatient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. The authors of this study, published in the American Journal of Surgery, hypothesised that an upgraded reporting system that included the ability to report positive behaviours would increase behavioural reports in the perioperative environment. After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. The authors believe that a robust reporting system has contributed to a culture of safety at their institution.
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Content ArticleAccess film footage of the recent 'Improving Patient Safety and Care' conference held on 13 February 2020 at the Royal Society of Medicine, London. All speakers and their presentations have been filmed. Past conferences can also be accessed. Govconnect's Open Access Library seeks to provide unrestricted online access to their events to ensure that key information is available to all health and social care professionals. All of their conferences are professionally filmed and broadcast so that content can be shared to a wider audience post event with the aim that as many people as possible can benefit from outcomes.
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Content ArticleHealthy eating and fitness mobile apps are designed to promote healthier living. However, for young people, body dissatisfaction is commonplace, and these types of apps can become a source of maladaptive eating and exercise behaviours. Furthermore, such apps are designed to promote continuous engagement, potentially fostering compulsive behaviours. This study, published by JMIR Publications, highlights the necessity for careful considerations around the design of apps that promote weight loss or body modification through fitness training, especially when they are used by young people who are vulnerable to the development of poor body image and maladaptive eating and exercise behaviours.
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Content ArticleThe objective of this paper, published by the BMJ, was to determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England, and to determine the association with the trust’s hospital-wide standardised mortality ratio assessed using the two commonly used methods - the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI).
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Content ArticleIn 2016, a national review by the Care Quality Commission (CQC) found that the NHS was missing opportunities to learn from patient deaths and that too many families were not being included or listened to when an investigation happened. A key recommendation from this review was that a national framework be developed, so that NHS Trusts have clarity on the actions required when someone dies in their care. The National Guidance on Learning from Deaths published by the National Quality Board (NQB) in March 2017, recommended all Trusts to publish a policy on how the organisation responds to and learns from deaths of patients who die under their management and care. The frameworks purpose is to initiate a standardised approach for reporting, investigating and learning from deaths in care. This policy sets out the Northamptonshire Healthcare NHS Foundation Trust's approach to meeting the National Guidance on Learning from Deaths (NQB 2017) and how they seek to learn from the care provided to patients who die. This policy makes clear the procedure for responding to and learning from patient deaths across the Trust including: How the process will respond to the death of an individual. Determine the categories and selection of deaths in scope for review. How the Trust engages with bereaved families and carers, including how the trust supports them and involves them in investigations. How staff affected by the deaths of patients will be supported by the Trust. How the Trust learns from deaths to improve and inform clinical practice. The themes and issues identified from review and investigation, including examples of good practice. How the findings, themes and issues from reviews and investigations will be used to inform and support quality improvement activity; any other actions taken, and progress in implementation. How the Trust collects specific information every quarter of those who die, outcomes of reviews of care and publish this information on a quarterly basis to public board meetings.
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Content ArticleThe National Guidance on Learning from Deaths was published by the National Quality Board in March 2017 to initiate a standardised approach, ensuring that learning from a review of the care provided to patients who die should be integral to a provider’s clinical governance and quality improvement work. To fulfil the standards and new reporting, this policy identifies and highlights: The Trust’s governance arrangements. The Trust’s processes on reporting, reviewing and investigation of deaths, including those deaths that are determined more likely than not to have resulted from problems in care. The Trust’s processes, to share and act upon any learning derived from these processes. This policy covers how Dorset Healthcare (DHC) University NHS Foundation Trust responds to patient deaths in care generally, not just those amounting to 'serious incidents', which will continue to be dealt with under the existing NHS Improvement’s 2015 'Serious Incident Framework'.
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Content ArticleThis action plan was produced by the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group following a treatment delay for a patient in intensive care.
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Content ArticlePatient-controlled personal health records facilitate coordinated management of chronic disease through improved communications among, and about, patients across professional and organisational boundaries. An NHS foundation trust hospital has used 'Patients Know Best' (PKB) to support self-management in patients with inflammatory bowel disease; this paper published in Digital Health presents a case study of usage.
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Content ArticleA ‘critical incident' is one that challenges your own assumptions or makes you think differently’. They provide the following helpful prompts to guide reflection on critical incidents. Here is a simple example of critical incident reflection produced by Birmingham City University. Key learning points What happened, where and when? Give a brief history of the incident. What is it that made the incident ‘critical’? What were your immediate thoughts and responses? What are your thoughts now? What has changed/developed your thinking? What have you learned about (your) practice from this? How might your practice change and develop as a result of this analysis and learning? Example+Critical+Incident+Reflection+-.pdf
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Content ArticleThe Royal College of Nursing (RCN) offers advice and templates on how to write a statement if your employer asks for one. What can I learn? Tips from the statement checking team Statements in different contexts Statement templates Where to find further information
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Content ArticleThe UK Government has announce a statutory public inquiry into the handling of the Covid-19 pandemic - the Hallett inquiry. However, in light of the wide-ranging impact of the pandemic, the inquiry faces a huge task to decide on the highest priority areas for investigation. This long read by Tim Gardner, Senior Policy Fellow at The Health Foundation, aims to examine what the parameters and structure of the UK Covid-19 Inquiry could be, and set out what it might realistically cover.
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Content ArticleThis longitudinal study in BMJ Quality & Safety aimed to examine the impact of nursing team size and composition on inpatient hospital mortality. The authors found that registered nurse staffing and seniority levels were associated with patient mortality. The lack of association for healthcare support workers and agency nurses indicates they are not effective substitutes for registered nurses who regularly work on the ward.
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Content ArticleThis study in BMJ Open examines the impacts of the four episodes of industrial action by English junior doctors in early 2016. The authors looked at the impact of the strikes on A&E visits, outpatient appointments and cancellations, admitted patients and all in-hospital mortality. The study concluded that industrial action by junior doctors during early 2016 had a significant impact on the healthcare provided by English hospitals. It also found that t here were regional variations in how these strikes affected providers, and that there was not a measurable increase in mortality on strike days.
