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Found 81 results
  1. Content Article
    In this multi-centre randomised clinical vignette survey study, published in JAMA, diagnostic accuracy significantly increased by 4.4% when clinicians reviewed a patient clinical vignette with standard AI model predictions and model explanations compared with baseline accuracy. However, accuracy significantly decreased by 11.3% when clinicians were shown systematically biased AI model predictions and model explanations did not mitigate the negative effects of such predictions.
  2. Content Article
    Inpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
  3. Content Article
    In this article, published by the Institute for Government, Sam Freedman looks at the state of the NHS pre and post pandemic and how staffing, bed shortages, staff churn and other issues have had an impact.  Sam argues we are drifting further into crisis due to a stubborn refusal by the government to to engage properly with these issues.
  4. 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
  5. News Article
    A trust has admitted it ‘missed opportunities’ to identify that a locum doctor – who was arrested on hospital premises for two sexual offences — had already been cautioned for indecent exposure. Salman Siddiqi admitted two offences – attempting to engage in sexual communication with a child and attempting to arrange or facilitate a meeting with a child for sexual offences – last month. East Kent Hospitals University Foundation Trust, where he was working as a locum paediatric registrar at the time of the January offences, has now said there had been “missed opportunities” to identify his previous caution. Chief medical officer Rebecca Martin told HSJ the trust had taken steps to ensure that these missed opportunities could not happen again. She said in a statement: “This includes standardising DBS checks for temporary workers booked through an agency and escalating all DBS and General Medical Council checks that feature conditions, cautions or warnings.” Read full story (paywalled) Source: HSJ, 23 February 2023
  6. News Article
    Patients, or carers of patients, who carry Emerade 300 or 500 microgram adrenaline auto-injector pens should immediately contact their GP to obtain a prescription for, and be supplied with two auto-injectors of a different brand. Pharmacists and pharmacy teams can also help with obtaining new prescriptions and dispensing of new pens. Patients or carers should then return all Emerade 300 and 500 micrograms auto-injectors to their local pharmacy. Patients should only return their Emerade pens when they have received a replacement from their pharmacy which will be an alternative brand - either EpiPen or Jext. They should ensure they know how to use the replacement pen, as each brand of pen works differently. Patients should ask their doctor, pharmacist, or nurse for help with this. Instructions are included inside the pack, along with details of the manufacturer’s website that also provides information, including videos, on how to use a new EpiPen or Jext adrenaline pen. This precautionary recall is because some 300 microgram and 500 microgram Emerade auto-injector pens may rarely fail to activate if they are dropped, meaning a dose of adrenaline would not be delivered. Premature activation has also been detected in some of the 300 microgram and 500 microgram pens after they have been dropped, meaning that a dose of adrenaline is delivered too early. The activation failure and premature activation was detected during a design assessment conducted by the manufacturer and therefore means there is a potential for some 300 microgram and 500 microgram Emerade pens to fail during use after having been dropped. Read MHRA Press Release. 9 May 2023
  7. News Article
    Certain cough medicines sold behind the counter at pharmacies are being withdrawn over safety concerns. Health experts say there is a very rare chance that some people could experience an allergic reaction linked to an ingredient called pholcodine. People should check the packaging of any cough tablets or syrups they have at home to see if pholcodine is listed among the ingredients. If it is, talk to your pharmacist about taking a different medicine. Products containing pholcodine do not need a prescription, but cannot be bought without consultation with the pharmacist as they are kept behind the counter. The Medicines and Healthcare Products Regulatory Agency (MHRA) described removing the products from sale as a precautionary measure. Read full story Source: BBC News. 15 March 2023
  8. Content Article
    In this document, Charles Vincent and colleagues from Imperial College London, propose a new framework to help find the elusive answer to the question – how safe is care today?
  9. News Article
    No formal risk assessment was done on a man who beat a fellow care home resident to death, a review has found. Alexander Rawson attacked 93-year-old Eileen Dean with a metal walking stick at a care home in south-east London. Mrs Dean suffered catastrophic injuries to her head and body and died later in hospital. A review found Fieldside Care Home in Catford did not provide the specialist mental health services that Rawson - who had a history of violence - needed. Rawson, who had a history of mental health problems caused by alcoholism, was 62 when he was placed in the home a few days before Christmas 2020. He was put in the room next to Mrs Dean and, in the first week of 2021, he went into her room at night and attacked her. In a review published on Friday, the Lewisham Safeguarding Adults Board said Rawson had been moved into the home after being an inpatient at a psychiatric unit run by the South London and Maudsley NHS Foundation Trust. The care home was the only place that agreed to take him after his discharge from hospital. In the months before he was moved into the care home, Rawson was involved in at least 34 recorded incidents of violence or threats to patients and health staff, including a threat to kill. Before he was placed in the home, no attempts were made to find out whether Rawson had come into contact with the criminal justice system over his behaviour, the report found. It states that the care home had asked about the risks Rawson posed before they took him and had been reassured by a social worker and medical staff. Read full story Source: BBC News, 12 November 2022
  10. News Article
    An advanced nurse practitioner working in primary care services at Grimsby Hospital has called on the hospital senior leadership to ‘see for themselves how unsafe it is’. The nurse, who has penned a letter to bosses at Northern Lincolnshire and Goole NHS Foundation Trust says they are having “worst experience to date” in their career and fears somebody will die unnecessarily unless something is urgently done. “I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having ECGs down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately," says the nurse. Hospital bosses say they are taking the letter seriously and are investigating. Earlier this month it was revealed that some hospitals were being forced to deploy ‘corridor nurses’ in a bid to maintain patient safety while dealing with unprecedented demand. Dr Peter Reading, Chief Executive, said: “I can confirm we have received this email and that the hospital and North East Lincolnshire CCG are taking these concerns seriously. The person who raised the concerns with us has been contacted and informed that we are jointly investigating what they have told us. Read full story Source: Nursing Notes, 22 January 2020
  11. News Article
    All healthcare leaders, providers, patients and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?” “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.” Read full story Source: Hospital News, 3 December 2019
  12. Content Article
    In this systematic review published in BMJ Open, the authors analyse and compare the focus of 694 studies about safety culture in hospitals. The review identifies 11 key themes relating to safety culture across the studies. The authors suggest that the wide range of methods and tools available highlights a persistent lack of consensus in defining patient safety. They also highlight the value of qualitative and mixed method approaches in providing context and meaning to quantitative surveys that assess safety culture.
  13. Content Article
    This article, published in Surgical Patient Care, looks at the importance of developing surgical standards to mitigate risks and the subsequent development of the Surgical Safety Checklist to improve quality of care.
  14. Community Post
    Stephen Moss, Patient Safety Learning Trustee, suggests four practical tips to help staff keep patients safe: With your colleagues ask a random selection of patients if they have felt unsafe in the last 24 hours (you might want to select a different form of words). If the answer is yes, get under the skin of why they have felt unsafe, pool the knowledge and agree what action you are going to take, or what might need escalating to your line manager. Have a discussion with your colleagues about how you can support each other to uphold your values and professionalism when the going gets tough. Be clear about what help you might need from outside of the team, and follow it up. When looking at your Ward Assurance results, satisfy yourself that where it is possible, they are outcome orientated rather than just focusing on compliance with a process. Look for ways of 'humanising' the data i.e. use a language that identifies the impact on patients and, importantly, use language throughout that will be understood by patients and the public. Too many times I see Ward Assurance results on ward corridors, for the attention of patients and families, written in 'NHS speak' ! When measuring your compliance with the Duty of Candour, don't just look at the numbers! Find a way that also establishes how families feel about the 'quality' of the response, i.e. was it open, honest and transparent and did it give what they needed. How do you think these tips could benefit your patients or service users? Have you tried anything similar that you've found has really helped? Let us know your thoughts and please feedback if you try any of them.
  15. Community Post
    Interesting blog posted from @Sarahjane Jones on her research findings on staff safety: Do you work in mental health? We'd be interested to hear your own experiences? What challenges do you face?
  16. Community Post
    Hello I would be interested in hearing from anyone who has done any work on how we monitor patient deterioration overnight? I am currently working on am improvement project looking at patient surveillance of deterioration during night shifts. I have chosen this project as part of a Clinical Improvement Scholarship Program I am on. The program is combined with my day job as a Critical Care Outreach Sister as well as enabling me to develop my research and leadership skills alongside implementing improvements in clinical care. I am in the early stages of my work, however I have some literature and local research around deficiencies in how we monitor patients for deterioration overnight (as well as personal experiences as a CCOT nurse) which is why this topic is so important to me. I would be interested in hearing from anyone who has worked on anything similar, or can point me in the direction of anyone who maybe able to help. Thank you ?
  17. News Article
    More Care Quality Commission (CQC) inspections will take place from next month as pressures from COVID-19 continue to ease. Board papers published ahead of a meeting on Wednesday have revealed the CQC will return to inspecting and rating NHS trusts and independent healthcare services which are rated “inadequate” or “requires improvement”, alongside those where new risks have come to light. From April, the CQC also plans to carry out well-led inspections of NHS and private mental healthcare providers, and programmes of focused inspections on the safety of maternity departments and providers’ infection prevention processes. Focused inspections into emergency departments, which the CQC began in February, will continue. Inspections into GP services rated “requires improvement” and “inadequate” will also resume in April, focusing on safety, effectiveness and leadership. Finally, the papers said the watchdog would prioritise inspections of “high-risk” independent healthcare services, such as ambulances, cosmetic surgery or where closed cultures may exist. Read full story (paywalled) Source: HSJ, 24 March 2021
  18. News Article
    Consultants at a major tertiary centre have written to their chief executive, warning services are in ‘an extremely unsafe situation’ and calling for elective work to be diverted elsewhere. Surgeons and anaesthetists at the former Brighton and Sussex University Hospitals Trust — now part of University Hospitals Sussex Foundation Trust — said: “We are devastated to report that the care we aspire to is not being provided at UHS… we are forced to contemplate that it is not safe to be open as a trauma tertiary centre and we feel elective activity must be proactively diverted elsewhere.” The letter from BSUH’s anaesthetist and surgical consultant body is dated yesterday and was sent to UHSussex chief executive Dame Marianne Griffiths. The Royal Sussex County Hospital in Brighton — part of the trust — is the major trauma centre for the South East coast, from Chichester to parts of Kent. In the letter, seen by HSJ, the consultants claimed a shortage of theatre staff is leading to “clinical safety issues, gross operational inefficiencies and burnout within our remaining depleted staff groups”. Read full story (paywalled) Source: HSJ, 21 September 2021
  19. Content Article
    Patients are becoming increasingly involved in their health through technology such as health apps, and regulators are already struggling to control the market without constraining innovation. Clinical Safety must therefore adapt to the ever-changing world of health apps, if it is to fulfil its purpose and ensure that only the safest technologies are used by patients. In this blog, GP Tom Micklewright looks at some of the safety issues relating to health apps. He highlights that unlike with other new systems, health apps are rarely deployed in a controlled environment, which can cause problems when trying to apply clinical safety standards to them. He looks at five of the issues health apps can cause for safety teams: Intended scope and use Updated health apps Clinical safety, health apps and AI Different places, different features Monitoring clinical safety He then offers some potential solutions to these problems: Continuous assessment of health apps Centralise clinical safety, don’t localise Differentiated approach to clinical safety Aggregated incident reporting
  20. Content Article
    The Care Quality Commission (CQC) has introduced a new assessment framework that it will use to set out its view of quality and make judgements about health services. The framework is being introduced in phases, and the CQC has published it before it comes into use so that providers and other stakeholders can start to become familiar with it.
  21. Content Article
    As set out in Implementing Better Births: Continuity of Carer, continuity of carer means each woman: • Has consistency in the midwife or clinical team that provides hands on care for a woman and her baby throughout the three phases of her maternity journey: pregnancy, labour, and the postnatal period. • Has a named midwife who takes on responsibility for coordinating her care, and for ensuring all her needs and those of her baby are met, at the right time and in the right place, throughout the antenatal, intrapartum and postnatal periods. • Has “a midwife she knows at the birth”. • Is enabled to develop an ongoing relationship of trust with her midwife who cares for her over time.
  22. Content Article
    Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the ‘Helsinki Declaration on Patient Safety in Anaesthesiology’. Authors of this article, published in the European Journal of Anaesthesiology, hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.
  23. Content Article
    Despite the extensive attention and public commitments towards patient safety over the last two decades, levels of avoidable harm in healthcare around the world remain unacceptably high.  This book is free to download.
  24. Content Article
    In part 1 of my blog series, I said "This will be a series of short blogs that will cover the investigation process, answer questions about humans, and shine a light on the method of forensic investigations”. It is time to answer some questions
  25. Content Article
    There has been growing interest in the concept of safety cases for medical devices and health information technology, but questions remain about how safety cases can be developed and used meaningfully in the safety management of healthcare services and processes. This paper in Reliability Engineering & System Safety presents two examples of the development and use of safety cases at a service level in healthcare. These first practical experiences at the service level suggest that safety cases might be a useful tool to support service improvement and communication of safety in healthcare. Sujan et al. argue that safety cases might be helpful in supporting healthcare organisations with the adoption of proactive and rigorous safety management practices. However, it is also important to consider the different level of maturity of safety management and regulatory oversight in healthcare. Adaptations to the purpose and use of safety cases might be required, complemented by the provision of education to both practitioners and regulators.
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