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Found 48 results
  1. Content Article
    The trend towards health system mergers and acquisitions in the US is likely to continue in 2024. Mergers can be beneficial. However, post-merger integration can take years to complete and can have an adverse effect on patient safety, care culture and care quality. Some healthcare researchers have dubbed mergers as 'life events' for health systems.[1] Health system mergers and acquisition projects need to include a special task force to assess the risks to patient safety management practices. 
  2. Content Article
    ECRI's Top 10 Health Technology Hazards for 2024 list identifies the potential sources of danger ECRI believe warrant the greatest attention this year and offers practical recommendations for reducing risks. Since its creation in 2008, this list has supported hospitals, health systems, ambulatory surgery centres and manufacturers in addressing risks that can impact patients and staff. 
  3. News Article
    Most trusts are thought to have missed the deadline to launch a new national incident reporting system that has already been beset with difficulties and delays. Seventy per cent of more than 150 patient safety managers polled during a patient safety management network meeting last month said their organisation would not meet the 30 September go-live deadline for the new learning from patient safety events (LFPSE) incident reporting system. LFPSE is a key part of NHS England’s safety strategy and replaces the historic national reporting and learning system. The new reporting system was originally due to be implemented by March 2023. However, this deadline was pushed back six months, after widespread concerns were raised by patient safety managers, which included software quality, incident reporting form complexity and lack of time for testing. Managers have pinned the latest launch delay on RLDatix – the vendor which provides incident software for more than 60% of trusts – claiming it could not provide the functionality needed and its releases were “not fit for purpose”. Read full story (paywalled) Source: HSJ, 16 October 2023
  4. News Article
    New artificial intelligence software being rolled-out in NHS hospitals will be able to predict daily A&E admissions weeks in advance. The software, which launched in 100 hospitals across England on Monday, analyses data, including Covid infections rates, 111 calls and traffic to predict the number of patients that will seek emergency care. It also takes into consideration public holidays, such as New Year’s Eve, when A&E is more likely to be busy. The AI software is being rolled after trials showed an “impressive” ability to forecast admissions up to three weeks in advance. The NHS believes it will help tackle the record waiting list and allow hospitals to more easily manage their patient and bed capacity, prepare for busier days and staff up when needed. Nine trusts were given the software to use during the pandemic which notified them of expected spikes in cases, staff levels and numbers of beds and equipment necessary. However, hospitals receiving the new equipment have also been warned uncertainties within the data mean the system should be used as a “starting point to consider an operational response, not as a definite signal for action.” Read full story Source: The Independent, 28 March 2022
  5. News Article
    A serious revelation may derail the Cerner Millenium rollout. A draft report by the Department of Veterans Affairs (VA) Office of Inspector General (OIG) states that a flaw in Cerner’s software caused the system to lose 11,000 orders for specialty care, lab work, and other services – without alerting healthcare providers the orders (also known as referrals) had been lost. This created ‘cases of harm’ to at least 150 veterans in care. The VA patient safety team classified dozens of cases of “moderate harm” and one case of “major harm.” The major harm cited affected a homeless veteran, aged in his 60s, who was identified as at risk for suicide and had seen a psychiatrist at Mann-Grandstaff in December 2020, after the implementation. After prescribing medication to treat depression, the psychiatrist ordered a follow-up appointment one month later. That order disappeared in the electronic health record and was not scheduled. The consequences were that the veteran, weeks after the unscheduled appointment date, called the Veterans Crisis Line. He was going to kill himself with a razor. Fortunately, he was found in time by local first responders, taken to a non-VA mental health unit, and hospitalized. The draft report implies that the ‘unknown queue’ problem has not been fixed and continues to put veterans at risk in the VA system. There may be as many as 60 other safety problems. Other incidents cited in the draft report include one of “catastrophic harm” and another case the VA told the OIG may be reclassified as catastrophic. Catastrophic harm is defined by the VA as “death or permanent loss of function.” Read full story Source: Telehealth and Telecare Aware, 21 June 2022
  6. News Article
    A new report has highlighted how point-of-care scanning in the NHS can help to improve patient safety, saving the NHS millions of pounds. Six NHS hospital trusts which implemented regular point-of-care scanning have ensured complete traceability of healthcare items to help improve patient safety while securing millions of pounds of savings and releasing thousands of hours of clinical time, a new report reveals. ‘A scan of the benefits: the Scan4Safety evidence report’ details the results at hospital trusts that took part in a national two-year programme, known as Scan4Safety, to investigate the benefits of point-of-care barcode scanning in the NHS. Full article here We wonder if @Richard Price might like to post more about what the impact of Scan4safety has been at University Hospitals Plymouth. Perhaps here: https://www.pslhub.org/learn/commissioning-service-provision-and-innovation-in-health-and-care/digital-health-and-care-service-provision/other-health-and-care-software/
  7. News Article
    The NHS has launched a patient safety inquiry after a private contractor failed to send more than 28,000 pieces of confidential medical correspondence to GPs. NHS bosses are trying to find out if any patients have been harmed after 28,563 letters detailing discussions at outpatient appointments were not sent because of a mistake by Cerner, an IT company. The letters should have been sent by doctors at Barnet and Chase Farm hospitals in north London to GPs after consultations with 22,144 patients between June last year and last month. However, a “clinical harm review” is under way after it was found they had not been dispatched. The incident has prompted concern among GPs and patient representatives. “Patients who have attended these two hospitals will now be very worried about whether their care might have been compromised by this IT bungle”, said Rachel Power, the chief executive of the Patients Association. Read full story Source: The Guardian, 18 February 2020
  8. News Article
    A new app has been piloted in North East London to help district nurses document chronic wound management more efficiently. The tech has been used in community services and stores a catalogue of photographs to accurately document chronic wounds. District nurses can use the app on a smartphone – making it lightweight, portable and easy to clean. Using two calibration stickers placed either side of the wound, the app can scan it and capture its size and depth to build a 3D image. Nurses can then fill out further characteristics on the software such as colour, pain level, location and smell to give a full picture of the wound’s development. Read full story Source: Nursing Times, 12 February 2020
  9. News Article
    New monitors that can detect the deadly blood condition sepsis are being fitted at a Scottish children's hospital. The equipment will be installed at the Royal Hospital for Children in Glasgow. Charlotte Cooper, who lost her nine-month-old daughter Heidi to sepsis last year, said she had "no doubt" the monitors would help save babies' lives. She told BBC Scotland: "You don't have time to come to terms with the fact that someone you love is dying from sepsis because it happens so quickly." Ms Cooper now wants to see the monitors installed in every paediatric ward in Scotland. "We need to do whatever we can to stop preventable deaths from sepsis in Scotland," she said. The monitors record and track changes in heart rate, temperature and blood pressure, and can pick up early sepsis symptoms. The machines, which have been installed in a critical care area, use the Paediatric Early Warning Scores to monitor the children for any signs of deterioration in their condition. Sepsis Research said early warning of the changes would mean sepsis being diagnosed and treated faster. The monitors were accepted on behalf of the hospital by senior staff nurse Sharon Pate, who said: "In a very busy paediatric word it is vital all our patients are monitored regularly and closely for signs of deterioration. The addition of these new monitors will greatly improve our ability to monitor patients and provide vital care." Read full story Source: BBC News, 4 February 2020
  10. News Article
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation. Read full story (paywalled) Source: The Times, 5 January 2020
  11. Content Article
    Ransomware attacks against healthcare providers are increasing and puts patient safety at risk. Ransomware attacks can severely affect a healthcare provider's ability to provide care to patients (e.g., diversion of emergency vehicles, cancellation of appointments) delay or prevent a facility's ability
  12. Content Article
    Wearable devices are a modern marvel. They teach users exactly how many calories you can burn by running up a flight of stairs, record sleep patterns down to the minute a neighbour’s safety light wakes you up, monitor your heart rate and alert you if anything gets out of whack, and even control your music during a workout. And that’s not even touching on the medical wearables that patients use to manage chronic conditions. We’re living in a time when so much information is available on our wrists or in our palms, and these devices are improving the lives and health of users all over the world. And yet, they’re not perfect. Software Advice surveyed over 450 US patients who currently use medically-prescribed wearable devices to better understand their experiences.
  13. Content Article
    Systems and software engineering contribute not only to advancing and improving the delivery of healthcare but also to doing it more safely than has been the case in the past.
  14. Community Post
    Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame? Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, has written a blog for the hub looking at why this has come about and what needs to be done to improve incident reporting. Do you have any ideas on how we can improve incident reporting? We'd love to hear from you. Reply to this topic below.
  15. Content Article
    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. In this blog, Kenny Fraser, CEO of Triscribe, explains why we need to deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses.
  16. Event
    This Webinar hosted by Hamilton Medical, will focus on the clinical use of intelligent ventilation software. Agenda Intro from Chair Luigi Camporata Presentation from Prof. Giorgio A. Iotti : “ The birth and growth of the visionary idea” Presentation from Laura Buiteman-Kruizinga: “Lung protective ventilation in the time of COVID-19” Followed by a Q&A Register for the webinar
  17. Content Article
    This document provides the principles, concepts, terms and definitions for health software and health IT systems, key properties of safety, effectiveness and security, across the full life cycle, from concept to decommissioning. It also identifies the transition points in the life cycle where transfers of responsibility occur, and the types of multi-lateral communication that are necessary at these transition points. This document also establishes a coherent concepts and terminology for other standards that address specific aspects of the safety, effectiveness, and security (including privacy) of health software and health IT systems.
  18. Content Article
    Earlier this year, information technology (IT) systems at one of the largest hospital trusts in the NHS stopped working for 10 days. This was the latest in a long history of NHS IT system failures across primary and secondary care. As “paperless” is now the default operating mode for many healthcare systems globally, IT failures block access to records, prevent clinicians from ordering investigations, restrict service provision, and bring to a halt the everyday business of healthcare. Increasing digital transformation means such failures are no longer mere inconvenience but fundamentally affect our ability to deliver safe and effective care. They result in patient harm and increased costs. There is a growing disconnect between government messaging promoting a digital future for healthcare (including artificial intelligence) and the lived experience of clinical staff coping daily with ongoing IT problems., writes Joe Zhang and Hutan Ashrafia in a BMJ Editorial. Digital capabilities exist in a strict hierarchy, with IT infrastructure as the foundational layer. This digital future will not materialise without closer attention to crumbling IT infrastructure and poor user experiences. 
  19. Content Article
    Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the number of cases of coronavirus disease (COVID-19) in the United States has exponentially increased. Identifying and monitoring individuals with COVID-19 and individuals who have been exposed to the disease is critical to prevent transmission. Traditional contact tracing mechanisms are not structured on the scale needed to address this pandemic. As businesses reopen, institutions and agencies not traditionally engaged in disease prevention are being tasked with ensuring public safety. Systems to support organisations facing these new challenges are critically needed. Most currently available symptom trackers use a direct-to-consumer approach and use personal identifiers, which raises privacy concerns. Kassaye et al. developed a monitoring and reporting system for COVID-19 to support institutions conducting monitoring activities without compromising privacy.
  20. Content Article
    As trusts consider clearing the waiting list, there is an absence of objective approaches to prioritisation. There are 40 million variations of operative type and the NHS elective waiting list may reach more than 10 million. A coronavirus second wave may cause further delays and expansion of the waiting list. This blog from hub topic lead Richard Jones describes a proven approach to prioritising the waiting list built around individualised risk-adjustment for each patient and evolved from the core POSSUM methodology that is widely used for individual risk assessment pre-operatively.
  21. Content Article
    This article describes the qualitative methodology developed for use in CIRAS (Confidential Incident Reporting and Analysis System), the confidential database set up for the UK railways by the University of Strathclyde. CIRAS is a project in which qualitative safety data are disidentified and then stored and analysed in a central database. Due to the confidential nature of the data provided, conventional (positivist) methods of checking their accuracy are not applicable; therefore a new methodology was developed – the Applied Hermeneutic Methodology (AHM). Based on Paul Ricoeur’s ‘hermeneutic arc’, this methodology uses appropriate computer software to provide a method of analysis that can be shown to be reliable (in the sense that consensus in interpretations between different interpreters can be demonstrated). Moreover, given that the classifiers of the textual elements can be represented in numeric form, AHM crosses the ‘qualitative–quantitative divide’. It is suggested that this methodology is more rigorous and philosophically coherent than existing methodologies and that it has implications for all areas of the health and social sciences where qualitative texts are analysed.
  22. Content Article
    Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame? Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, looks at why this has come about and what needs to be done to improve incident reporting.
  23. Content Article
    An honest account from a junior doctor on moving from paper to electronic observation charts and why user testing should be done before rolling it out in hospitals.
  24. Content Article
    Healthcare is advancing at a quicker rate than ever before. With the introduction of Artificial Intelligence (AI), you can now get a cancerous mole diagnosed with a mobile device. The reliance on technology has never so great. With technology predicted to replace as much as 80 per cent of a physician’s everyday routine, we must question what the new threats posed to patient safety are? This article, written by CFC Underwriting, explains some of the pitfalls of the new technology. CFC is a specialist insurance provider.
  25. Content Article
    The Patient Experience Journal (PXJ) is a peer-reviewed, open-access journal published in association with The Beryl Institute. PXJ is committed to disseminating rigorous knowledge and expanding the global conversation on evidence and innovation on patient experience. Grounded in their core principles, PXJ engages all perspectives, with a strong commitment to patients included.
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