Jump to content

All learn

Showing articles.

To sort the content by type, date or tags you will need to be logged into the hub. Join the hub today to enjoy full member benefits.

This stream auto-updates

  1. Today
  2. Content Article
    High volumes of patients are transferred every day between health and care settings. Whilst efforts have have been made over several years to improve this process through the implementation of standards and the sharing of digital information, there is more to be done. Whole system improvements are required and significant further progress can be made to improve the quality and consistency of data shared between organisations. The Professional Standards Record Body (PRSB) has published a number of standards that support the transfer of care of patients between settings.  This toolkit concentrates on the PRSB eDischarge Summary Standard, which specifies the data to be shared between secondary and primary care to support the discharge of a patient from hospitals across the UK. This toolkit does not propose a one-size-fits-all approach and recognises that health and care services are organised in different ways across the UK.
  3. Content Article Comment
    Love the infographic. It is a great group of people all focussed on improving and making it better for our patients and our staff. Well done Claire.
  4. Content Article
    This article looks at recent efforts to increase awareness of female genital mutilation (FGM) amongst healthcare professionals in the UK. Dr Victoria Kinkaid conducted a UK-wide survey to find out how much medical students knew about FGM. Results from the survey highlighted a gap in medical student education around FGM. Further exploration with the help of focus groups revealed that this knowledge gap also affected other frontline professionals with mandatory reporting duties for FGM, including teachers, midwives and social workers.  Working with her MSc supervisor, Dr Heather May Morgan, Victoria launched a four week course entitled 'Female Genital Mutilation (FGM): Health, Law, and Socio-Cultural Sensitivity' in 2022 to try and bridge this gap. This article looks at the impact of the course and how Victoria and Heather's work to increase awareness is expanding.
  5. Content Article
    Polypharmacy is a term used to describe when a patient is taking a number of medicines at the same time. This study in the British Journal of Clinical Pharmacology aimed to measure how common polypharmacy is and describe the prescribing of selected medications known for overuse in older people with polypharmacy in primary care. It was a multinational retrospective cohort study that used data from patients with a mean age of 75-76 years from six countries: Belgium, France, Germany, Italy, Spain and the UK. The results revealed a high prevalence of polypharmacy with more than half of the older population being prescribed at least five drugs in four of the six countries. Whilst polypharmacy may be appropriate in many patients, the authors found worryingly high usage of PPIs and benzodiazepines. The study's results support current efforts to improve polypharmacy management across Europe.
  6. Yesterday
  7. Content Article
    Medicines reconciliation is the process of compiling a complete list of a person’s current medicines. When a patient registers at a new primary care setting, medicines reconciliation contributes to patient safety and continuity of care. This article in The Pharmaceutical Journal explores how to optimise the multidisciplinary team and involve pharmacy technicians in the process, using four case scenarios. The article aims to help those working in community pharmacy teams to: identify potential risks and appropriate management strategies for new patients with complex medication needs, including those with chronic conditions and those requiring specialist care. understand the importance of timely referrals, communication with specialists, and adherence to guidelines in ensuring safe and effective medication management. recognise the significance of interdisciplinary collaboration and patient-centred approaches in addressing the diverse healthcare needs of patients, particularly those from other cultural backgrounds. You can access this article by signing up for a free account with The Pharmaceutical Journal.
  8. Content Article
    The Independent Healthcare Providers Network (IHPN) have launched a toolkit to support independent healthcare providers to further improve multi-disciplinary team (MDT) working in the sector.  MDT working is an established practice in many areas of healthcare, including in the independent sector, and for patients with complex care needs such as cancer, MDTs are viewed as the gold standard for care. 
  9. Content Article
    East Lancashire Hospitals NHS Foundation Trust share their guide on human factors. It describes what human factors is and why it is so important alongside example case studies of how human factors is being used within the Trust.
  10. Content Article
    This blog is part of a series written by Dr Charlie*, taking a closer look at some of the patient safety issues affecting people lives today. In this blog Dr Charlie describes how their homeless friend Robbie* has struggled to access the care and clarification he needed around his liver abscesses. Dr Charlie explains how important it is for healthcare professionals to take into account individual circumstances if they are to provide people with the information and care they need. *not their real name
  11. Content Article
    A fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.
  12. Last week
  13. Content Article
    Online reporting tools are a key component of professional accountability programmes as they allow hospital staff to report co-worker unprofessional behaviour. Ethos is a whole-of-hospital professional accountability programme that includes an online messaging system, which has now been implemented across multiple Australian hospitals. This study examined reported unprofessional behaviour that staff indicated created a risk to patient safety. It included 1310 Ethos submissions reporting co-worker unprofessional behaviour between 2017 and 2020 across eight Australian hospitals. The findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organisations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety.
  14. Content Article
    Children are at higher risk of medication errors due to the complexity of drug prescribing and administration. Intravenous (IV) paracetamol overdose differs from overdose by ingestion as there is no enteral absorptive buffering. This study outlines the first national UK data focusing on paediatric IV paracetamol poisoning. The data show that unintentional IV paracetamol overdose appears to occur more frequently in young children. A significant proportion of errors were calculation errors, which were often 10-fold errors. While these errors have the potential to cause serious harm, thankfully most cases were asymptomatic. Errors with IV paracetamol might be reduced by electronic prescribing support systems, better communication regarding administration and consideration of whether other routes are more appropriate.
  15. Content Article
    The Patient Safety Movement Foundation offers a unique educational opportunity for healthcare professionals around the world to expand their knowledge in the theory and practice of patient safety. Building on the World Health Organization Global Patient Safety Action Plan, the fellowship aims to develop future leaders particularly from lower middle and middle income countries. The programme combines a year-long curriculum developed by patient safety experts in a variety of areas, taught via monthly live virtual classroom sessions. Fellows complete monthly readings on specific topics, actively participate in discussions on the interpretation of theory and methods, and its implication to practice. Fellows submit monthly reflections on their learning as well as a longer reflection at the end of the fellowship. Applied learning is achieved by completing a hands-on improvement project that explores and advances issues of patient safety in each fellow’s respective professional environment. Fellows are encouraged to publish the outcome of their project and present at conferences. Fellows are driven by a deep passion for patient safety, often sparked by first-hand encounters with patient harm events, and a desire to improve care outcomes in their home communities and workplace settings. They become part of a global social movement for patient and healthcare worker safety. Information on how to apply can be found in the link below.
  16. Content Article
    This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long-standing, the benefits of the ‘human error approach’ to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community.
  17. Content Article
    Few previous studies evaluating the benefits of diagnostic decision support systems have simultaneously measured changes in diagnostic quality and clinical management prompted by use of the system. This report describes a reliable and valid scoring technique to measure the quality of clinical decision plans in an acute medical setting, where diagnostic decision support tools might prove most useful.
  18. Content Article
    Clinical safety is about keeping patients safe. It applies not only to us in the NHS, or social care organisations, but to you when building healthcare software. The law requires you to ensure your software is clinically safe, which means minimising the potential for harm to patients. This page on the NHS Digital website explains what you need to know about clinical safety when building healthcare software.
  19. Content Article
    Read the latest case studies from the National Guardian’s Office.
  20. Content Article
    In the dynamic landscape of healthcare, the unexpected deterioration of a hospital patient presents formidable challenges for medical professionals and families alike. It is during these critical moments that the concept of patient rescue becomes profoundly significant. Families, empowered with knowledge and effective communication strategies, play a pivotal role alongside healthcare providers in advocating for their loved ones and contributing to the success of rescue efforts. Watch this video from the World Patients Alliance to enhance your skills and confidence in advocating for patients' needs.
  21. Content Article
    The healthcare systems of nearly every country are straining to keep up with the demands placed on them by advances in both treatment and technology. In this article, Timothy Ferris explores ways in which technology can reduce the burden on already under-resourced healthcare workforces. Acknowledging the complexity of healthcare compared to other industries, and the highly professional nature of the workforce, he uses the concept of 'unit cost' to look at how the financial and time burden associated with healthcare interactions can be reduced.
  22. Content Article
    Diagnostic error is largely discovered and evaluated through self-reporting and manual review, which is costly and not suitable for real-time intervention. AI presents new opportunities to use electronic health record data for automated detection of potential misdiagnosis, executed at scale and generalised across diseases. The authors of this study propose a new, automated approach to identifying diagnostic divergence considering both diagnosis and risk of mortality. The aim of this study was to identify cases of misdiagnosis of infectious disease in the emergency department by measuring the difference between predicted diagnosis and documented diagnosis, weighted by mortality. Two machine learning models were trained for prediction of infectious disease and mortality using the first 24 hours of data. Charts were manually reviewed by clinicians to determine whether there could have been a more correct or timely diagnosis.
  23. Content Article
    Clive Flashman, Patient Safety Learning's Chief Digital Officer, presented at a Health Tech Alliance meeting to innovators on how to engage with patients to improve the safety of digital health innovation. Clive addressed the challenges in patient engagement such as accessibility, interoperability, safety standards and privacy and data use. The presentation slides from the meeting can be downloaded from the attachment below.
  24. Content Article
    Suicide is a leading cause of maternal death during the perinatal period, which includes pregnancy and the year after birth. While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK, the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth. This qualitative study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt. The researchers spoke to women with lived experience of perinatal mental illness. Their results highlighted three key themes: Trauma and Adversities which captures the traumatic events and life adversities with which participants started their pregnancy journeys. Disillusionment with Motherhood which brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. Entrapment and Despair which presents a range of factors that lead to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control. The authors called for further research into these factors which could lead to earlier detection of suicide risk, improving care and potentially prevent future maternal suicides.
  25. Content Article
    The new PIER approach will enable the effective management of acute physical deterioration in health and care and will apply to all conditions, clinical settings and specialities. The new PIER approach views deterioration as a whole pathway which is supported by systems rather than only advocating a single strategy for identification. Acute physical deterioration is the rapid worsening of a patient’s condition. It can be identified from changes in physiology, such as respiratory rate, blood pressure or consciousness, or more subtle signs, such as not eating and a patient or their family’s concerns and observations around wellness, mental status or behaviour. Deterioration can occur in any health and care setting and is the common pathway in all emergency admissions, prolonged illnesses and deaths.
  26. Content Article
    Alzheimer’s Society estimates that there are currently around 900,000 people living with dementia in the UK. Unlike other major conditions, there is no national clinical pathway for dementia, and despite there being a national target, there is wide variation in dementia diagnosis rates across England.  Alzheimer’s Society commissioned The King’s Fund to explore the development of Integrated Care Systems (ICSs) through the lens of dementia diagnosis—to consider what opportunities ICSs present to approach dementia differently and to improve diagnosis rates by doing so. The research team explored enablers and barriers to improving dementia diagnosis through interviews with stakeholders and people affected by dementia in three case study ICSs.
  27. Content Article
    Although diagnostic errors are estimated to affect about 12 million Americans each year in ambulatory care settings alone, the conceptual and pragmatic scientific foundations for their measurement are under-developed. Further progress towards reducing diagnostic errors will rely on our ability to overcome measurement-related challenges. This article in BMJ Quality & Safety outlines a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). The authors describe how Safer DX serves as a conceptual foundation for system-wide safety measurement, monitoring and improvement of diagnostic error. They believe it lays robust groundwork for measurement and monitoring techniques to ensure diagnostic safety.
  28. Content Article
    Nurses, midwives and paramedics make up over half of the healthcare workforce in the UK National Health Service and have some of the highest prevalence of mental ill health. This study in BMJ Quality & Safety explored why mental ill health is a growing problem and how we might change this. The authors identified the following key themes:It is difficult to promote staff psychological wellness where there is a blame cultureThe needs of the system often over-ride staff psychological well-being at workThere are unintended personal costs of upholding and implementing values at workInterventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressorsIt is challenging to design, identify and implement interventions.They suggest that healthcare organisations need to rebalance the working environment to enable healthcare professionals to recover and thrive. This requires:high standards for patient care to be balanced with high standards for staff mental well-being.professional accountability to be balanced with having a listening, learning culture.reactive responsive interventions to be balanced by having proactive preventative interventionsthe individual focus balanced by an organisational focus.
  1. Load more activity
×
×
  • Create New...