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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A couple whose child died before birth due to failings in her care hope a new documentary can support their calls for a public inquiry into England's maternity services. Jack and Sarah Hawkins' daughter Harriet was stillborn at Nottingham City Hospital in April 2016. They hope an ITV programme - Maternity: Broken Trust - shown on Sunday evening can help their bid for a wider probe. An independent review into failings in maternity services in Nottingham is now the biggest maternity investigation in NHS history, but a report is not expected to be returned until 2025. Dr and Ms Hawkins - who received a £2.8m settlement over failings in their daughter's care - said a wider investigation was needed to highlight national issues. "I think maternity services across England are absolutely terrible," Ms Hawkins said. "We're in contact with people with dead babies from Leeds to Plymouth, and I think what really needs to happen is for there to be a public inquiry into England's maternity services. "It's not just Nottingham, it's everywhere, and hopefully this platform will give people the strength to come forward and speak up." Read full story Source: BBC News, 10 June 2024
  2. Content Article
    Shared with the hub, this audit tool is designed to assess theatre compliance with the five-steps to safer surgery, which includes the World Health Organisation (WHO) Surgical Safety Checklist. The checks included in the five steps are designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and by verifying and checking essential care interventions.
  3. Content Article
    The Surgical Burns Action Group (SBAG) is a leading reference point for conversations around surgical burn and fire prevention. The SBAG consolidates clinical and patient support to remove the significant gaps in the NHS’ reporting of surgical burns, ensuring patients are properly informed on the risk of a fire, and clinicians on the necessary safety requirements. The SBAG website includes useful information and materials about surgical fires and burns.
  4. Content Article
    Example of two action cards used for incorrect swab count and incorrect instrument count.
  5. Content Article
    This study sought to understand the types of clinical processes, such as image and medication ordering, that are disrupted during electronic health record (EHR) downtime periods by analysing the narratives of patient safety event report data. Patient safety report data offer a lens into EHR downtime–related safety hazards. Important areas of risk during EHR downtime periods were patient identification and communication of clinical information; these should be a focus of downtime procedure planning to reduce safety hazards. The study concluded that EHR downtime events pose patient safety hazards, and the authors highlight critical areas for downtime procedure improvement.
  6. Content Article
    This full-length, award-winning documentary unearths the shattering truth that millions of people worldwide are injured by prescribed psychiatric medications. Interweaving stories of harm with expert testimony, the film reveals how a profit-driven industry hides the risks of long-term use. This untold story is a compelling call to examine the consequences of medicating normal human suffering.
  7. Event
    Join Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in collaboration with Radar Healthcare for an engaging discussion on Learning from Patient Safety Events (LFPSE) and the Patient Safety Incident Response Framework (PSIRF), highlighting their combined impact on patient safety improvement. This webinar will delve into pivotal aspects crucial for integrating LFPSE and PSIRF into your incident and reporting software, including: User-Centric Approach: Understand the significance of aligning LFPSE and PSIRF principles with the end-user's perspective, ensuring a seamless and intuitive experience. Success Story: Learn how GSTT implemented both LFPSE and PSIRF, surpassing standard levels of incident reporting and advancing patient safety practices. Data Empowerment: Discover how GSTT was able to address its patient safety priorities and facilitate the provision of critical data to the national patient safety improvement programs led by NHSE. This session will spotlight how GSTT adapted to new processes and frameworks like LFPSE and PSIRF, contributing to both national and local safety initiatives. Speakers: Charles Martin, Trust Head of Risk and Quality Assurance - Guy’s and St Thomas’ NHS FT Paul Johnson, CEO - Radar Healthcare Jack Forshaw, Project & LFPSE Lead - Radar Healthcare Chair: Jon Hoeksma, CEO - Digital Health Register
  8. Content Article
    When healthcare students witness, engage in, or are involved in an adverse event, it often leads to a second victim experience, impacting their mental well-being and influencing their future professional practice. This study aimed to describe the efforts, methods, and outcomes of interventions to help students in healthcare disciplines cope with the emotional experience of being involved in or witnessing a mistake causing harm to a patient during their clerkships or training.
  9. Content Article
    Electronic health record (EHR) nursing summaries have the potential to support nurses in locating and synthesising patient information. However, nurses’ role-specific perspectives are often excluded in the design of the EHR system. The purpose of this study was to describe nurses’ current use of nursing summaries and vital sign information within them and glean their ideas for design improvements. en clinical inpatient nurses participated in interviews and co-design activities. Nurses hardly use the nursing summary to overview a comprehensive patient's health status. The current design of a nursing summary lacks comprehensive patient information and contains much irrelevant data. Nurses prefer vital signs to be prominently displayed on the summary screen for easy visibility. Involving nurses in the design process can lead to a nursing summary that better meets their needs.
  10. Content Article
    This publication describes East London NHS Foundation Trust’s 10 years of experience with learning how to apply quality improvement throughout the organisation and embed a culture of improvement, in partnership with the Institute for Healthcare Improvement (IHI).
  11. Content Article
    Do you know the science behind what works and doesn’t work when it comes to keeping people safe in your organisation? Each week join Dr Drew Rae and Dr David Provan from the Safety Science Innovation Lab at Griffith University as they break down the latest safety research and provide you with practical management tips.
  12. Content Article
    Patient feedback on diagnostic errors may improve the quality and safety of care. This analysis examined patient feedback on what went well with the diagnostic process. Results mirrored those of studies on diagnostic errors, stating feeling heard, appreciated, and timely communication contributed to a good diagnostic process.
  13. Content Article
    This guide is for trusts who have an electronic patient record system (EPR) already in place and want to realise the transformational opportunities it presents. It focuses on the role of the board in leading these changes. In December 2022, NHS England estimated that over 85% of trusts in England had some form of EPR and set a target for EPRs to be implemented in at least 90% of trusts by December 2023. A well implemented and optimised EPR improves patient safety, staff satisfaction, patient flow and data quality. But this can only be achieved with continuous optimisation and investment. A poor EPR implementation, followed by a lack of investment in its ongoing development, can frustrate staff and create disillusionment. This in turn leads to poor usage and unsafe workarounds. In time this will negatively impact productivity and result in substandard data informing clinical decision making. If you are part of an integrated care system (ICS) looking to share or align EPRs across a number of organisations, this guide will also help you consider issues of convergence, scale and shared governance. It does not address procurement and implementation.
  14. Event
    There is currently remarkable consensus across think tanks, institutions, and political parties that a move towards a preventive state is key to creating a healthier nation. A preventive approach can help people live healthily for longer while also addressing many of the problems within the health and care system, allowing for proactive population health management and tackling of health inequalities. Creating a healthier nation needs a collaboration between people, places, the NHS, and businesses, as well as government. If the new government wants to improve the health of the nation, it should create an approach to health that spans all government departments, includes actions to reduce health inequalities, and implements measures that help people to make healthier choices. At this in-person event, the case is presented for how prevention can create a healthier nation, why it is particularly important now, and propose tangible actions for making this shift at the national, system and local levels. Join the King's Fund to understand why prevention is key to supporting healthier lives and how it can be made a reality. Join leaders and experts from across health and care, thinks tanks and politicians to explore: why moving towards a preventive state is particularly important now given the context of widening health inequalities and stalling of life expectancy how to make the shift to prevention a reality at national, system, and local levels the importance of measuring preventive expenditure the role of prevention when taking a population health approach the link between health and housing and how healthier communities can support a wider approach to prevention. how place-based approaches to prevention are key. Register
  15. Content Article
    Sohier Elneil, surgeon, expert in women’s pain, and founder of the first NHS vaginal mesh removal centre, speaks to the Rebecca Coombes about fighting for better care for her female patients.
  16. News Article
    Dan Harrison, who had schizophrenia and psychotic delusions about his parents, had been sectioned ten days before he attacked his father. He was detained at Neath Port Talbot Hospital, run by the Swansea Bay University Health Board. During those ten days he received no treatment or medication. He escaped through a door being held open by a member of staff who was talking to someone else and immediately headed for the family home where he killed his father. The attack came after Dan's mother, Jane, and her husband repeatedly asked for help from mental health services as their son’s state of mind and behaviour deteriorated. They were refused. Last month Kirsten Heaven, assistant coroner for Swansea, recorded in a narrative verdict that there had been repeated failings by the Swansea University Health Board and local council. She said multiple system failures had contributed to Kim’s death and warned of more deaths if they were not addressed. Jane is speaking out now, with her son’s permission, after a Sunday Times investigation highlighted the scale of mental health-related killings in Britain. There have been at least 233 reported since 2020 and there have been repeated warnings about NHS services failing to provide crisis care. Read full story (paywalled) Source: The Times, 1 June 2024
  17. News Article
    Three more babies have died from whooping cough this year as cases continue to rise across the country, according to the UK Health Security Agency. Since January, there have been 4,793 confirmed cases of whooping cough, with 181 babies under the age of three months diagnosed with the illness. A total of eight babies have now died from whooping cough this year. Pregnant women have been urged to get the whooping cough vaccine in order for their babies to be protected before they are old enough to receive the vaccine themselves. Babies can first be vaccinated against the disease when eight weeks old, while pregnant women are advised to get the vaccine at 16 and 32 weeks. Dr Gayatri Amirthalingam, a consultant epidemiologist at UKHSA, said: “Our thoughts and condolences are with those families who have so tragically lost their baby. “With whooping cough case numbers across the country continuing to rise and sadly the further infant deaths in April, we are again reminded how severe the illness can be for very young babies. “Pregnant women should have a whooping cough vaccine in every pregnancy, normally around the time of their mid-pregnancy scan (usually 20 weeks). This passes protection to their baby in the womb so that they are protected from birth in the first months of their life when they are most vulnerable and before they can receive their own vaccines. “The vaccine is crucial for pregnant women, to protect their babies from what can be a devastating illness.” Read full story Source: The Guardian, 6 June 2024
  18. Content Article
    From 1 April 2009 to 31 March 2019, NHS Resolution were notified of 631 clinical negligence claims relating to surgical burns to patients. Out of these 631 claims, 459 were settled, 58 were unmeritorious and 114 are still open. This has led to NHS Resolution paying £13.9m in damages and legal costs on behalf of NHS organisations.
  19. Content Article
    Reducing social inequalities in health and health determinants, including physical activity (PA), is a major challenge for public health. PA-promoting interventions are increasingly implemented. Little is known, however, about the impact of these interventions on social inequalities. For prioritising interventions most likely to be effective in reducing inequalities, studies of PA interventions need to conduct equity impact assessments. The aim of this article is to describe the development of a logic model framework for equity impact assessments of interventions to promote PA. The framework was developed within the prevention research network AEQUIPA—Physical activity and health equity: primary prevention for healthy ageing, informed by an equity-focused systematic review, expert interviews, exploratory literature searches, and joint discussions within the network. The framework comprises a general equity-focused logic model to be adapted to specific interventions. The intervention-specific equity-focused logic models illustrate the key elements relevant for assessing social inequalities in study participation, compliance with and acceptance of interventions, as well as the efficacy of interventions. Equity impact assessments are beneficial for prioritising interventions most likely to be effective in reducing health inequalities.
  20. Content Article
    Design creativity describes the process by which needs are explored and translated into requirements for change. This chapter examines the role of design creativity within the context of healthcare improvement. It begins by outlining the characteristics of design thinking, and the key status of the Double Diamond Model. It provides practical tools to support design creativity, including ethnographic/observational studies, personas and scenarios, and needs identification and requirements analysis. It also covers brainstorming, Disney, and six thinking hats techniques, the nine windows technique, morphological charts and product architecting, and concept evaluation. The tools, covering all stages of the Double Diamond model, are supported by examples of their use in healthcare improvement. The chapter concludes with a critique of design creativity and the evidence for its application in healthcare improvement.
  21. News Article
    One out of every six people have symptoms when they stop taking antidepressants - fewer than previously thought, a review of previous studies suggests. The researchers say their findings will help inform doctors and patients "without causing undue alarm". The Lancet Psychiatry review looked at data from 79 trials involving more than 20,000 patients. Some had been treated with antidepressants and others with a dummy drug or placebo, which helped researchers gauge the true effect of withdrawing from the drugs. Some people have unpleasant symptoms such as dizziness, headache, nausea and insomnia when they stop taking antidepressants, which, the researchers say, can cause considerable distress. Previous estimates suggested antidepressant discontinuation symptoms (ADS) affected 56% of patients, with almost half of cases classed as severe. But this review, from the Universities of Berlin and Cologne, estimates one out of every every six or seven patients can expect symptoms when stopping antidepressants and one in 35 will have severe symptoms. Read full story Source: BBC News, 6 June 2024
  22. Content Article
    Uncontrolled sensory stimuli can hinder healthcare delivery quality in trauma rooms. High noise and temperature levels can increase staff stress and discomfort as well as patient discomfort. Conversely, proper lighting can decrease staff stress levels and reduce burnout. Sensory overload in trauma rooms is a crucial concern, but no studies have been conducted on this issue.
  23. Content Article
    Diagnostic management teams (DMT), which are comprised of experts in specialised fields, review patient cases and produce reports with diagnostic interpretations and recommendations for future testing or treatments. This pre/post study evaluates the effectiveness of a coagulation DMT at one hospital. Cases reviewed by the DMT were twice as likely to have a diagnostic conclusion (i.e., ruled in or ruled out coagulopathy) than cases without DMT.
  24. News Article
    The United State's largest nurses union is demanding that artificial intelligence tools used in healthcare be proven safe and equitable before deployment. Those that aren’t should be immediately discontinued, the union says. Few algorithms, if any, currently meet their standard. “These arguments that these AI tools will result in improved safety are not grounded in any type of evidence whatsoever,” Michelle Mahon, assistant director of nursing practice at National Nurses United, told Fierce Healthcare. NNU represents 225,000 nurses in the US and has a presence in nearly every state through affiliated organisations, like the California Nurses Association, which protested the use of AI in healthcare in late April. NNU nurses also represent nearly every major hospital and health system in the nation. Most AI nurses interact with is integrated into electronic health records and is often used to predict sepsis or determine patient acuity, union nurses said at an NNU media briefing last month. EHRs cause an estimated 30,000 deaths per year, which is the third leading cause of death in the nation, Mahon said. Adding what they call “unproven” algorithms to EHRs is not how the health system should be spending dollars, NNU says. The union is demanding that all AI used in healthcare meet the precautionary principle, a philosophical approach that requires the highest level of protection for innovations without significant scientific backing. Any AI solution that does not meet this principle, which NNU claims is most of the AI currently on the market and deployed in hospitals, should be immediately discontinued, they say. Read full story Source: Fierce Healthcare, 3 June 2024
  25. Content Article Comment
    An email sent to Patient Safety Learning. The sender wishes to remain anonymous. "I am a patient in the Heart Failure Clinic at a London hospital. I am also a patient at a GP surgery which is a mere ten minutes from hospital. Yet, their computers cannot communicate with each other as they are different hospital trusts. Ridiculous. Therefore, my GP rarely knows about my clinic meetings in Cardiology, does not know the meds if they are altered, etc. etc. I do not get reports, or test results, either. A cloud of darkness. I asked PALS to send some test results to my GP surgery and they did, but I think it is a one-off. I had (have) to keep ringing the nurse specialist helpline or the Consultant's secretary for information. Meantime, messages from MyChart arrived in droves, all telling me my appointment letters and test results were there, awaiting me. However, when I logged in (numerous times) - there was never anything at all. No letters, test results, zilch, nothing. I, finally, managed to cancel the not-working MyChart. I have multiple medical problems and am 90 years old. Fortunately, I can work my computer, use the telephone and get to appointments. However, it is stressful and tiring to have to be ever alert because there is an accident waiting to happen. Software is not new. Computers arrived in the eighties. Who are the idiots who put these systems together but forgot to hook them up?"
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