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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this article, Nicholas T H Farr, research fellow at the Department of Materials Science and Engineering at the University of Sheffield, looks at the need for improved preclinical testing methods to ensure the safety of new medical devices. He highlights cases where lack of testing has led to significant harm to patients and argues that to reduce the risk to patients, the research community needs rigorous and comprehensive testing methods that can more accurately predict how the human body will respond to implantable materials and devices. Nicholas has previously written for the hub, in this blog about the importance of investing in the development of testing methods to ensure medical devices are safe to use.
  2. Content Article
    The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration it can be difficult for them to effectively contribute to escalation of care. This article looks at a process evaluation of the RESPOND quality improvement programme—Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration. It identifies enablers and barriers to the implementation of patient-led escalation systems found during the programme.
  3. Event
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    Despite the NHS’s global reputation for safe childbirth, efforts to uphold exceptional maternity care standards persist. With a substantial increase in the annual maternity budget by ￡165 million since 2021, the focus remains on strengthening the maternity workforce and advancing neonatal care. This webinar hosted by GovConnect looks at disparities in maternal healthcare. Key Objectives: Understanding the significance of equity and equality in maternity and neonatal care. Acknowledging the influence of cultural norms on pregnancy and childbirth. Tackling disparities in accessing prenatal care and maternal health services among different communities. Fostering inclusivity and cultural competency within healthcare settings to better serve diverse patient groups. Collaborating with community partners to enhance support for expectant mothers and newborns from underserved backgrounds. Implementing strategies for delivering equitable neonatal care and ensuring healthy infant development across diverse populations. Register for the webinar
  4. Content Article
    Teamwork in the operating room is very important for high-quality patient care. It has been shown that increased team member familiarity predicts improved teamwork and is associated with shared mental models and mutual trust, which are in turn important factors for team effectiveness. The aim of this study in Surgery was to investigate the relationship between team member familiarity and perceived team effectiveness in operating room teams. The authors found that greater team member familiarity predicts greater team effectiveness, and this relationship is mediated by shared mental models. They concluded that training should be aimed at these aspects of team functioning to optimise team performance in the operating room.
  5. Content Article
    Adverse childhood experiences (ACEs) are associated with poorer health outcomes. However, the association between ACEs and healthcare engagement remains relatively underexplored, particularly within the UK. This report presents the findings of an online survey of adults living in Wales and England which looked at the association between ACEs and healthcare engagement, including comfort in the use of healthcare services. The report highlights the following key findings: High ACE exposure is associated with greater medication use. Individuals with four or more ACEs were more likely to report having been prescribed antibiotics in the last 12 months and to be currently using prescription medicine.  Having two or more ACEs was associated with current use of prescription medicine for mental ill-health, with odds of reporting such a prescription being doubled in those with four or more ACEs. There is a relationship between ACEs and medication adherence, with individuals with two or more ACEs being more likely to report poor medication adherence. ACE exposure was linked to having not received all routine childhood vaccinations. Individuals with multiple ACEs were substantially more likely to perceive that professionals do not care about their health or understand their problems. People exposed to multiple ACEs were more likely to report a poor childhood experience with health services.
  6. Content Article
    The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. This study in the Journal of Patient Safety aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterise the nature of the risk controls proposed. The authors did a content analysis of 126 action plans of serious incident investigation reports from a multisite and multi-speciality UK hospital over a three-year period to identify the risk controls proposed. They found that: a substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. most of the proposed risk controls in action plans were assessed as weak, typically focusing on individualised interventions, even when the problems were organisational or systemic in character. They identified six broad approaches to risk controls: improving individual or team performance defining, standardising or reinforcing expected practice improving the working environment improving communication process improvements disciplinary actions. The authors concluded that advancing the quality of risk controls after serious incident investigations requires involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning. This should be supported by a common framework.
  7. Event
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    Join Fallon Hughes, DNP, RN, senior director of Nursing Practice, Innovation, Research and EBP for WellSpan Health, and Alisha Wike, RN, bedside nurse at WellSpan Good Samaritan Hospital, in an educational webinar on virtual nursing. They will discuss current evidence on the role of virtual nursing in healthcare and the role of the virtual nurse in an acute care setting, compare virtual nurse operational considerations to those of a traditional nurse staffing model, identify implications for patient safety, and interpret virtual nurse implementation outcomes for application at your own facility. Register for this webinar, hosted by the Pennsylvania Patient Safety Authority.
  8. Content Article
    In these presentation slides, Erik Hollnagel, Professor at the University of Southern Denmark, explains what is meant by the terms 'work as done' and 'work as imagined'. The presentation looks at the implications of designing with the two concepts in mind and highlights ways to better align system design with the realities of work as done.
  9. Content Article
    Surgical conditions are common in older patient and often require major surgery on frail patients. Strong understanding of the risks for different patients is crucial for decision-making and establishing goals of care. This study in the American Journal of Surgery aimed to find out which clinical factors increase the risk of older patients dying within 30 days of a colectomy or small bowel resection. The results showed that the highest predictors of mortality were American Society of Anesthesiologists (ASA) status 5, septic shock and dialysis. Without risk factors, mortality rates were 11.9% after colectomy and 10.2% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4% following colectomy and 100% following small bowel resection.
  10. Content Article
    US doctor Frederick Gibson describes his experience having a sudden cardiac arrest as a 26 year-old medical student. It took paramedics 45 minutes to resuscitate him in his kitchen and two further rounds of CPR before he reached the hospital to keep him alive. Frederick describes the profound impact the experience has had on him and his partner and reflects on how it has changed his attitude to the experience of being a patient. He highlights the significance of interactions between doctors and their patients—a doctor's words, tone and attitude are carried by the patient in their everyday life, outside of the consultation room, for the next few months and years.
  11. Content Article
    This study in the International Journal of Infectious Diseases aimed to identify the highest-risk subgroups for Covid-19 and Long Covid, particularly relating to influenza and cardiovascular disease (CVD). The authors looked at the records of patients with Covid-19 and Long Covid in linked electronic health records for England. They compared all-cause hospitalisation and mortality by prior CVD, high CV risk, vaccination status (Covid-19/influenza) and CVD drugs, to investigate the impact of vaccination and CVD prevention. The results of the study showed that prior CVD and high CV risk are associated with increased hospitalisation and mortality in Covid-19 and Long Covid. The authors call for targeted Covid-19 vaccination and CVD prevention to be prioritised.
  12. Content Article
    In this webinar, Tracey Herlihey, Head of patient safety incident response policy, NHS England, looks at how the Patient Safety Incident Response Framework (PSIRF) is changing the culture amongst healthcare workers and what this means for individuals. Dr Henrietta Hughes discusses the events leading up to the creation of the Patient Safety Commissioner role, her priorities and the role of leaders. She also explores the importance of ‘what matters to you'—that is, why we must listen to patients and what happens if we don’t.
  13. Content Article
    This film demonstrates how using SEIPS can help illuminate contributory factors within a work system, such as unconscious bias, stereotyping, workload, incivility, societal pressures and environmental factors under the six entity headings. Staff watch an animated explanation of SEIPS and then a short fictional maternity scenario looking out for relevant contributory factors. After viewing the film staff take part in a facilitated discussion to reflect. It is hoped that those using this film will be able to build on this experience, and then reflect on their own clinical service through the SEIPS lens, as taking a systems-based approach will strengthen a Just Culture, reduce blame and supports the PSIRF process.
  14. Content Article
    This video provides an in-depth look at how Patient and Public Involvement (PPI) can enhance quality improvement projects. Involving patients and the public ensures transparency and enriches the team dynamic, bringing new thinking and ideas. It looks at the collaborative approach adopted in an HDR-UK funded initiative which demonstrates the significant impact of PPI and co-production. The video was produced by the Healthcare Quality Improvement Partnership (HQIP) to mark Clinical Audit Awareness Week 2024.
  15. Community Post
    Hi Kim, Thanks for sharing your experience - I'm sorry to hear you are living with these symptoms. We have an existing forum related to vaccine injury on the hub - if you post your experience there you may get some response from people in a similar situation. There is also information about a support group on Facebook hosted by UKCV-Family
  16. Content Article
    Modern patient safety approaches in healthcare highlight the difference between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined). Research in this area has looked at case study examples, but has lacked insights on how results can be embedded within the studied context. This study used Functional Analysis Resonance Method (FRAM) for aligning work-as-imagined with work-as-done. It aimed to show how FRAM can be effectively applied to identify the gap between work prescriptions and practice. It also aimed to show how these findings can be transferred back to and embedded in the daily ward care process of nurses.
  17. Content Article
    This blog by Tom Geraghty provides a definition of 'work as 'imagined' and how this differs from 'work as done'. He outlines the roots of the concept of difference between how people think work is done and the reality and also describes the concepts of 'work as prescribed' (how we think the work should be done) and 'work as disclosed' (what we say about the work that has been done). He discusses how we can close the gap between work as done and work as imagined through honest conversations, observations and simulations.
  18. Content Article
    The incidence of early-onset colorectal cancer has increased significantly over the past decade. Although there has been research on the relationship between outcomes and socioeconomic status in older adults, data on socioeconomic and racial disparities in younger adults is lacking. This US study in Surgery aimed to fill this gap by investigating factors affecting screening, treatment and outcomes for adults under 50 years at the time of diagnosis. The authors found that socioeconomic and racial disparities in early-onset colorectal cancer affect diagnosis, treatment and survival. They call for interventions to boost early diagnosis and access to surgery among minorities and patients living in neighbourhoods with low socioeconomic status.
  19. Content Article
    This webinar recording explores the potential benefits of self-referral, its effects on health inequalities and the factors which enable self-referral. The webinar panel includes RCP outpatients clinical lead Theresa Barnes, RCP digital lead Anne Kinderlerer and head of patient partnership at the Patients Association Sarah Tilsed.
  20. Content Article
    This document by the Centre for Perioperative Care outlines principles that should be used to design checklists for invasive procedures.
  21. Content Article
    In recent years, both of the UK's largest political parties have made explicit commitments to tackle the country's geographic health inequalities. In their starkest form, health inequalities—whether based on race, class, gender, geography and so on—will mean that those at the wrong end have, on average, fewer years to live and worse health when alive. This article in IPPR Progressive Review argues that the reason progress on tackling health inequalities is not being made is the failure of national leaders to identify mechanisms of change.
  22. Content Article
    Journalist Jessie Hewitson has two children with autism and has first hand experience of the difficulties autistic people face when accessing healthcare. In this inews article, she looks at the shocking statistic that autistic people die between 6 and 16 years earlier than the rest of the population and suggests that many small interactions and obstacles contribute to poorer outcomes. She highlights three key factors that contribute to health inequalities for autistic people: communication difficulties, anxiety about phoning the GP and difficulties with interoception—the ability to know and respond appropriately to your bodies signals.
  23. Content Article
    This podcast by the National Patient Safety Board asks how healthcare can address the systemic challenges that have prevented progress on patient safety for decades. Hosted by Karen Wolk Feinstein, this episode looks at lessons that can be taken from other industries that have made safety a top priority. Karen talks to guests Professor Nancy Leveson, engineer and systems safety expert, and Dr. Michael Shabot, former healthcare executive and expert in high-reliability healthcare safety and quality.
  24. Content Article
    This commentary in JAMA Network Open looks at the increasingly recognised problem of burnout among US healthcare professionals. General Social Survey data suggest that almost one-half of US health care workers experienced symptoms of burnout often or very often in 2022, up from less than one-third in 2018. The article explores research that demonstrates the extent of the issue and highlights studies looking at ways to reduce burnout. The authors conclude that systemic change will be required to tackle the issue.
  25. Content Article
    This webpage outlines the role and purpose of the Norwegian Healthcare Investigation Board (NHIB)—or 'Ukom' in Norwegian—an independent government agency set up in 2019. NHIB investigates serious adverse events and other serious concerns involving Norwegian healthcare services, aiming to improve patient and user safety by learning for improvement. Its investigations focus on systems and processes in healthcare, identifying factors that could have led, or could potentially lead, to harm for patients. On this page, you can also access NHIB reports and summary reports that have been translated into English, including: Death at a psychiatric intensive care ward: Risk factors in conjunction with seclusion Early diagnosis and treatment of serious illness in the febrile child Adolescents with mental health issues Investigation following the tragic drowning in Tromsø: What can we learn about integration and refugee health? Maintaining patient safety with new surgical and invasive methods
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