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EventuntilThis face-to-face event by The Royal College of Emergency Medicine will look at research around burnout and other psychological impacts of working in the emergency department. It will feature talks from clinicians promoting staff wellbeing and explore opportunities to work with the Sustainable Working Practice Committee. View the event programme Book this event. Reduced fees are available for RCEM members and student members LMIC clinicians and students.
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Content ArticleIn this podcast episode, host Aaron Harmon speaks to Dr Neil Vargesson, chair in developmental biology at the University of Aberdeen, about the importance of Good Laboratory Practice (GLP) and why pre-clinical studies are key to keeping people safe. They discuss the history of Primodos, a hormone-based pregnancy test that was given to women between 1959 and 1978. It was developed before GLP and before standardised testing for teratogenesis (causing birth defects). There are data that suggests Primodos caused birth defects, but more questions remain.
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Content ArticleIn this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. The authors also examine the impact that learning projects based on incident reporting can have on clinicians involved in the initial incidents, highlighting that revisiting errors may prevent individuals from moving on from them.
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Content ArticleThis report describes the findings of the Care Quality Commission (CQC) review of children and young people’s mental health services. The report focuses on three main aspects of the mental health system for children and young people: People’s experience of and involvement in care How partners plan and deliver services that offer high quality care that can be accessed in a timely fashion How partners in the local area identify mental health needs and what they do to start the process of getting the right support for children and young people The CQC spoke with staff working across different parts of the system, children, young people, parents, families and carers. They also reviewed policies and procedures, and used ‘case-tracking’ to examine in detail how individual children and young people with mental health problems moved through the system.
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Content ArticleThis paper in the Journal of Intellectual Disabilities and Offending Behaviour describes the nature and impact of a restraint reduction strategy implemented within a secure learning disability service in response to the national Positive and Safe programme. Once the programme was completed, the following results were achieved: prone restraint was eliminated mechanical restraint was eliminated 42% reduction in general use of restraint 42% reduction in use of seclusion 52% reduction in rapid tranquilisation.
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Content ArticleThis study in Pain Research and Management reviewed available literature about gender bias in the treatment of pain and gendered norms towards patients with chronic pain. The authors found that gendered norms about men and women with pain are present in research from different scientific fields. They highlight that awareness of the issue can help counteract gender bias in healthcare and support healthcare professionals to provide more equitable care.
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Content ArticleThis independent external quality assurance review looks at the independent investigation into the care and treatment of mental health service user Mr M at Greater Manchester Mental Health NHS Foundation Trust.
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Content ArticleThis special article in Mayo Clinic Proceedings outlines practical recommendations for diabetes injections and infusions, developed at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Italy in 2015. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries. Recommendations are organised around the themes of anatomy, physiology, pathology, psychology and technology and aim to produce more effective therapies, improved outcomes and lower costs for patients with diabetes.
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Content ArticleIn this blog for the British Journal of Nursing, John Tingle, Lecturer in Law at Birmingham Law School, considers the two opposing viewpoints on the need for change in the clinical negligence litigation system. He concludes that reducing the costs of litigation with require more than refining how the system of compensation works. He states that the way care is delivered in the NHS needs to be examined at a more fundamental level.
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EventuntilThis free webinar from the Patient Safety Movement Foundation in the US takes place at 7.30am PT (3.30pm GMT). Healthcare professionals around the world are facing immense burnout at unprecedented level. Yet the systems they work in perpetuate burnout due to unnecessary waste. The panelists in this webinar will identify actionable recommendations for healthcare leaders and professionals to minimise burnout on individual, organisational and system-wide levels. Objectives: Identify root causes of burnout within the healthcare setting. Recognise signs of burnout in self and colleagues. Examine ways to mitigate burnout at an individual and organisational level. Moderator: Vonda Vaden Bates, CEO, 10th Dot, Medical Safety Advocate Panelists: Kimberly A. Baker MSN, RN, CARN, NPD-BC, Behavioral Health Programmatic Nurse Specialist, University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital Oscar San Roman Orozco, MD, MPH, Applied Global Public Health Initiative, Universidad Autonoma de Queretaro, Mexico Louis Stout, RN, MS, Colonel (Retired), US Army Nurse Corps, Chief Nursing Officer, Madigan Army Medical Center Register for this webinar
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Content ArticleIn the Scottish Government’s Programme for Government 2020-21 it committed to establishing a Patient Safety Commissioner for Scotland. The decision to create this role came about as a result of a specific recommendation in the First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review), published in July 2020. The Scottish Government held a consultation process seeking views on a range of issues relating to the creation of a new Patient Safety Commissioner role between 5 March 2021 and 28 May 2021. This report analyses responses from the public and other interested parties.
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Content ArticleThis analysis uses data from the Office for National Statistics UK Coronavirus (Covid-19) Infection Survey data to estimate the prevalence of self-reported Long Covid in the UK.
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Content ArticleThese resources from Queen Margaret University, Edinburgh were developed following a study funded by the Chief Scientist Office in Scotland. The study was based on an online survey which people completed between July and August 2020, followed by a further survey six months later. Some participants also took part in a telephone interview to enhance understanding of their responses. The study used the responses of people living with Long Covid to: develop a resource with advice for people accessing services for Long Covid. write guidance for people providing services relevant to people with Long Covid. write recommendations to inform policy and service design that relate to Long Covid and other impacts of the pandemic. plan a series of short podcasts, interviewing people who have lived experience of Long Covid.
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Content ArticleThis article in the Journal of Minimally Invasive Gynaecology provides an interpretation of the 2014 US Food and Drug Administration (FDA) statement on power morcellation, a gynaecological procedure in which a device is used to slice up fibroid tissue for extraction through small incisions. Although use of power morcellation makes surgery less invasive, it has been shown to spread cancer if it exists within the patient's tissues. This article looks at the legal impact of the FDA statement, which warns against using laparoscopic power morcellators in the majority of women undergoing hysterectomy or myomectomy for uterine fibroids.
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Content ArticleIn this opinion piece for the BMJ, David Oliver, a consultant in geriatrics and acute general medicine, draws lessons from the Grenfell Tower disaster and subsequent public inquiry. 72 people lost their lives in the fire that destroyed Grenfell Tower in 2017. Evidence to the public inquiry has shown that several residents had raised concerns about the building's safety over many years, and that architects, building contractors, and providers and fitters of cladding material had also expressed concerns about the safety of the exterior cladding used on Grenfell Tower. David Oliver highlights that had these concerns been listened to and acted on, the disaster could have been avoided and many lives saved. He draws parallels with concerns being raised by patients about the safety of the healthcare system and highlights the role of staff in repeatedly raising and keeping a record of concerns. He states that NHS leaders must create a culture where no one is afraid to speak out and act to mitigate safety issues. Leaders must expect to be held accountable for their response - or lack of response - to safety issues raised.
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Content ArticleThis is the first National Institute for Health Research (NIHR) report into how sex, ethnicity, disability and age affect how the organisation awards health research funding. Using their new Equality and Data Reporting system, the NIHR has been able to collect data on equality diversity and inclusion (EDI) for the first time. The information in this report is a benchmark for further reporting and will form the basis of the NIHR's new EDI strategy.
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Content ArticleThis training documentary by the South East Perinatal Mental Health team explores race inequalities within the NHS maternity system. It uncovers the stories behind the MBRRACE report figures and looks for answers from leading race and diversity health professionals and campaigners. In the film, midwives and mothers talk frankly about the issues and how individuals can make a difference to create a positive impact on race inequality outcomes for mothers and within maternity teams.
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Content ArticleThis white paper sets out the UK Government's 10-year vision for adult social care, and provides information on funded proposals that they will implement over the next three years. It highlights the factors that will cause an increase in demand for social care over the next decade and identifies stakeholders who the proposed changes to social care will affect. A key proposal in this white paper is the cap on how much individuals in England will contribute to their care costs from October 2023, which aims to make care costs predictable and limited.
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Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
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Content ArticleIn 2020, all NHS organisations were instructed to name a single executive board member as their senior responsible person for tackling health inequalities. Across the NHS, there should now be over 450 dedicated health equality named leads in healthcare organisations. This report published by the independent NHS Race & Health Observatory in collaboration with The King’s Fund sets out recommendations to help ensure senior NHS officials responsible for improving health inequalities are able to make a difference.
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Content Article
Blog: At the edge of inside (24 June 2016)
Patient-Safety-Learning posted an article in Culture
In this opinion piece for The New York Times, David Brooks looks at the value of being 'at the edge of the inside'. He argues that being within an organisation, but not so close to the centre that you are subsumed by the 'group think', puts an individual in a good position to positively influence the organisation's culture and practice. -
Content ArticleThe rapid review was commissioned by NHS England and NHS Improvement, following concerns raised by staff at The Christie Hospital in relation to the Research & Innovation department. The review makes a number of recommendations and the Trust will be developing and action plan to address these.
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Content ArticleIn this blog for the British Journal of General Practice comment and opinion website, BJGP Life, GP Will Mackintosh discusses the impact of health inequalities on patients' ability to play an active role in their care. He calls for training for all GPs to understand the constraints and pressures that may be affecting their patients, so that they can better assess the causes of health issues and therefore treat them more effectively. The article examines concepts of freedom for both GP and patient, and argues that a purely evidence-based approach does not help patients from deprived backgrounds overcome health issues. The author highlights that GPs operate in a 'grey zone' between the medical and the non-medical, and argues that this means they are well placed to understand and help tackle the root causes of health disparities.
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Content ArticleThis study in The British Journal of General Practice aimed to quantify the time GPs spend on different activities during clinical sessions, to identify the number of operational failures they encounter and to define the nature of operational failures and their impact for GPs.
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Content ArticleThis report from the Queen's Nursing Institute’s International Community Nursing Observatory (ICNO) describes the role of district nursing in ensuring continuity of care and preventing unnecessary hospital admissions. It highlights the advanced skills in assessment, diagnosis and patient management of District Nurse Team Leaders - skills that could be used to provide safe and effective care for people at home.
