Patient-Safety-Learning
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Content ArticleThe Patient Experience Platform (PEP) is a listening tool which offers a new approach to collecting and analysing the views of patients on health services. The platform delivers comprehensive real-time reporting of what patients think about their care and provides actionable insights to inform operational decisions. This second annual report explains how PEP data is collected and analysed and explores some key findings on trends and variations in patient experiences across hospitals in England.
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Content ArticleResearch shows that patient safety walk rounds are an appropriate and common method to improve safety culture. This observational study in The Joint Commission Journal on Quality and Patient Safety combined walk rounds with observations of specific aspects of patient safety and measured the safety and teamwork climate. Healthcare workers were observed in specific aspects of patient safety on walk rounds in eight settings in a Swiss hospital. They were also surveyed using safety and teamwork climate scales before the initial walk rounds and six to nine months later. The authors evaluated the implementation of planned improvement actions following the walk rounds. The authors found that walk rounds with structured in-person observations identified safe care practices and issues in patient safety. However, improvement action plans to address these issues were not fully implemented nine months later, and there were no significant changes in the safety and teamwork climate.
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Content ArticleThis study in the International Journal of Radiation Oncology, Biology and Physics assesses the impact of the early Covid-19 pandemic on incident learning through evaluation of events reported to the Radiation Oncology Incident Learning System® (RO-ILS) in the USA. The authors conclude that reporting to RO-ILS declined during the early Covid-19 pandemic, especially in hotspot areas, suggesting that resources and time were diverted away from incident reporting to address other critical needs. However, three of the five top reporting practices that stopped reporting during early Covid have since reported events after the analysis timeframe, suggesting the decline may be temporary.
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Content ArticleThis study in the British Journal of Clinical Pharmacology involved searching electronic health records to uncover how many people in prisons have been affected by a potential problem related to their prescribed medication. Researchers looked at published studies and worked with prison healthcare staff to develop and implement prescribing safety indicators (PSIs) for prison electronic health records. The authors found that PSIs provide a significant opportunity to measure and improve medication safety for people in prisons and that more patients were affected by some PSIs than others. The study also investigated how the searches could be used more widely in prisons and interviewed 20 prison health care staff to explore this topic. The staff they spoke to said that it was important to have people who can take on leadership of the searches and to promote team-based responses to them.
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Content ArticleThis review by Healthcare Inspectorate Wales considers the impact of ambulance waits outside emergency departments on the overall experience of patients, which included their safety, care, privacy and dignity. It covers the period between 1 April 2020 and 31 March 2021, during the Covid-19 pandemic. The report highlights that although patients were positive about their experience with ambulance crews, handover delays are having a detrimental impact upon the ability of the healthcare system to provide responsive, safe, effective and dignified care to patients. It makes 20 recommendations for consideration by the Welsh Ambulance Services NHS Trust, health boards and the Welsh Government.
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Content ArticleChristopher Collinson was admitted to the Medical Assessment Unit at Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism. He was admitted at 1.28pm on 14 June 2021, but was not seen by a Doctor until 9.33pm. He was later prescribed a prophylactic dose of Enoxaparin, rather than the therapeutic dose which the doctor had intended to prescribe. He collapsed at 11.00pm suffering a cardiac arrest and could not be revived. He died at 2.14am on 15 June 2021.
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EventuntilThe Independent is hosting an expert panel, as part of a virtual event series, to examine exactly why maternity inequalities exist within the UK. Health correspondent Shaun Lintern has reported regularly on the shocking realities often facing pregnant women in the UK who are either black or from an ethnic minority. To discuss the matter further he will be hosting a panel of experts, which includes Marian Knight, Professor of Maternal and Child Population Health at the University of Oxford, to try and tackle exactly what the issues are that cause such staggering inequality to be experienced by black or ethnic minority women who are pregnant here in the UK on a daily basis. Medical professionals have long assumed the death rate can be explained by pre-existing conditions amongst black women such as high blood pressure, or the higher prevalence of complications such as pre-eclampsia. Rather, research from the US points to a more complex picture. So what is really happening? Register for this free event
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Content ArticleThis report by the Royal College of Occupational Therapists (RCOT) sets out practical ways in which decision-makers and system designers can use the skills offered by occupational therapy to ensure all patients get access to the support they need. Health equity is one of RCOT’s priorities for 2022 and this report looks at the role of occupational therapists in widening access to care in the following areas: Primary care Housing Children, young people, and families Community rehabilitation Community mental health Criminal justice system
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Content ArticleThis systematic review in Nursing Open synthesises the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute care hospitals. The review included nine studies and found that nurses with positive safety attitudes reported: fewer patient falls and medication errors fewer pressure injuries and healthcare-associated infections fewer mortalities fewer physical restraints and vascular access device reactions higher patient satisfaction. The authors also found that effective teamwork led to a reduction in adverse patient outcomes. They conclude that a positive safety culture results in fewer reported adverse patient outcomes, and that nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
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Content ArticleThis editorial in the Journal of Patient Safety & Risk Management discusses the significant role patients and their families can have in improving patient safety. The author argues that having a patient present shifts the conversation to the patient perspective, results in a kinder and more respectful tone and promotes a greater urgency to find solutions. He describes patient engagement and empowerment as "perhaps the most powerful tool to improve patient safety" and discusses the significance of the World Health Organization's Patients for Patient Safety program (PFPS).
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Content ArticleThis qualitative study in Patient Education and Counseling collected narrative accounts from doctors, nurses and patients to determine whether their perspectives can add new content to quality of care frameworks. The three groups raised the following 'quality of care' aspects: Successful communication among staff, with patients and care companions Staff motivation Frequency of knowledge errors Prioritisation of patient-preferred outcomes Institutional emphasis on building “quality cultures” Organisational implementation of fluid system procedures The study found that respondents primarily referred to care processes, rather than structure or outcomes, in their descriptions of 'quality of care'. 'Hippocratic pride' (in response to care successes) and 'rapid reactivity' (in response to (near) failures) emerged as two new outcome indicators of high-quality care.
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Content ArticleThis article published in BMJ Open aimed to explore the experiences of service users, carers and staff seeking or providing secondary mental health services during the Covid-19 pandemic. The authors found that patient and carer experiences of remote care were mixed. Some service users valued the convenience of remote methods as it allowed them to maintain contact with familiar clinicians, but most participants commented that a lack of non-verbal cues and the loss of a therapeutic ‘safe space’ challenged therapeutic relationship building, assessments and identification of deteriorating mental well-being. The study highlights the importance of taking a tailored, personal approach to decision making in this area, and the authors state that future research should focus on which types of consultations best suit face-to-face interaction, and for whom and why.
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Content ArticleThis patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help adults with type 2 diabetes understand the risks and benefits of taking a second medication, so that they can make an informed decision about their care.
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Content ArticleThis patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help family members and carers of severe stroke patients under 60 understand the risks and benefits of decompressive hemicraniectomy, so that they can make an informed decision about treatment.
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Content ArticleThis article in Studies in Health Technology and Informatics looks at how patient-peer support can be a valuable resource for patients in the context of hospital safety. Hospitalised patients often lack access to safety systems and face difficulties in having a proactive role in their safety. The authors of this study conducted semi-structured interviews with 30 patients and caregivers at a paediatric and an adult hospital. They highlight the potential benefits of incorporating patient-peer support into patient-facing technologies and argue that helping patients access such support can help them engage with and improve the quality and safety of their hospital care.
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Content ArticleThis patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help patients with high blood pressure understand the risks and benefits of different treatment options so that they can make an informed decision about their care.
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Content ArticleThis review in Medical Decision Making looks at how healthcare organisations might successfully use patient decision aids (PtDAs) to support person-centred care. It aimed to develop context-specific program theories that explain why and how PtDAs are successfully implemented in routine healthcare settings. Based on the results of their review, the authors recommend the following strategies for organisations wishing to embed PtDAs: Co-production of PtDA content and processes (or local adaptation) Training the entire team Preparing and prompting patients to engage, Ensuring senior-level buy-in Measuring to improve
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Content Article
NHS England: Our National Patient Safety Alerts
Patient-Safety-Learning posted an article in Patient Safety Alerts
This webpage provides links to all recent NHS England national Patient Safety Alerts and sets out the criteria for issuing a Patient Safety Alert. -
Content ArticleThis is the report of an independent assurance review of North West Boroughs’ internal investigation which considered the care and treatment of mental health service user A. User A was found guilty of manslaughter in May 2018 and was ordered by the court to be detained under Section 37/41 of the Mental Health Act (1983) in a medium secure hospital. At the time of the homicide, mental health service user A was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust.
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Content ArticleThis is the recording of a presentation given to the Bristol Patient Safety Conference 2021 by Annie Laverty, Director of Patient Experience and Anna Burhouse, Director of Quality Development at Northumbria Healthcare NHS Foundation Trust. It outlines the Trust's approach to assessing staff satisfaction and wellbeing and developing improvement plans based on feedback from staff. It focuses on the impact of the Covid-19 pandemic and highlights key measures that helped maintain staff wellbeing during the first wave in Spring 2020.
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Content ArticleThis report details an independent investigation into a homicide committed by an individual receiving treatment for mental health issues. It identifies lessons that can be learned from this incident and areas where improvements to services could help prevent similar incidents occurring.
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Content ArticleThis article in BMC Health Services Research looks at a range of macro, meso and micro factors influencing eHealth innovation in the English NHS. eHealth is a broad term which encompasses e-health, m-health, telemedicine and telecare, public health surveillance, personalised medicine/patient engagement, health and medical platforms, self-tracking, medical imaging, healthcare information systems, mobile connectivity, social networking, sensors and wearables, gamification, electronic health records, big data, health information technology, health analytics, digitised health systems, robotics and active assistive living. The study found that the fragmentation of the NHS is the most significant factor limiting the adoption of eHealth innovations, arguing that national policy has intensified the digital divide. It states that the NHS Long Term Plan places great emphasis on the role of digital transformation in aiding communication and enabling people to access care quickly and easily, highlighting significant implications for effectiveness, efficiency and equity.
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Content Article
Spotting the sick child - online learning tool (2020)
Patient-Safety-Learning posted an article in Paediatrics
This online interactive tool was commissioned by the Department of Health and Health Education England to support health professionals in assessing acutely sick children. It includes footage of real patients, guidance on assessing common symptoms and real test cases. -
Content ArticleThis is the recording of a Royal College of Nursing (RCN) online event with actor David Harewood in conversation with mental health workers Simon Arday and Kojo Bonsu. Drawing on expertise from Black health care professionals and those with lived experience, the event explored what needs to be done to improve black people's experiences of mental health services. The event was chaired by Catherine Gamble RCN Fellow and Associate Director of Nursing Education South West London and St George's Mental Health NHS Trust.
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Content ArticleThis report by the Primary Care Foundation considers the question: 'Is the drive to improve outcomes and the quality of integrated urgent care being compromised by poor data quality?' The report highlights that monitoring the performance of NHS contracts is vital to allow commissioners to understand and compare the effectiveness of services, and that this monitoring cannot occur without accurate data. The authors conducted a detailed study of current data before exploring how issues in the system might be overcome. The report aims to build consensus for change within the urgent care sector.
