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Content ArticleMany prisoners still struggle to access hospital services despite their significant health care needs, and early data suggests the pandemic has worsened access further. This report by the Nuffield Trust considers new evidence relating to pre-existing health conditions before prison, the use of remote consultation, different ethnic groups' use of health services and the early impact of the Covid-19 pandemic.
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Content ArticleThis study in BMJ Quality & Safety examines how much electronic differential diagnostic support (EDS) systems improve diagnostic accuracy, and whether EDS should be used early or late in the diagnostic process. Using a volunteer sample of medical students and doctors at six Canadian medical schools, the authors compared the rate of correct diagnosis when EDS was used early and late in the diagnostic process. The study found that EDS increased the number of diagnostic hypotheses and the likelihood of correct diagnosis, and that these effects persisted whether EDS was used early or late in the diagnostic process.
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Content ArticleIn this blog for The BMJ, several doctors who are experiencing long term impacts of Covid-19 share their report of a meeting with the World Health Organization's Covid-19 response team in August 2020. They highlighted the importance of patient-led research and and engaging with patients with Long Covid.
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Content ArticleThis study in Anaesthesia reviewed accidental spinal administration of tranexamic acid. The review identified 20 cases of accidental administration resulting in life-threatening neurological or cardiac complications and 10 patient deaths. These cases were analysed using a Human Factors Analysis System Classification model to identify contributing factors. Ampoule error was the cause in 20 incidents, and all were classified as skills-based errors. Organisational policy, storage of medication and preparation for anaesthesia were all identified as contributing factors. The authors concluded that all of these events could have been avoided if four published recommendations for the prevention of spinal medication administration were implemented.
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Content ArticleIn this article, the journalist Peter Hitchens examines the link between mental illness, prescription and illegal drugs and violent acts of terrorism. He argues that more attention needs to be given to defendants' mental health record, medication history and any past substance abuse.
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Content ArticleThis is a presentation given by the Quality and Safety Department at the Sussex Community NHS Foundation Trust to the Patient Safety Management Network on 22 October 2021. It provides an overview of how they have been developing the Trust’s approach to patient safety, focusing on safety culture, learning for improvement and aiming to raise the profile of patient safety within their organisation.
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Content ArticleRacial and ethnic disparities in health and healthcare continue to be widespread. Research has repeatedly confirmed that members of racial and ethnic minority groups in the US are more likely to experience disparities in care, including having an increased risk of being uninsured or underinsured, lacking access to care, and experiencing worse health outcomes for treatable and preventable conditions. This brief from the Emergency Care Research Institute (ECRI) outlines strategies for understanding, detecting and reducing disparities. It demonstrates that alongside the moral case for addressing racial and ethnic disparities in care, there are further benefits for staff and healthcare organisations.
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Content ArticleIn this blog, Kerry Robinson, director of performance, improvement and organisational development at The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, describes a systemic approach to quality improvement that involves board members having a visible role in the process. The aim is to ensure the board's actions match up with the rhetoric on leadership for improvement. Kerry explains the actions she is personally taking as a board member to lead by example in quality improvement.
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Content ArticleIn this blog for The BMJ Opinion, John Middleton argues that the Government must act now, or be faced with much tougher decisions and less popular choices as the winter kicks in. He describes the increasing rates of Covid-19 in the UK and the need for action to avoid a healthcare crisis this winter, highlighting that the NHS and the BMA have both called for urgent action to protect the NHS. He urges the Government to take a multi-faceted approach and use the 'Swiss Cheese' model to combat the spread of coronavirus, rather than focusing on single measures. Living with the virus involves changes to normal life, but they are a small price to pay to save lives, protect people from the long term effects of Covid and prevent the evolution of new virus strains.
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EventuntilThis virtual national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). The PSIRF now been published for the early adopter sites, the final version is due in Spring 2022, and is due to be fully introduced in all organisations during 2022. The conference will examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. This conference will enable you to: network with colleagues who are working to improve the investigation of serious incidents and deaths in mental health services ensure your approach to Serious Incident Investigation is in line with the NHS Patient Safety Strategy learn from outstanding practice in implementing the Royal College of Psychiatrists Mortality Care Review Tool reflect on the lived experience of a bereaved relative improve the way you involve and engage families and carers in the investigation process develop your skills in incident investigation and mortality review understand how you can improve serious incident investigation and understand the recent developments including the New Patient Safety Incident Response Framework identify key strategies for undertaking a self assessment, and continuous review of deaths and investigation practice in your organisation understand how human factors can help improve learning from serious incident investigation ensure you are up to date with the role of the coroner understand how you can better support staff when a serious incident occurs self assess and reflect on your own practice gain CPD accreditation points contributing to professional development and revalidation evidence. Find out more and book a place Flyer - investigation-of-deaths-in-mental-health-jan-2022.pdf
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Content ArticleIn this episode of the podcast Health on the Line, Professor Trish Greenhalgh, professor of primary care health sciences at the University of Oxford provides a scientific take on the COVID-19 pandemic and its implications on primary care and scientific innovation. The world-renowned professor and trained GP also offers her view on virtual care, vaccine inequity and why innovation happens at times of turbulence.
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Content ArticleThis document provides guidance for maternity services and Local Maternity Systems on how to develop a local plan for achieving Midwifery Continuity of Carer as the default model of care offered to all women. The guidance sets out recommended practice, how delivery against these plans will be assured nationally, and how provision will be measured at provider and Local Maternity System level. Midwifery Workforce Tools designed to help midwifery leaders safely plan, simulate and design maternity services can be used alongside this guidance.
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Content ArticleIn this blog for the Nursing Times, Fiona Hibberts, head of the Nightingale Academy and consultant nurse at Guy's and St Thomas' NHS Foundation Trust, discusses the importance of huddles in improving patient safety and care, and in providing emotional support for staff. The author describes a huddle as "a gathering of key individuals, at a given time, to briefly discuss safety aspects of care of a group of patients in real time, escalate concerns and make plans," and highlights their importance for staff morale during the COVID-19 pandemic.
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Content ArticleA Patient Safety Huddle is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. This evaluation of The Huddle Up for Safer Healthcare (HUSH) project in BMC Health Services Research aims to assess the impact on teamwork and safety culture of the project, which implemented PSHs in 92 wards at five hospitals, across three NHS Trusts. This paper also seeks to add to the evidence-base around huddles as a mechanism for improving safety.
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Content ArticleShared decision making (SDM) is when patients and clinicians work together to make evidence-based decisions based on patient values and preferences. This may be to select a test or intervention, such as going ahead with surgery. SDM ensures individuals are supported to make decisions which are right for them. The Centre for Perioperative Care has a number of resources on their website on shared decision making.
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Content Article
This white paper sets out the symbiotic relationship between healthcare worker safety and patient safety. It makes the case for a new focus on improvements in patient and healthcare worker safety, and on the relationship between them, to prevent safety incidents and deliver better outcomes for all. It has been published by the Safety for All campaign, set up by the Safer Healthcare and Biosafety Network (SHBN), an independent forum focused on improving healthcare worker and patient safety, including Patient Safety Learning and the Association of British HealthTech Industries. -
Event
Long Covid Nurse Expert Group Re-launch
Patient-Safety-Learning posted an event in Community Calendar
untilThe Queen's Nursing Institute (QNI) is delighted to invite you to a free online event for the Long Covid Nurse Expert Group Re-launch. The Long Covid nurse expert group was set up by the QNI to examine issues and practice related to the management of Long Covid in community, primary care and social care settings. Find out more about the Long Covid Nurse Expert Group Sign up for the event If you have any queries about the group or event, contact Eve Thrupp -
EventuntilSurgical site infections after spine surgery increase the likelihood of patient mortality and drive up the cost of care. More than 156,000 postoperative spine infections could be averted with better screening and preventative measures, according to a study published in Global Spine Journal. During this webinar, experts will discuss the problem of spine surgery SSIs and effective preventative measures. Learnings include: Best practices for improving surgical outcomes in spine procedures. Protocols to mitigate the risk of surgical site complications in spine procedures and increase patient satisfaction. Presenters Joshua Heller, MD, MBA, Associate Professor, Neurological Surgery and Orthopaedic Surgery, Jefferson University Hospitals Roger Hartl, MD, Neurological Surgery, Weill Cornell Medicine
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Content ArticleToo often in healthcare, when effective solutions to prevent avoidable harm are found, there is a lack of means to share these more widely. This gap between learning and implementation means that while we may we know what improves patient safety, this information can often remain siloed in specific organisations and health care systems. This results in patients continuing to experience harm from problems that have already been addressed by others. This article published in the Journal of Patient Safety and Risk Management describes how the charity Patient Safety Learning created the hub, a platform to encourage and support shared learning for patient safety. Designed by and for patient safety professionals, clinicians and patients, the hub offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients.
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Content ArticlePatients and their families are usually the first to notice new or changing symptoms and they can play an important role in preventing diagnostic errors. This blog in BMJ Opinion describes how researchers, healthcare professionals and patients worked together to develop OurDX, an online tool designed to improve the efficiency of medical appointments and reduce diagnostic errors.
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Content ArticleThe national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is to support standardised perinatal mortality reviews across NHS maternity and neonatal units. Unlike other reviews or investigation processes, the PMRT makes it possible to review every baby death after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,981 reviews which were completed between March 2020 and February 2021.
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Content ArticleThese tools and worksheets have been produced by NHS England to assist staff in conducting patient safety incident investigations. NHS England stresses that patient safety investigation is an important and complex task and should only be undertaken by those who have attended training and gained skills and experience from specialists in the field.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk caused by delays in diagnosing lung cancer. Lung cancer is the third most common cancer diagnosed in England, but accounts for the most deaths. Two-thirds of patients with lung cancer are diagnosed at an advanced stage of the disease when curative treatment is no longer possible, a fact which is reflected in some of the lowest five-year survival rates in Europe. Chest X-ray is the first test used to assess for lung cancer, but about 20% of lung cancers will be missed on X-rays. This results in delayed diagnosis that will potentially affect a patient’s prognosis. The HSIB investigation reviewed the experience of a patient who saw their GP multiple times and had three chest X-rays where the possible cancer was not identified. This resulted in an eight-month delay in diagnosis and potentially limited the patient’s treatment options.
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Content ArticleAppreciative inquiry is a collaborative, strengths-based approach to change in organisations and other human systems. It identifies the positive strengths of an organisation or system and builds on these, rather than focusing on problems that need to be fixed. This article for PositivePsychology.com outlines the history, theory and framework of appreciative inquiry, as well as looking at real-life examples.
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Content ArticleThis article in Social Science & Medicine examines how GPs and patients explore medical and existential uncertainty in consultations. The authors analysed 20 naturally occurring clinical consultations between general practitioners and patients in England, focusing on interactions and how they negotiated uncertainty. They found that the doctor-patient dynamic contributes significantly to the way in which medical uncertainty is discussed. By conceptualizing uncertainty in an indirect and depersonalized manner, GPs manage to safeguard against clinical errors without compromising their authority and credibility.
