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Content ArticleThis article from Healthwatch outlines the communications patients should expect from their healthcare provider while they are waiting for treatment. It also describes how healthcare staff should involve patients in shared decision-making about their care and communicate clearly, personally and transparently.
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Content ArticleThis report by The Hearts, Minds and Genes Coalition for Eating Disorders aims to highlight the cost of eating disorders in the UK. It examines: the financial cost of eating disorders to the NHS the financial, social and emotional impact on individuals, families and wider society the ongoing loss of lives to treatable illnesses. It estimates the costs of eating disorders, highlights current gaps in data and gives recommendations for change.
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Content ArticleWhile the NHS delivered a remarkable amount of elective treatment during the pandemic, the pressure of caring for large numbers of patients seriously unwell with COVID-19 has led to the waiting list for elective care reaching the highest level since current records began. This analysis from The Health Foundation looks in detail at the impact of the pandemic on the waiting list for elective care in England. It highlights that: 6 million fewer people completed elective care pathways between January 2020 and July 2021 than would have been expected based on pre-pandemic numbers the backlog of elective care is not evenly distributed across England patients living in socioeconomically deprived areas faced more disruption and delays than those in England’s least deprived areas. It also looks at the difficulty in predicting how long the backlog will take to clear and how much it will cost. One unknown factor that complicates this task is 'missing' patients - those who did not or could not seek care during the pandemic. These patients may present at a healthcare setting requiring more urgent, intensive treatment as a result of missing out on earlier intervention.
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Content ArticleSerious Hazards of Transfusion (SHOT) introduced a new Human Factors Investigation Tool (HFIT) in 2021. The tool can be used to investigate and capture systemic as well as individual factors where there has been an error. This case study uses the updated Human Factors Investigation Tool and Systems Engineering Initiative for Patient Safety (SEIPS) framework to work through an ABO incompatible red cell transfusion case reported to SHOT.
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Content ArticleThis article in Patient Safety looks at a new approach to identifying and monitoring patients with sepsis developed by a team of nurses at WellSpan Health in the USA. The Central Alert Team (CAT) works remotely, looking for indicators of sepsis in patient charts and vital signs. They relay information and treatment advice to nurses working at the bedside and take an adaptive approach to find the best ways of working. This focused approach means the CAT nurses are able to quickly identify patients who are deteriorating and ensure treatment is administered at the right time.
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Content ArticleThis article published in Patient Safety discusses the role of patients and families in supporting a culture of safety. It looks at the concept of 'preoccupation with failure', a feature of high reliability organisations (HROs) and examines how patients can contribute to safety by being engaged in this process. The authors discuss a case study in which a patient contributes to safety improvements by sharing specific concerns. They draw out the importance of encouraging and empowering patients and their families to raise issues.
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Content ArticleThis article in The Joint Commission Journal on Quality and Patient Safety reports on the findings of a pilot programme to improve healthcare staff wellbeing. Between November 2018 and May 2020, researchers engaged five healthcare sites to take part in a pilot intervention. The pilot used evidence-based approaches to wellbeing including a comprehensive culture assessment, redesigning daily workflow and leadership and team development. The researchers found that healthcare worker wellbeing improved when: an integrated, skills-based approach was taken there was a focus on team culture, interactions and leadership workflows were redesigned to promote positive emotions. This study suggests that combining a number of these approaches at the same time can improve healthcare working environments and reduce levels of staff burnout.
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Content ArticleThis Annual Review contains data and infographics about patient and staff engagement with Care Opinion at 17 NHS boards in Scotland between April 2020 and March 2021. The theme of the review is 'Communication, connectivity and relationships' and it notes that use of online communication has become more widespread as a result of the COVID-19 pandemic, a factor which has contributed to increases in online patient feedback.
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Content ArticleIn this blog, PC Barry Calder, Lead of the Metropolitan Police Service Disability Staff Association COVID Peer Support Group, raises concerns about the potential impact of long COVID on staff and organisations. He highlights that organisations can take proactive steps to mitigate the consequences of staff being affected by long COVID, such as staff absences and changes to job roles. He recommends that organisations: introduce regular contingency planning activities (such as COVID Resilience meetings) ensure managers are trained to support staff living with long COVID ensure occupational health and staff wellbeing services include support relevant to long COVID consider establishing peer support groups for affected staff.
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Content ArticleWard audit is a specific and common form of audit and feedback used in hospitals around the world. This study in BMC Health Services Research describes the content of ward audits and how they are carried out. The authors found that ward audits can have unintended and sometimes negative consequences, often caused by punitive feedback. They highlight the need to make feedback more constructive, for example, by including suggestions for improvement.
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Content ArticleThis leaflet produced by Clare Rayner for The PACS (Post-Acute Covid Syndrome) International Working Group provides information for patients on diagnosing Covid-19 without a positive swab test.
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Content ArticleThis blog in The BMJ Opinion by Steph O'Donohue, content and engagement manager at Patient Safety Learning, looks at the benefits and potential risks of the midwifery continuity of carer model. Steph highlights that seeing the same midwife throughout pregnancy and during labour allows patient and midwife to build a relationship of trust and results in improved outcomes for patients and their babies. She argues that patients and families would be more vocal advocates for continuity of carer if they better understood the benefits of the model. Further reading: Midwifery Continuity of Carer: What does good look like?' Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
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Content ArticleThis new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
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Content ArticlePeople in Place highlights the fundamental skills and people issues which will determine the future of health and care in the UK. The Covid-19 pandemic has made these issues clearer and more pressing, but it has also revealed an appetite for change and resulted in innovative ways of working. This report argues that building effective collective leadership into systems and places is vital to overcome staffing and governance issues in the NHS. Focusing on building long-term frameworks for change rather than responding to immediate pressures, it suggests practical tools and resources that could be used to bring about transformation within the system.
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Content ArticleIn this systematic review published in BMJ Open, the authors analyse and compare the focus of 694 studies about safety culture in hospitals. The review identifies 11 key themes relating to safety culture across the studies. The authors suggest that the wide range of methods and tools available highlights a persistent lack of consensus in defining patient safety. They also highlight the value of qualitative and mixed method approaches in providing context and meaning to quantitative surveys that assess safety culture.
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Content ArticleMany diagnostic mistakes are caused by reasoning errors, but lack of feedback makes it difficult for healthcare providers to make improvements in this area. This paper, published in BMJ Quality & Safety, describes the reason for and process of developing 'The Diagnosis Learning Cycle', a new model for feedback and improvement in diagnosis. The model is based on theory and knowledge from both outside and within the field of healthcare. It proposes a standardised feedback mechanism that includes concrete measures of factors such as reasoning and confidence.
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Content ArticleThe authors of this research study, published in BMJ Quality & Safety looked at the issues of hazardous prescribing and inadequate monitoring in patients with mental health issues being managed in primary care. They identified a lack of data in this area, despite most patients with mental illness receiving treatment in a primary care setting. The study found that: 9.4% of patients ‘at risk’ triggered at least one indicator for potentially hazardous prescribing. The risk was greatest for patients aged 35–44, females and those receiving more than 10 repeat prescriptions. 90.2% of patients ‘at risk’ triggered at least one indicator for inadequate monitoring. The risk was particularly high in people under the age of 25, females and those with one or no repeat prescription. The authors of the study hope their findings will support providers to reduce risk and improve care for patients who receive mental health treatment in primary care.
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Content Article
Mindfulness and safety
Patient-Safety-Learning posted an article in Incentives and techniques
Current research suggests that staff mindfulness practices can contribute to better safety outcomes. Researchers at the University of Houston have conducted a systematic review of studies that assess the relationship between mindfulness and safety at work. The study suggests that: mindfulness training does not need to be lengthy or frequent to have a significant impact on workplace safety different mindfulness training techniques are better suited to specific industries such as healthcare and the military. -
Content ArticleThe Children and young people with Long COVID (CLoCk) study is the largest study to date of children and young people in the world. It aims to describe how children and young people are affected by post-COVID physical symptoms and mental health problems and to identify those most at risk. The CLoCk study is led by UCL and Public Health England and involves collaboration with researchers at the universities of Edinburgh, Bristol, Oxford, Cambridge, Liverpool, Leicester, Manchester as well as King’s College London, Imperial College London, Public Health England, Great Ormond Street Hospital and University College London Hospitals (UCLH).
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Content ArticleThis article in the Journal of Patient Safety & Quality Improvement examines the impact of the Covid-19 pandemic on patient safety reporting and procedures in 33 healthcare settings in Indonesia. The authors found that: patient safety data was recorded and reported less often during 2020, partly due to fewer hospital attendances. the pandemic has had a significant positive impact on hospital staff's compliance with handwashing policies. surgical procedures were less accurate during 2020, as surgical staff sought to reduce infection risk by missing safety procedures such as the surgical checklist.
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Content ArticleMany elective orthopaedic procedures were cancelled due to the Covid-19 pandemic and the number of patients on waiting lists for surgery is rising. This study looks at the disparities between inpatient and day-case orthopaedic waiting list numbers and the ‘hidden burden’ that exists due to reductions in elective secondary care referrals. The authors looked at elective procedures at a single District General Hospital in the UK between 1 April and 31 December 2020 and compared data with the same nine-month period from 2019. The study found: a 52.8% reduction in elective surgical workload in 2020 the total number of patients on waiting lists had risen by 30.1% in just 12 months inpatient waiting lists have risen by 73.2%, compared to a 1.6% rise in the day-case waiting list new patient referrals from primary care and therapy have reduced by 49.7%. The authors highlight the disparity between inpatient and day-case waiting lists and predict an influx of new referrals as the pandemic eases. They call for robust planning and allocation of adequate resources to deal with the backlog.
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Content ArticleThis report by Roger Kline brings together a range of research evidence to suggest practical steps NHS employers can take to reduce inequalities in staff recruitment and career progression. It specifically focuses on the treatment of female, disabled and BAME staff. Written for practitioners, it summarises some of the research evidence on fair recruitment and career progression. It highlights principles drawn from research that underpin the suggestions made for improving each stage of recruitment and career progression.
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Content ArticleDouble-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors. The authors found that: most nurses complied with mandated double-checking, but the process was rarely independent when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious. They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.
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Content ArticleIn this editorial for BMJ Quality & Safety, Dr Tamasine Grimes makes the case for greater patient involvement in managing medication, particularly at points of transition in care. She comments on a recent report on the effects of MARQUIS2, an evidence-based toolkit trialled in North American hospitals to help manage complex medication. The report found that interventions that involved patients in managing their medication had a significant effect in decreasing medication discrepancies, while purely system-level interventions did not.
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Content ArticleDiagnostic errors have a negative impact on patient treatment and cost healthcare systems a large amount in wasted resources. This paper published by the Deeble Institute for Health Policy Research looks at diagnostic errors related to medical imaging in Australian public healthcare. It also looks at health policies that have been used internationally to improve the use of diagnostic imaging and reduce the consequences of diagnostic errors. The authors recommend: implementing a national strategy in Australia to identify and prevent diagnostic errors analysing medical indemnity claims to help measure the incidence and consequences of diagnostic errors.
