Jump to content
 View Profile  See their activity

  • Posts

    4,057

  • Joined

  • Last visited

Patient-Safety-Learning

PSL Moderators

 Content Type 

Everything posted by Patient-Safety-Learning

  1. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Magda talks to us about her role as Family Liaison Officer Team Lead, how PSIRF has changed the way her Trust involves patients and families after patient safety incidents and the importance of placing patient and family perspectives at the heart of learning responses.
  2. Content Article
    This cohort study in JAMA Network Open aimed to assess how patients receiving radiation treatment for cancer rated their satisfaction with fully remote management by doctors. It also identified the associated safety events, financial implications and environmental consequences. The authors found that: more than 99% of safety events did not reach patients or caused no harm to patients. 98% of patient ratings of satisfaction with fully remote management were good to very good. out-of-pocket cost savings associated with fully remote management totalled approximately $612 913 ($466 per patient). estimated carbon dioxide emissions decreased by 174 metric tons.
  3. Content Article
    In this JAMA Internal Medicine article, doctors Jessica Holtzman and Rita Redberg argue that for decades, women have been inadequately represented in clinical trials of drugs and devices evaluated by the US Food and Drug Administration (FDA). Looking at existing evidence on the issue, they identify barriers and improvements to women's representation in trials. They argue that the FDA needs to take action by declining to review medical devices and drugs if the representation of women does not reflect the intended use population.
  4. Content Article
    More than four million people have type 2 diabetes in the UK and the use of new technologies is becoming essential for effective diabetes care and patient empowerment. This report by Public Policy Projects (PPP) highlights the benefits of continuous glucose monitoring (CGM) for people with type 2 diabetes who use insulin, but finds that access remains limited due to stigma and financial barriers. The report contains findings that emerged during the second roundtable of PPP’s System-wide Strategies for Better Diabetes Care programme, which is designed to identify opportunities for improvements and transformation in diabetes care. The roundtable was attended by more than 30 sector leaders from primary and secondary care, pharmacy and integrated care system (ICS) and key industry representatives. The overarching theme was the opportunities and challenges brought by CGM technology to type 2 insulin users and other patient groups. The report finds that primary care staff are under-resourced to deal with the number of new guidelines published, and this is influencing willingness to adopt and push this technology. Also, financial constraints and stigma around the visibility of the sensor are slowing down the effective rollout of the technology across the UK.
  5. News Article
    An ambulance trust with a long history of cultural problems saw the proportion of staff reporting being bullied or harassed increase in 2023. The survey by East of England Ambulance Service Trust found 35 per cent of staff who responded said they had experienced bullying or harassment over the last 12 months—up from 32 per cent in 2022, and 25 per cent in 2020. The work commissioned by the trust also found that many staff who had experienced or seen bullying, or racial or sexual harassment, did not report it, with fear of retaliation being a key factor in their decision. Less than 40 per cent said they would speak to a Freedom to Speak Up Guardian about concerns. The trust—which has made high-profile efforts to address cultural issues in recent years—said it was normal to see a rise in complaints as staff became aware poor behaviour would not be tolerated, and felt safer to speak out. Hein Scheffer, the trust’s director of strategy, culture and education, said: “Bullying, harassment and poor behaviour have no place in our organisation and we regularly survey our people’s experience of workplace behaviours to help us root this out. We are working hard to improve our culture and we are among the most improved NHS organisations in England for staff feeling confident in speaking out – with 63% describing the trust as supportive." Read full story (paywalled) Source: HSJ, 12 June 2024
  6. Content Article
    Hospital-acquired pressure injuries (HAPIs) pose significant challenges in healthcare and cause increased patient suffering, longer hospital stays and higher healthcare costs. Children in hospital face unique risks, but evidence about this remains scarce. This study in the Journal of Advanced Nursing aimed to identify and describe HAPI admission incidence and severity predictors in a large Australian children's hospital. The authors found that HAPI injuries in paediatric patients are unacceptably high. They argue that prevention should be prioritised and the quality of care improved globally. They also call for further research to develop targeted prevention strategies for these vulnerable populations.
  7. Content Article
    People who have used health services are often invited to offer their expertise through research, service evaluation, giving patient experience talks or other forms of feedback. This is often referred to as Patient and Public Involvement (PPI). This guidance by Imperial College London and the National Institute for Health and Care Research (NIHR) is intended for healthcare professionals, staff who work in patient experience roles, healthcare organisations, researchers and others who interact with service users and their relatives who are giving insight and feedback through a PPI process. It has evolved from the lead author’s observations when contributing to PPI activities, and the recognition that more needs to be done to create a safe psychological environment to enable people to feel comfortable when contributing and to be involved without harm.
  8. Content Article
    Using open-text responses from the Bereaved Family Survey (BFS), this study in the American Journal of Surgery sought to explore Veteran family experiences on end-of-life care after surgery. Families that left open text comments often expressed a belief in their loved one's unnecessary pain, expressing distrust in the treatment decisions of the care team. The results also showed that limited communication about the severity of disease or risks of surgery caused conflicting and unresolved narratives about the cause or timing of death. Families also described feelings of disempowerment when they were not involved in decision-making and when their wishes were not respected.
  9. Content Article
    The doctor-patient relationship should be immune from bias, but growing evidence challenges doctors’ objectivity. In this study in Science, the authors analysed vast data from US military emergency departments, where active-duty doctors and patients have military ranks and some patients outrank their assigned doctor. The study found that patients who outranked their doctors enjoyed more clinician effort and better health outcomes because more resources were inequitably invested in their care. The results also showed that White physicians consistently put less effort into caring for Black patients. The authors suggest that power-driven variation in behaviour can harm the most vulnerable populations in health care settings.
  10. Content Article
    In this blog, Laura Green, Consultant Haematologist at NHS Blood and Transplant and Barts Health NHS Trust, describes how a new electronic process to improve the safety of blood transfusions was implemented across all four Barts Health sites. She explains why the new system was needed, outlines the benefits for staff and patients and highlights the role of project governance and staff training in successful implementation.
  11. Content Article
    Intravenous drug administration has been associated with severe medication errors in hospitals. This narrative review and aimed to describe the recent evolution in research on systemic causes and defences in intravenous medication errors in hospitals. It highlights a growing interest in systems-based risk management for intravenous drug therapy and in introducing new technology, particularly smart infusion pumps and preparation systems, as systemic defences. The authors conclude that when introducing new technologies, prospective assessment and continuous monitoring of emerging safety risks should be conducted.
  12. Content Article
    This article in the Journal of Patient Safety argues that embedding patient safety initiatives is not just about establishing linear protocols, but changing the habits of complex organisations, beginning at the level of the clinical team. They highlight that Safety II is drawing attention to the complexity in healthcare systems and outline the use of Cultural-Historical Activity Theory (CHAT) as a way to align learning theory and complexity theory as a framework for patient safety initiatives.
  13. Content Article
    Evidence shows that nurse staffing affects patient safety events (PSEs), but the role of an appropriate nursing care delivery system remains unclear. This Japanese study aimed to investigate whether nursing care delivery systems could prevent PSEs. The findings suggest that in an emergency intensive care unit, a collaborative nursing care delivery system was associated with a decrease in PSEs.
  14. Content Article
    The NHS is the world’s largest publicly funded health service. It is also the world’s largest repository of healthcare data, but these data are fragmented and underutilised. Making them accessible in one place would improve health and deliver wealth for the nation. This report by the Tony Blair Institute for Global Change proposes the creation of a National Data Trust (NDT)—an organisation which would be majority-owned and controlled by the government and the NHS, together with investment from industry partners. It would aim to connect NHS data, attract private investment in new medical discoveries and bring the economic benefits of health innovation to citizens. The authors believe the NDT would accelerate the NHS’s development of cutting-edge innovations, provide quicker access to these advancements at reduced costs and generate a new funding source for the healthcare system. 
  15. Event
    This webinar for UK healthcare professionals will be delivered by DISN UK Group committee members. It will focus on using diabetes technology–insulin pumps, CGM, POCT–in the hospital. We will discuss and outline the newest JBDS technology guideline and provide the attendees with most up to date information regarding using diabetes technology when a person with diabetes is admitted to hospital. Educational outcomes – 3 points: Recognise different types of diabetes technology Use of diabetes technology in the different scenarios in inpatient setting Effective support for people with diabetes and use of diabetes technology when admitted to hospital Register for the webinar
  16. News Article
    The proportion of NHS staff who have experienced physical violence from patients has fallen to its lowest levels in five years, according to the latest survey data. New figures showed the percentage of staff reporting at least one incident of physical violence from patients or the public, within the last 12 months, had declined from 15.1 per cent in 2019, down to 13.7 per cent in 2023. That is also almost one percentage point lower than 14.6 per cent in 2022, which is the biggest year-on-year percentage point fall in the five years. The 2023 NHS staff survey, first published in early March, was updated recently to include the questions on physical violence. NHS England said earlier this week it had received a “higher than expected rate of missing data” for the questions, which meant they were not originally reported, but these issues had now been resolved. However, ambulance workers remain disproportionately affected by physical violence compared to other roles, with 27.6 per cent saying they had experienced at least one instance of physical violence from patients or the public in the past year. This is down from 32.5 per cent five years ago in 2019. Acute and community staff were the next highest (13.7 per cent), followed by mental health (13.5 per cent), community (7 per cent), and then acute specialist (5.3 per cent). Read full story (paywalled) Source: HSJ, 5 June 2024
  17. Content Article
    The maternity disadvantage assessment tool (MatDAT) is a standardised tool for assessing social complexity during maternity care based on women and birthing people’s broad social needs. Developed by the Royal College of Midwives (RCM), it provides a guide for midwives to identify the woman’s care level (Level 1–4) and develop a personalised care and support plan (PCSP), as well as facilitating smooth communication with the multidisciplinary team. The tool and the MatDAT Planning Guide also support maternity services to plan and allocate resources to level of care pathways.
  18. News Article
    A national study is examining whether a treatment for premature babies could cause harm, amid concerns about the deaths of four infants last year, it has emerged. HSJ has learned a national study into the use of prophylactic low-dose hydrocortisone steroids, also known as “premiloc”, is being carried out at the Neonatal Data Analysis Unit, part of the Imperial College London Medical School. Meanwhile, University College London Hospitals Foundation Trust confirmed that four children died in January and February 2023 last year, having been transferred from UCLH to nearby Great Ormond Street Hospital, after receiving the treatment. They had been given hydrocortisone steroids at UCLH to reduce the risk of developing a lung condition called bronchopulmonary dysplasia. UCLH said its own internal investigations “did not confirm a direct link” between the deaths and the drug, “but concern remained” so they were reported to the regional neonatal network. UCLH noted that the national study at Imperial was now under way, although the Imperial team told HSJ it was not specifically aware of the UCLH/GOSH deaths last year. A report from GOSH’s safety team last year, seen by HSJ, said: “In all four deaths the mortality review group identified modifiable/potential modifiable factors around the administration of premiloc prior to admission to GOSH. Administration of premiloc (hydrocortisone steroids) to these babies may have been associated with the subsequent perforations. A series of incidents of perforations was flagged to the UCLH neonatal unit who reviewed data and have stopped the administration of premiloc.” Read full story (paywalled) Source: HSJ, 5 June 2024
  19. Content Article
    This study in BMC Infectious Diseases aimed to estimate the contribution of individual interventions (together and in combination) to the effectiveness of the overall package of interventions implemented in English hospitals during the Covid-19 pandemic. The study simulated scenarios to explore how many nosocomial infections might have been seen in patients and healthcare workers if interventions had not been implemented. We simulated the time period from March 2020 to July 2022 encompassing different strains and multiple doses of vaccination.
  20. Content Article
    Sofia Mettler, MD, describes the day when the electronic medical records (EMR) system at her hospital failed and the impact this had on clinical decision making. She highlights that the downtime forced doctors across the hospital to speak with patients about their condition and symptoms, and to collaborate with the nurses who had been monitoring them all night. It also made her realise that the many test results she was used to referencing for every patient were not all necessary to make clinical decisions. She reflects, "The EMR downtime made me realise that while the system seems to make our clinical routine convenient, it may not result in increased efficiency or better patient care."
  21. Content Article
    This multihospital prospective study in Surgery aimed to determine whether strict adherence to an enhanced recovery after surgery protocol leads to improvement in outcomes, compared with less strict compliance. The study looked at all consecutive anatomic lung resection patients on the thoracic enhanced recovery after surgery pathway from May 2021 to March 2023 and compared this cohort with a historical control from January 2019 to April 2021. The authors found that enhanced recovery after surgery protocols improve outcomes after anatomic lung resection, and that increasing compliance to individual elements further improves patient outcomes. They argue that continued efforts should be directed at increasing compliance to individual protocol elements.
  22. News Article
    More hospital patients with learning disabilities will die if politicians do not tackle the “devastating collapse” in specialist nurse numbers, a leading charity and a union have warned. The number of specialist learning disability nurses working in the NHS has dropped by 44 per cent over the course of the Conservative party’s time in government, a new analysis by the Royal College of Nursing (RCN) has revealed. The nursing union found a 36 per cent drop in applicants for specialist nursing degrees, while applicants are so low some universities have stopped funding courses altogether, according to a report shared exclusively with The Independent. The RCN and the charity Mencap have warned specialist nurses are vital in keeping patients with learning disabilities in hospital safe, as they are trained to spot life-threatening illnesses, such as sepsis, which can present differently. Dan Scorer, head of policy at Mencap, said: “Learning disability nurses have that in-depth training and understanding about the complexity of how people with a learning disability can present, and about how they will show they are experiencing pain. They’ve got vital expertise and insights to make sure that we don’t miss things.” He said the government must increase the number of training places available, and warned some universities have stopped courses altogether. He added: “I think the government removing bursaries for nurse training was pretty devastating. The impact of that was really significant, and whilst that’s been partially reversed, it significantly impacted the undergraduate training capacity that was available.” Read full story Source: The Independent, 4 June 2024
  23. Content Article
    Over 65% of all new drugs undergo expedited drug approval in the USA, and these drugs have been linked to a higher prevalence of adverse drug reactions, raising concerns about safety. It is well documented that women generally report a higher frequency of adverse drug reactions than men, but whether women have more adverse drug reactions than men from drugs approved via expedited pathways is unknown. This brief Lancet article outlines the findings of a systematic review that assessed sex differences in data reporting and highlighted a knowledge gap as to whether women face a higher risk of harm through expedited approval pathways than men.
  24. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Making Families Count is an organisation that offers practical training based on lived experience to healthcare professionals.  Rosi talks to us about how MFC training benefits patient safety and improves the way in which patients and families are involved in incident investigations. She explains how she came to be involved in MFC after the death of her son Nico and outlines the vital importance of seeing patient and family voices as equal to those of people working for healthcare organisations.
  25. Content Article
    Despite not being indicated for lactation in the UK, the anti-sickness medicine domperidone is increasingly being prescribed or bought illegally to aid lactation, but its side-effects can include anxiety, depression and suicidal thoughts. In this account for The Guardian, Rose Stokes describes her experience of being prescribed domperidone after the birth of her son. When her milk production didn't increase and with her mental health rapidly deteriorating, Rose bought her own supply of the drug online and through a private doctor and ended up taking more than five times the NHS maximum dose. When her mental state continued to worsen, she decided to suddenly stop taking domperidone which left her suicidal. She describes receiving no guidance on the mental health risks associated with the medication or sudden withdrawal.
×
×
  • Create New...