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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    This article in The Lancet looks at the need to prioritise palliative care and medications during armed conflict. The authors argue that the Israel–Hamas conflict amplifies the dire need for access to morphine and other essential palliative care medicines included on WHO's Model Lists of Essential Medicines in order to alleviate serious health-related suffering during humanitarian crises. They outline calls that the global palliative care community has made to the World Health Organization (WHO) and other aid organisations to: add adequate oral and injectable morphine and other pain-relieving medicines in humanitarian aid response packages ensure adequate essential medicine supplies for surgery and anaesthesia provide guidelines on the safe use of essential medicines and their distribution to all aid and health workers collaborate with receiving authorities to prevent removal of controlled medicines from emergency kits include paediatric essential medicine formulations for children. They argue that opioids and other essential palliative care medicines equip health workers with the means to relieve serious health-related suffering across clinical scenarios when curative or life-saving interventions are unavailable.
  2. Content Article
    In its 75th anniversary year, the strains on the NHS are all too clear, with demand from an ageing population increasing, while the number of patients treated is still lower than before the pandemic. The Chancellor recently announced the “most ambitious productivity review ever undertaken by government”, yet it is unclear how to bring about the necessary productivity improvements in the NHS to meet the challenges of the future.  For the 2023 REAL challenge lecture, Professor Dame Diane Coyle, Bennett Professor of Public Policy at the University of Cambridge, explored some of the key drivers of UK healthcare productivity and discuss what we might hope the NHS will look like when it reaches its centenary. You can watch the video of the lecture and download the slides below.
  3. Content Article
    The National Child Mortality Database (NCMD) has published its latest Thematic Report. Based on data from April 2019 to March 2022, this report includes child deaths where infection may have contributed to the death and those where infection provided a complete and sufficient explanation of death. The Thematic Report covers: variations in incidence of child deaths with infection infection related deaths characteristics of children who died where infection may have contributed or caused the death and where infection provided a complete and sufficient explanation of death details of the infections and their clinical presentations. It also includes learning from Child Death Overview Panel (CDOP) completed child death reviews where death was categorised as infection, as well as next steps.
  4. Content Article
    This cross-sectional study in JAMIA Open aimed to identify concerns, barriers and facilitators impacting the use of patient portals by older patients, as well as desired features in future updates. The authors held two focus group discussions culminating in an anonymous survey completed by women who were 65 years and older receiving urogynaecology care in Northwest Ohio. The authors concluded that the lack of age-aligned medical access software and products may lead to worsening digital exclusion and disparities in healthcare. Portal application developers and healthcare systems must advance efforts that consider the needs of those who are older when designing patient portals.
  5. Content Article
    Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice, but little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the Covid-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which can be accessed via the link to the paper). These provide: an introduction to the AAR facilitation process a simulation of a facilitated formal AAR techniques for handling challenging situations that may arise in an AAR reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.
  6. Content Article
    In this article for the Byline Times, Saba Salman highlights the results of the latest NHS-funded annual review of deaths among people with learning disabilities. The report lays bare how people with learning disabilities are less likely to survive health problems that are preventable and treatable than those without learning disabilities. Researchers at King’s College London, the University of Central Lancashire and Kingston University London reviewed the deaths of 3,648 people with a learning disability. Overall, almost half died an avoidable death, compared to two in 10 in the general population. The median age of death in was 63 years, which is around 20 years less than for people without learning disabilities.
  7. Content Article
    In this article, NHS England reports on progress in achieving the aims of the National patient safety strategy which was released in 2019: saving an additional 1,000 lives and £100 million per year. The article suggests that in 2023, the NHS is halfway to reaching this target and shares the following highlights: The National Patient Safety team, supported by staff across the NHS identifying and recording patient safety incidents, continues to save an estimated 160 lives per year through mitigation of risk. This is also estimated to reduce disability due to severe harm incidents by around 480 cases per year and to save £13.5 million in additional treatment costs. Since the strategy was launched, an estimated 291 fewer cases of cerebral palsy have occurred since September 2019 due to the administration of magnesium sulphate during pre-term labour as part of the PReCePT programme, supported by the Patient Safety Collaboratives. This has saved up to £291 million in lifetime care costs, assuming £1 million per case. Work supported by the Maternity and Neonatal Safety Improvement Programme to ensure optimal cord management during labour has saved up to 465 lives since 2020. We estimate 414 fewer deaths and 2,569 fewer cases of moderate harm due to long term opioids following the work of our Medication Safety Improvement Programme since November 2021. The Medication Safety Improvement programme has also led to: 420 fewer admissions for major bleeds per year from anticoagulants and non-steroidal anti-inflammatory drugs (NSAIDs), 1,979 fewer cases of drug induced acute kidney injury, 104 fewer asthma/COPD admissions due to sub-optimal inhaler prescribing, 1,000 fewer patients at risk of methotrexate overdose and 16,920 hospital readmissions avoided by Discharge Medicines Service. It is estimated this has released over £7 million in admissions costs. Early adopters of the Patient Safety Incident Response Framework (PSIRF) are reporting improved safety cultures, identification of more effective risk reduction strategies and early signs of harm reduction, due to their revised approach. It is estimated that there are 36 fewer gas misconnection events every year, each one representing a potential death or severe harm event, due to a focus on reducing risks through the Never Events Framework and National Patient Safety Alerts (NPSAs). 11,621 care homes have been engaged on work to improve management of patient deterioration. This leads to reduced 999 calls, fewer emergency admissions and shorter lengths of stay. 38 mental health wards piloting work on restraint, seclusion and rapid tranquilisation have seen a 15% reduction in those practices.
  8. Content Article
    The ethnicity data gap pertains to three major challenges to address ethnic health inequality: Under-representation of ethnic minorities in research Poor data quality on ethnicity Ethnicity data not being meaningfully analysed. These challenges are especially relevant for research involving under-served migrant populations in the UK. This study in BMC Public Health aimed to review how ethnicity is captured, reported, analysed and theorised within policy-relevant research on ethnic health inequities. The authors concluded that the multi-dimensional nature of ethnicity is not currently reflected in UK health research studies, where ethnicity is often aggregated and analysed without justification. Researchers should communicate clearly how ethnicity is operationalised for their study, with appropriate justification for clustering and analysis that is meaningfully theorised.
  9. Content Article
    Health and social care standards have been widely adopted as a quality improvement intervention. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve stakeholders at multiple levels and multiple activities across diverse services. As such, challenges exist with their implementation. Existing literature relating to standards has focused on accreditation and regulation programmes and there is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. This systematic review aimed to identify and describe the most frequently reported enablers and barriers to implementing (inter)nationally endorsed standards, in order to inform the selection of strategies that can optimise their implementation.
  10. Content Article
    NHS organisations are able to record patient safety events to the Learning From Patient Safety Events (LFPSE) system via the online recording form or via LFPSE service compliant risk management software. This web page provides details on which organisations have connected to the LFPSE service via their local risk management system.
  11. Content Article
    Elective recovery plans in part rely on the strengths of Surgical Hubs (SH) and Community Diagnostic Centres (CDC) to provide additional support. This report by the Medical Technology Group (MTG) considers how well these new tools are working for the NHS. It raises questions about how SHs and CDCs have been established and the decision making processes within these services.
  12. Content Article
    The Paediatric Intensive Care Audit Network (PICANet) has published the National Paediatric Critical Care Audit State Nation Report 2023. Based on a data collection period from January 2020 to December 2022, it describes paediatric critical care activity which occurred within Level 3 paediatric intensive care units and Specialist Paediatric Critical Care Transport Services in the United Kingdom (UK) and Republic of Ireland (ROI). This report contains key information on referral, transport and admission events collected by the National Paediatric Critical Care Audit to monitor the delivery and quality of care in relation to agreed standards and evaluate clinical outcomes to inform national policy in paediatric critical care. It reports on the following five key metrics relevant to Paediatric Intensive Care services: case ascertainment including timeliness of data submission retrieval mobilisation times emergency readmissions within 48 hours of discharge unplanned extubation in PICU mortality in PICU.
  13. Content Article
    David Logan talks about the five kinds of tribes that humans naturally form—in schools, workplaces, even the driver's license office. He argues that by understanding our shared tribal tendencies, we can help lead each other to become better individuals.
  14. Content Article
    This rapid evidence review and economic analysis makes the business case for investing in the wellbeing of NHS staff. It was written by a team from the University of East Anglia, RAND Europe and the International Public Policy Observatory (IPPO) and includes a narrative review of data on the current state of the mental health and wellbeing of NHS staff. Data shows that nearly half of staff reported feeling unwell as a result of work-related stress in the most recent survey, that sickness absence has increased and that there are high vacancy and turnover rates in some trusts. Research also shows that patient care can be affected by poor healthcare staff wellbeing. 
  15. Content Article
    In this essay for Interactions magazine, Donald A Norman argues that human-centred design has become such a dominant theme in design that it is now accepted by interface and application designers automatically, without thought, let alone criticism. He believes this as a dangerous state and his essay aims provoke thought, discussion and reconsideration of some of the fundamental principles of human-centred design.
  16. Content Article
    What, when, and how often you take your medications are what make up your medication routine. The routine can be confusing if you are taking two or more medications or you need to take medications at different times of the day. When possible, keeping your medication routine simple can help prevent mistakes with medications. This newsletter from SafeMedicationUse.ca shares ideas to help patients simplify and manage their medication routine.
  17. Content Article
    In this opinion piece for the BMJ, Scarlett McNally looks at the issue of sexual assault and harassment by and against NHS staff. She argues that rather than focusing solely on reporting mechanisms, there needs to be more emphasis on prevention. In order to change the culture in NHS workplaces, all members of the team need to consider how they may contribute to a culture that allows sexual misconduct to happen.
  18. Content Article
    In a report published in 2000 by the UK's Chief Medical Officer, it was estimated that 400 people in the UK die or are seriously injured each year in adverse events involving medical devices, and that harm to patients arising from medical errors occurs in around 10% of admissions—or at a rate in excess of 850 000 per year. The cost to the NHS in additional hospital stays alone is estimated at around £2 billion a year. This article examines system safety in healthcare and suggests a 20-item checklist for assessing institutional resilience (CAIR).
  19. Content Article
    Since the Covid-19 pandemic, there has been a significant increase in telehealth use for patient evaluations. The US Veteran Health Administration (VHA) has tripled phone and video visits across several specialties. Although there are hesitations in phone-call-based communication for procedural subspecialties, phone calls to veterans have proven safe and efficacious after general surgery procedures. Telehealth has additional benefits, including reducing transportation barriers, improving access to care and reducing delays in medical care. This article in the journal Surgery aimed to evaluate clinic access after the establishment of routine telehealth use through phone calls by the surgeon.
  20. Content Article
    The Situation Awareness for Everyone (S.A.F.E.) programme has been used at 50 sites over four years to help reduce 50 sites over four years. This toolkit has been produced by the Royal College of Paediatrics and Child Health (RCPCH) to support child health professionals to use S.A.F.E. principles at their sites. The toolkit contains four modules: Translating quality improvement into action Theories of patient safety and application to the S.A.F.E programme The S.A.F.E programme: from reaction to anticipation Team perspectives
  21. Content Article
    This article by NHS England looks at a national project on aligning quality improvement (QI), experience of care and co-production. It explains the principles of co-production and the approach taken to implement the project, as well as highlighting identified themes and key findings. It makes some practical recommendations based on these findings.
  22. Content Article
    This article in the International Journal of Environmental Research and Public Health proposes a new approach to hospital bed planning and international benchmarking. The number of hospital beds per 1000 people is commonly used to compare international bed numbers. The author, Rodney Jones, suggests that this method is flawed because it doesn't consider population age structure or the effect of nearness-to-death on hospital use. To remedy this problem, Jones suggests a new approach to bed modelling that plots beds per 1000 deaths against deaths per 1000 population. Lines of equivalence can be drawn on the plot to delineate countries with a higher or lower bed supply. This method is extended to attempt to define the optimum region for bed supply in an effective health care system. England is used as an example of a health system descending into operational chaos due to too few beds and manpower. The former Soviet bloc countries represent a health system overly dependent on hospital beds. Several countries also show evidence of overuse of hospital beds. The new method is used to define a potential range for bed supply and manpower where the most effective health systems currently reside. The role of poor policy in NHS England is used to show how the NHS has been led into a bed crisis. The method is also extended beyond international benchmarking to illustrate how it can be applied at a local or regional level in the process of long-term bed planning.
  23. Content Article
    NHS hierarchies and paternalistic cultures can mean patients’ and families’ concerns are dismissed or undermined—but challenging them can be lifesaving. In this opinion piece for the BMJ, Zosia Kmietowicz shares the story of her son's experience at A&E, when a nurse intervened to question a doctor's treatment plan to ensure he received antibiotics for meningitis. She highlights the need for a system that allows staff to intervene when they are concerned, regardless of their status or position in the system.
  24. Content Article
    In this series of blogs, Stephen Shorrock looks at different interpretations of the term 'human factors'. He outlines four key ideas that seem to exist, each of which has a somewhat different meaning and implications. The human factor Factors of humans Factors affecting humans Socio-technical system interaction
  25. Content Article
    This study in The American Journal of Surgery aimed to assess the impact of gender on imposter syndrome among surgical trainees. An online national survey was distributed to surgical subspecialty residents between March and September 2022 which included demographics, validated Clance Imposter Scale and a short questionnaire evaluating depression and anxiety. The study found that Women surgical trainees were found to be more affected by imposter syndrome, particularly frequent and intense imposterism. Risk factors found were being single, having no dependents, working in obstetrics and gynaecology and being a foreign medical graduate. The authors identified a need for residency programs to develop wellness curriculum to address imposter syndrome among all surgical trainees.
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