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Content ArticleAlthough diagnostic errors are estimated to affect about 12 million Americans each year in ambulatory care settings alone, the conceptual and pragmatic scientific foundations for their measurement are under-developed. Further progress towards reducing diagnostic errors will rely on our ability to overcome measurement-related challenges. This article in BMJ Quality & Safety outlines a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). The authors describe how Safer DX serves as a conceptual foundation for system-wide safety measurement, monitoring and improvement of diagnostic error. They believe it lays robust groundwork for measurement and monitoring techniques to ensure diagnostic safety.
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Content ArticleThis increased implementation of artificial intelligence (AI) in healthcare could be either great or terrible news for the safety of services, depending on how organisations develop and implement it. This blog, written by the Professional Record Standards Body in partnership with the user experience company HD Labs, looks at the safety risks associated with using AI in health and care and outlines how standards can help keep AI safe.
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Content ArticleIn this article, Ashley Milne-Tyte looks at how older people are treated by healthcare professionals and the impact that negative views can have on their care and treatment. She highlights examples of older people being marginalised by healthcare professionals, who sometimes shout at their patients or speak to family members rather than addressing their older patient directly. Emphasising the harm that this can cause, she cites research that shows that medical bias towards older people can accelerate cognitive decline, increase anxiety and depression and shorten lifespans by up to seven-and-a-half years.
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Content Article
Welsh Health Equity Solutions Platform
Patient-Safety-Learning posted an article in Health inequalities
The Welsh Health Equity Solutions Platform is part of the Welsh Health Equity Status Report initiative (WHESRi), which supports a healthier, more equal and prosperous Wales. The platform is a gateway to data, evidence, health economics and modelling, policies, good practice, innovative tools and practical solutions to help improve population wellbeing and reduce the health equity gap in Wales and beyond. It is structured around an innovative WHO framework of ‘Five Essential Conditions’ for healthy prosperous lives for all. The platform will link with and feed into a WHO health equity gateway, providing an example and inspiration for countries to learn and follow, as well as to contribute and share. -
Content ArticleThis editorial in The Lancet Infectious Diseases reflects on the consequences of the infected blood scandal, in which more than 30,000 people in the UK were infected after receiving contaminated blood products in the 1970s and 1980s. It examines the systems in place for blood donation and transfusion in low and middle income countries (LMICs) and argues that the chance of a blood scandal coming to light in LMICs is much higher. This is because blood donations in many LMICs go against the WHO recommendation of national blood systems being based on blood supply from voluntary donors. Instead, they rely heavily on paid-for donations and family or replacement donations, which are unsafe due to the higher prevalence of bloodborne infections.
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Content Article
Should hospital nurses be working 12-hour shifts? (12 May 2022)
Patient-Safety-Learning posted an article in Nurses
Increasingly, some nursing leaders say it’s time to move away from the 12-hour nursing shifts used by many hospitals. They say that health systems must develop other scheduling options to accommodate the changing needs of nurses as they progress in their careers. This article by Ron Southwick looks at the arguments for moving away from the 12-hour shift, including the risks that the current system poses to patient safety. -
Content ArticleEmergency general surgery performed among patients aged over 65 years represents a particularly high-risk population. Transferring emergency surgery patients between hospitals has been linked to higher mortality, but its impact on outcomes in the geriatric population is uncertain. This study in Surgery aimed to explore the effect of transfer between hospitals on postoperative outcomes in older people who have emergency general surgery. The authors concluded that transferring patients between hospitals contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. They call for further investigation into improved coordination between hospitals, tailored care plans and comprehensive risk assessments, to help improve outcomes for older emergency surgery patients.
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Content ArticleUse of artificial intelligence (AI) in healthcare is on the rise. Bodies including UK Governments, the National Institute for Health and Care Research and the NHS AI Lab are all investing in developing and deploying the technology. The Patient Information Forum (PIF) is an independent UK membership body for people working in health information and support. Developed in collaboration with PIF’s AI working group, this position statement aims to help members understand the AI landscape and how to manage it.
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Content Article
Taking persistent physical symptoms seriously (15 June 2024)
Patient-Safety-Learning posted an article in Diagnosis
Persistent physical symptoms (PPS) are distressing physical complaints lasting several months or more without a clear cause. They are very common—but complex—and can be overwhelming for patients and healthcare professionals. PPS can have a devastating effect on mental health and cause distress for patients when they are not believed. This Lancet editorial looks at the increasing knowledge we have of the risk factors and mechanisms involved in PPS and what this means for patient care. It looks at recent research studies and models of care designed specifically for dealing with PSS. -
Content ArticleSelf-advocacy is an individual's ability to communicate their own needs and is an important skill for patients. However, medical self-advocacy can be challenging, especially when there is a power imbalance between people in positions of authority and patients, who are often in a more vulnerable position. This power imbalance can be even more difficult to navigate for children and young people. In this personal account, Hannah Eaton describes her experiences as a disabled young person attempting to get support for diagnoses relating to chronic illness and neurodivergence. She aims to highlight the difficulties faced by children and young people accessing healthcare. She also makes some suggestions to improve how much children are able to take part in their own healthcare care and the healthcare system as a whole.
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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. -
Content ArticleThis 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.
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Content ArticleIn 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.
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Content ArticleMore 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.
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News Article
Bullying still on the rise at troubled trust
Patient-Safety-Learning posted a news article in News
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 -
Content ArticleHospital-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.
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Content ArticlePeople 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.
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Content ArticleUsing 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.
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Content ArticleThe 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.
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Content Article
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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. -
Content ArticleThis article describes how NHS England's National Patient Safety Team identified an issue relating to retained surgical instrumentation during complex procedures. A specific review of Never Event data revealed that some reports describing unintentionally retained instruments involved complex procedures where more than one surgical team was involved with multiple instrument trays, making the counting/checking process more difficult. There was no specific national guidance for this issue, so NHS England liaised with the Centre for Peri Operative Care (CPOC) as part of their review of the National Safety Standards for Invasive Procedures (NatSSIPs 2). This led to the addition of a caution moment in situations where there are multiple trays, teams and handovers, in the revised standard ‘Reconciliation of Items in the Prevention of Retained Foreign Objects’.
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Content ArticleIntravenous 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.
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Content ArticleThis 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.
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Content ArticleEvidence 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.
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Content ArticleThe 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.
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