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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In this guest blog for the Patient Safety Commissioner's Office, Rachel Power, Chief Executive of The Patients Association describes progress that has been made in engaging patients in healthcare since the publication of the Patient’s Charter in 1991. She highlights the results of various surveys and reports by The Patients Association that show a mixed picture of how well patients are being engaged in their care. She also looks at barriers to patient-centred care and shared decision making that need to be addressed. The blog ends with calls to the health system to: Enhance provision of information to facilitate patient/professional conversations Support patients to ask questions and participate in decisions Support patients to understand treatment options and consequences Promote consistency of care across different patient groups Strengthen accountability for treatment decisions and complaints Improve accessibility of medical records Provide resources to help patients understand medical language Provide comprehensive training in shared decision-making Support consistent shared decision-making practices among clinicians Create a culture of shared learning among healthcare staff.
  2. Content Article
    Patients in seclusion in mental health services require regular physical health assessments to identify, prevent and manage clinical deterioration. Sometimes it may be unsafe or counter-therapeutic for clinical staff to enter the seclusion room, making it challenging to meet local seclusion standards for physical assessments. Alternatives to standard clinical assessment models are required in such circumstances to assure high quality and safe care. The primary aim of this study was to improve the quality of physical health monitoring by making accurate vital sign measurements more frequently available. It also aimed to explore the clinical experience of integrating a technological innovation with routine clinical care. The results showed that the non-contact monitoring device enabled a 12 fold increase overall in the monitoring of physical health observations when compared to a real-world baseline rate of checks. Enhancement to standard clinical care varied according to patient movement levels. Patients, carers and staff expressed positive views towards the integration of the technological intervention.
  3. Content Article
    Preventing patients from self-harming is an ongoing challenge in acute inpatient mental health settings. New technologies that do not require continuous human visual monitoring and that maintain patient privacy may support staff in managing patient safety and intervening proactively to prevent self-harm incidents. This study in the Journal of Mental Health aimed to assess the effect of implementing a contact-free vision-based patient monitoring and management (VBPMM) system on the rate of bedroom self-harm incidents. The results showed a 44% reduction in bedroom self-harm incidents and a 48% reduction in bedroom ligatures incidents, suggesting that that the VBPMM system helped staff to reduce self-harm incidents, including ligatures, in bedrooms.
  4. Content Article
    In this webinar recording, Alex RK, a barrister, writer and educator, takes stock of the mental capacity and mental health law and policy landscape as at August 2023. It primarily focuses on England & Wales, but also includes developments in the UK and further afield, including thinking about the implications of the French language version of Article 19 CRPD providing not for ‘living independently’, but ‘autonomie de vie’.
  5. Content Article
    Patient harm due to unsafe healthcare is widespread, potentially devastating, and often preventable. Hoping to eliminate avoidable harms, the World Health Organization (WHO) published the Global Patient Safety Action Plan in July 2021. The UK's National Health Service relies on several measures, including ‘never events’, ‘serious incidents’, ‘patient safety events’ and coroners’ Prevention of Future Deaths reports (PFDs) to monitor healthcare quality and safety. This systematic narrative review of PubMed and medRxiv articles on 19 February 2023 aimed to explore the strengths and limitations of coroners’ PFDs and whether they could be a safety tool to help meet the WHO's Global Patient Safety Action Plan. The authors identified 17 studies that investigated a range of PFDs, including preventable deaths involving medicines and an assessment during the Covid-19 pandemic. The review found that PFDs offered important information that could support hospitals to improve patient safety and prevent deaths. However, inconsistent reporting, low response rates to PFDs, and difficulty in accessing, analysing and monitoring PFDs limited their use and adoption as a patient safety tool for hospitals. The authors concluded that to fulfil the potential of PFDs, a national system is required that develops guidelines, sanctions failed responses and embeds technology to encourage the prevention of future deaths.
  6. Event
    until
    Public Policy Projects is holding a roundtable "Improving access to genomic testing and medicine for better outcomes and reduced inequalities" on the 20th September from 10:30am to 12pm on Zoom. This session will be chaired by Parker Moss, Chief Commercial & Partnerships Officer at Genomics England, and will seek to explore how genomic technologies can be better utilised, and how services can be appropriately coordinated, to ensure that emerging technology can be used as a tool for reducing inequalities and bettering the overall standard of care for cancer patients in the NHS. The hosts are looking for individuals from Cancer Alliances, ICB, Genomic Laboratory Hubs, Cell Pathology Centres, and Clinical Diagnostic Centres to attend and share their experiences and views at this session. Find out more and register to attend
  7. Content Article
    This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.
  8. Content Article
    The Maternal, Newborn and Infant Clinical Outcome Review Programme, which is delivered by MBRRACE-UK, has published a report on UK Perinatal Deaths for Births from January to December 2021. Overall, it found that perinatal mortality rates increased across the UK in 2021, with 3.54 stillbirths per 1,000 total births and 1.65 neonatal deaths per 1,000 live births (3.33 and 1.53 respectively in 2020). However, there was a wide variation in stillbirth and neonatal mortality rates across organisations, though these rates increased in almost all gestational age groups. It was also found that inequalities in mortality rates by deprivation and ethnicity remain, but the most common causes of stillbirth and neonatal death are unchanged (for example, congenital anomalies continue to contribute to a significant proportion of perinatal deaths).
  9. Content Article
    This state-of-the-nation report from the National Hip Fracture Database (NHFD) focuses on the period from 1 January to 31 December 2022. It shows that the number of people who died in the month following a hip fracture now stands at 6.2%; down from 10.9% in 2007, when the NHFD was set up. However, the report also finds that it took longer for patients to reach a ward where a hip fracture team can work together (where there is the best chance of recovery) in 2022. It also states that fewer patients received prompt surgery to repair their broken hip by the day after they presented to hospital. There was an improvement in how many people with hip fracture received bone strengthening medicines to avoid future fractures in 2022, but some hospitals continue to report that none of their patients receive such treatment.
  10. Content Article
    Recent polling from Healthwatch England shows that a fifth of patients referred by a GP for consultant-led care end up in a ‘referral black hole’, with more than two million patients each year having to make four or more visits to their GP before a referral is accepted. The result is that tens of thousands of patients could be on a ‘hidden’ waiting list, meaning that GPs are managing greater clinical risk and a greater number of patients whose conditions are often worsening in primary care, whilst communication between providers and access to diagnostics are often not up to scratch.  This report by the think tank Policy Exchange looks at reforms that could be made to the interface between primary and secondary care in order to improve care and prevent patient harm. It considers how improved flows of information and expertise can: better support growing demand in general practice reduce unwarranted variation in service provision enhance care coordination – particularly for those referred for elective procedures enable opportunities to boost generalist medical skills for a new generation of doctors create opportunities for hospital specialists to deliver a greater proportion of care in primary or community care settings, reducing waiting times and the use of more expensive settings for care.
  11. Content Article
    Achieving shared interpersonal understanding between healthcare professionals, patients and families is a core patient safety challenge around the world. The SACCIA model promotes safe communication practice amongst healthcare teams and between providers patients. It was developed by Professor Annagret Hannawa, Director of the Center for the Advancement of Healthcare Quality & Safety in Switzerland. The interpersonal processes that are captured in the SACCIA acronym are considered 'safe' because they lead to a shared understanding between all care participants: Sufficiency Accuracy Clarity Contextualization Interpersonal Adaptation The five SACCIA competencies emerged from a communication science analysis of hundreds of critical healthcare incidents. They were identified as common deficient interpersonal processes that often cause and contribute to preventable patient harm and insufficient care. They therefore represent an evidence-based set of core competencies for safe communication, which constitute the vehicle to patient care that is safe, efficient, timely, effective and patient-centred.
  12. Content Article
    This Newsnight report looks at the case of Rebecca Wight, an advanced nurse practitioner who raised concerns about a colleague at at Manchester’s Christie cancer hospital and felt her treatment by Trust management as a whistleblower was poor. She is now taking The Christie to an employment tribunal for constructive dismissal. The video also features an interview with Helené Donnelly, a nurse who tried to raise the alarm more than 100 times at Mid Staffs and went on to be a key witness in the subsequent Francis inquiry. She calls for failing NHS managers to be struck off, highlighting that a decade on from one of the worst failings in NHS history, those raising concerns were still not being listened to.
  13. Content Article
    A recent report found that a third of female surgeons have been sexually harassed at work. In this opinion piece, Dr Liz O’Riordan speaks out about the abuse she suffered from male colleagues while working for the NHS. She describes her experiences, highlighting that incidents of sexual harassment are common amongst female surgical trainees who fear speaking out as it may affect their careers. She also draws attention to the fact that it is not just an issue amongst surgeons, but that many other healthcare professionals experience inappropriate sexual comments and behaviour while at work.
  14. Content Article
    The Acute Frailty Network (AFN) was a scheme run in England by NHS Elect, using an approach called Quality Improvement Collaboratives (QICs), to help trusts implement principles of Comprehensive Geriatric Assessment (CGA) as part of their acute pathway. In July 2023, Street et al published a paper in BMJ Quality and Safety analysing the impact of the AFN which concluded that there was no difference in length of hospital stay, in-hospital mortality, institutionalisation and hospital readmission between organisations that took part in AFN and those that did not. This article outlines the position of the British Geriatrics Society (BGS) on the paper, addressing why it thinks that focusing on older people’s healthcare is more important than ever. It highlights the importance of ensuring that the paper's findings are not used as a reason to abandon efforts to improve acute frailty care. Rather, they should be seen as a call to redouble efforts to identify and overcome the barriers to delivering CGA in acute settings.
  15. Content Article
    As awareness of the importance of psychological safety in the workplace increases, there is a corresponding increase in the number of psychometric tools, applications and services that attempt to measure psychological safety. This post on the blog Psychological Safety outlines some helpful principles for organisations to apply when choosing a psychometric tool. It lays out the following key principles, stating that in choosing a psychometric tool, we should ensure that we understand the methods and algorithms the tool uses. it’s usable and accessible for everyone. it’s secure. people retain ownership of their own data. the questions and statements actually correlate with psychological safety. it doesn’t make assumptions based upon majority culture. the tool doesn’t create perverse incentives.
  16. Content Article
    In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
  17. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm.
  18. Content Article
    For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviours may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications. This article in JAMA Surgery aimed to assess whether patients of surgeons with a higher number of coworker reports about unprofessional behaviour experience a higher rate of postoperative complications than patients whose surgeons have no such reports. The authors found that  patients whose surgeons had a higher number of coworker reports had a significantly increased risk of surgical and medical complications. These findings suggest that organisations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behaviour toward other medical professionals may increase patients’ risk for adverse outcomes.
  19. Content Article
    The nurse-to-patient ratio represents the number of patients a registered nurse cares for during a shift. Most hospitals have guidelines to ensure safe staffing ratios, but staffing shortages have led to heavier nursing workloads. This article outlines which US states have laws and regulations in place for safe staffing ratios.
  20. Content Article
    How we treat each other at work has an enormous impact on how teams perform—with potentially fatal consequences if you work in healthcare. Chris Turner, consultant in emergency medicine and founder of Civility Saves Lives, reveals the shocking impact of rudeness in the workplace. He highlights the importance of understanding the complex realities of practice and communication between healthcare professionals in different team environments, if we are to learn from patient safety incidents.
  21. Content Article
    The Patient Safety Network (PSNet) produces primers which provide guidance on  key topics in patient safety through context, epidemiology and relevant PSNet content. This primer focuses on nurse-related medication administration errors and highlights that despite error reduction efforts through implementing new technologies and streamlining processes, medication administration errors remain prevalent. It covers the background to the issue, low-tech and high-tech prevention strategies and the current context.
  22. 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. James talks to us about the value of patient feedback in boosting morale and enabling organisations to make real patient safety improvements. He also describes the power of the unique perspective patients have on safety, and asks how we can use this insight to shift culture and provide safer care.
  23. Content Article
    Most US healthcare organisations use staffing guidelines to decide a nurse's patient load on a given shift, but current staffing shortages are pushing nurse-to-patient ratios to the limit. In this article for Nurse Journal, registered nurse Alexa Davidson asks whether laws and regulations could prevent nursing workloads from getting out of control. She argues that mandated staffing ratios are a proven way to ensure patient safety. She describes the situation in Massachusetts and California, the two US states where laws have been passed mandating nurse-to-patient ratios, and outlines the implications of introducing ratios for nurses and patients.
  24. Content Article
    In this consultation, the Department of Health and Social Care (DHSC) is seeking views on the possible introduction of regulations mandating the disclosure of industry payments to the healthcare sector. The consultation concerns the possible introduction of new secondary legislation that would place a duty on manufacturers and commercial suppliers of medicines, devices and borderline substances to report details of the payments and other benefits they provide to healthcare professionals and organisations. This consultation aims to address the second part of recommendation 8 in the Independent Medicines and Medical Devices Safety (IMMDS) Review, regarding real and perceived conflicts of interest in the health system. The proposals will enable respondents to share views on: the information they would need to provide recipients in scope payments that would potentially need to be reported the timing and content of reporting alternatives to regulation. The consultation closes at 11:59pm on 16 October 2023.
  25. Content Article
    The Aviation Safety Reporting System (ASRS) is an important part of the continuing effort by the US government, industry and individuals to maintain and improve aviation safety. The ASRS collects voluntarily submitted aviation safety incident/situation reports from pilots, controllers and others. it analyses and responds to these incident reports to reduce the likelihood of aviation accidents. ASRS data are used to: identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities. support policy formulation, planning for and improvements to the NAS. strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally recognised that over two-thirds of all aviation accidents and incidents have their roots in human performance errors. The ASRS website outlines the purpose and aims of the system, provides details on how to submit reports and lists related research studies and resources.
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