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Content ArticleThis toolkit from the New South Wales Clinical Excellence Commission (CEC) provides information, resources and quality improvement (QI) tools for managers and clinicians to improve sepsis care. The resources can be adapted to suit local needs and cover: Getting started Making improvements Data for improvement Communicating changes Providing education Sustain and spread
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Content ArticleThe General Pharmaceutical Council (GPhC) has written via email to pharmacists and owners of pharmacies with the GPhC’s voluntary internet pharmacy logo, to address ongoing patient safety concerns affecting the online sector. The emails highlight that over 30% of the GPhC's open Fitness to Practise cases relate to online pharmacy—a disproportionate number for the sector of the market that online services occupy. Common issues raised in these cases include: medicines being prescribed to patients on the basis of an online questionnaire alone, with no direct interaction between the prescriber and either the patient or their GP . prescribing of high-risk medications or medications which require monitoring without adequate safeguards. prescribing of medicines outside the prescriber’s scope of practice. high volumes of prescriptions being issued by the prescriber in short periods of time. The emails also recognise the benefits and risks of online pharmacies, outline how the GPhC may take enforcement action against an online pharmacy, and recommend what actions pharmacists and pharmacy owners should take in response to the patient safety concerns raised. You can view the emails in full: Email to owners of pharmacies with the internet pharmacy logo Email to pharmacists
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Content ArticlePoor and ambiguous medication recording is a common issue identified by the Care Inspectorate during inspections or complaints activity. This guidance aims to support care staff working in residential care services who record medication administration and develop personal plans, by giving common sense guidance on medication recording and personal plans.
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Content ArticleThis article in the Anesthesia Patient Safety Foundation newsletter looks at the issues surrounding the contribution of anaesthetic gasses to healthcare pollution and emissions. The authors argue that the next patient safety movement should be sustainable healthcare. They highlight that anaesthetists have the opportunity to lead in the effort to reduce healthcare’s impact on population health, and demonstrate to the wider sector that sustainable healthcare is possible and important to the wellbeing of patients.
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Content ArticleEuropean Union Directive 2010/32/EU legally enforces a set of strategies aimed at preventing sharps injuries and determining the risk of bloodborne infections and psychological distress in healthcare workers. This article in the International Journal of Environmental Research and Public Health looks at the results of a national survey conducted in Italy in 2017 and repeated in 2021 to evaluate the progress of the Directive's implementation. The authors assessed the impact of the Covid-19 pandemic on implementation.
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Content ArticleOnline healthcare services and apps can help people take more control of their health, by getting access to care easily and when it suits them. This guidance for patients aims to help patients keep themselves safe when using online health services. Produced by a collaboration of UK health organisations, it includes six top tips for accessing healthcare online: Check if the online healthcare service and healthcare professionals working there are registered with UK regulators Ask questions about how the service works Answer questions honestly about your health and medical history Find out your options for treatment and how to take any medicines you’re prescribed Expect to be asked for consent for information to be shared with other healthcare professionals involved in your care Check what after-care you will receive
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Content ArticleCrisis resolution teams (CRTs) provide treatment at home to people experiencing mental health crises, as an alternative to hospital admission. This study in the International Journal of Mental Health Nursing aimed to measure whether CRTs adhere to a model of good practice, using one-day fidelity reviews of UK crisis teams. The authors found that despite a national mandate to implement the CRT model, there are wide variations in implementation in the UK and no teams in the sample achieved overall high fidelity.
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Content ArticleThere is a paradox of representation in public involvement in research; public contributors are seen as either too naïve to meaningfully contribute or too knowledgeable to represent ‘the average patient’. More expert contributors who have experience in research can therefore be a target for criticism. This study in the journal Health Expectations aimed to examine how representation was discussed in two different scenarios—expert involvement and lived experience. The authors analysed the case of a Lived Experience Advisory Panel (LEAP) chosen for direct personal experience of a topic and the case of an expert Patient and Public Involvement (PPI) panel. They concluded that researchers tend to enact a confirmation logic that seeks a simple, unified patient voice to legitimise decisions. Contributors are therefore limited in their ability to realise a synthesis logic that would actively blend different types of knowledge.
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Content Article
This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list six helpful reads related to medication safety in hospital settings. -
Content ArticleThe Irish Health Service Executive (HSE) has produced a selection of resources and guidance to help people use medicines safely. It offers information about the Know, Check, Ask campaign, encouraging members of the public to: Know your medicines and keep a list Check that you're using the right medicine the right way Ask your health professional if you're unsure The page also includes videos about: how to use the My medicines list tool designed to ensure patients and healthcare professionals know which medications and doses the patient should be taking. 5 moments for medication safety, a campaign linked to the World Health Organizations' WHO Medsafe app.
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Content ArticleThis article looks at the benefits and process of prewarming patients before surgery, in order to maintain normothermia (a normal, safe temperature) throughout the peri-operative process. Increasing the patient's core temperature helps prevent hypothermia later on in surgery, reducing the need to deal with temperature issues during and after surgery. The author highlights the link between warming and patient safety and describes different approaches that can be taken for different lengths and types of surgical procedure.
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Content ArticleImproving health care quality and ensuring patient safety is impossible without addressing medical errors, so it is important to accurately estimate incidence rates and implement the most appropriate solutions to reduce medical errors. This systematic review in the journal Frontiers in Medicine aimed to identify interventions that have the potential to decrease medical errors. The authors concluded that although many interventions have been suggested and tried, patient safety has not significantly improved. They call on policymakers to focus more on implementing selected interventions effectively.
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Content ArticleResearch suggests that there is a wide gap in knowledge about how medical conditions affect men and women differently, and about the conditions that only affect women. As a result, women are receiving poorer medical advice and diagnosis, often leading to worse outcomes. This handbook published by digital healthcare provider Livi looks at some of the evidence surrounding sex-based health inequalities and how they are affecting women in the UK.
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Content ArticleIn this blog, consultant on workforce culture Roger Kline looks at the case of Shyam Kumar, an orthopaedic consultant who was seconded as an inspector for the Care Quality Commission (CQC). After raising concerns about patient safety, harm, cover up and bullying of staff with the CQC, his secondment with them was terminated. An Employment Tribunal has found that Mr Kumar's concerns were well-founded and that he was then victimised for raising them by the CQC. The Tribunal accepted his claims that he was removed from his secondment as a CQC inspector as a result of making protected disclosures, accepted his evidence, and at a number of points did not believe the evidence provided by senior CQC staff. The blog raises the question of whether the CQC would fail on its own criteria for being a 'well led' organisation on the basis of this case. It also questions whether the CQC can credibly hold NHS organisations to account on whistleblowing after its response to having concerns raised by Mr Kumar, one of its own inspectors. The author asserts that "the CQC needs to urgently demonstrate it will apply accountability to its own decision making, and lack of support for those raising concerns, and hold its own senior leaders (up to the CEO) to account for decisions which are contrary to its own published standards."
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Content ArticleThis article in the journal Implementation Science aims to offer a system for classifying implementation strategies. The article recommends that authors not only name and define their implementation strategies, but also specify who enacted the strategy, and the level and determinants that were targeted.
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Content ArticleThis article tells the story of Ruth, whose baby son was left with severe cerebral palsy and several other injuries following oxygen starvation during his birth. Ruth's labour was badly mismanaged and she found gaps, omissions and additions to her medical notes when she requested copies. Following a lengthy legal case, Kate received compensation that allowed her family to pay for her son's medical and care needs and adapt their home.
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Content ArticleIn this blog, Bob Matheson, Head of Advice and Advocacy at the charity Protect, explains the case of Dr Chris Day and how it highlights the vital importance of reforms to UK whistleblowing law. Protect is campaigning for Reform of whistleblowing legislation in the UK. The author highlights loopholes in UK law that Dr Day has faced throughout his long legal battle with Health Education England (HEE). These gaps mean that whistleblowers lack certain important legal rights and protections, and this in turn may prevent individuals from raising concerns.
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EventuntilThe Patient Academy for Innovation and Research (PAIR), Organisation of Pharmaceutical Producers of India (OPPI) and DakshamA Health are celebrating World Patient Safety Day, with a webinar on the theme of "Role of stakeholders in GPSAP in the country's context to ensure medication safety". This event will bring all the stakeholders together to discuss their roles in ensuring medication safety and reducing medication-related harm through strengthening systems and practices of medication use, making the process of medication safer and free from harm and galvanizing action on the challenge by calling on all stakeholders to prioritize medication safety and address unsafe practices and system weaknesses. The objectives of World Patient Safety Day 2022 by WHO are - RAISE global awareness of the high burden of medication-related harm due to medication errors and unsafe practices, and ADVOCATE urgent action to improve medication safety. ENGAGE key stakeholders and partners in the efforts to prevent medication errors and reduce medication-related harm. EMPOWER patients and families to be actively involved in the safe use of medication. SCALE UP implementation of the WHO Global Patient Safety Challenge: Medication Without Harm. Register for the webinar The webinar will take place at 3.00-4.30 IST (10.30am-12pm BST)
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to consider the management and care of preterm labour and birth of twins. Preterm birth—defined as babies born alive before the completion of 37 weeks of pregnancy—is one of the main causes of death, long-term conditions and disability in under-fives worldwide, and 60% of twin pregnancies result in premature birth. The reference event for this investigation was the case of Sarah, who was pregnant with twins and was overseen by an obstetrician during her pregnancy. Sarah was assessed as having a higher-risk pregnancy as she had had previous medical intervention on her cervix and was pregnant with twins. Shortly after having been discharged from a hospital with a specialist neonatal unit following suspected early labour, she went to her local maternity unit at 29+2 weeks with further episodes of abdominal tightening. Her labour did not progress as expected and a caesarean section was required to deliver the babies at 29+6 weeks. The twin girls were born well, but 23 days after their birth a scan revealed brain injury in both babies. The investigation identified several findings to explain the experience of the mother in the reference event, including the lack of scientific evidence or specific guidelines and the uncertainty associated with the clinical decision making in this scenario. This highlighted the need for further research into preterm labour as a recognised risk factor for twin pregnancies. As part of the investigation, HSIB identified that since 2019 a large volume of national work and research in the area of twin pregnancy and preterm birth has been undertaken. The investigation report sets out the work currently in progress and seeks to understand if it will address gaps in knowledge.
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Content ArticleThe pandemic has had an enormous impact on health and care services in the UK. In this article, Nuffield Trust fellows Jessica Morris and Sarah Reed take a closer look at access and waiting times before and after the start of the Covid-19 pandemic. They highlight that before the pandemic, pressure on the system was already reducing access to NHS services and making waiting times longer. Covid-19 has made the situation significantly worse due to the need for heightened infection control practices, rising levels of staff sickness and burnout, the cancellation of routine care and redirection of staff. Enabling services to recover will be challenging given these ongoing pressures and real-term budget cuts for the NHS this year. The article examines the impact of the pandemic on waiting times relating to: General practice Elective (planned) care Diagnostic testing Cancer care A&E Ambulance
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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. Angela talks to us about how her role enables her to promote collaboration for patient safety between different layers of the healthcare system. She also tells us about how Northern Ireland is using World Patient Safety Day 2022 to help the public and healthcare staff understand how they can contribute to medication safety. -
Content ArticleThis cross-sectional study in BMJ Quality & Safety aimed to assess patient comfort in speaking up about problems during hospitalisation, and to identify patients at increased risk of having a problem and not feeling comfortable speaking up. The authors assessed the responses of 10,212 patients at eight hospitals in Maryland and Washington to the question, "How often did you feel comfortable speaking up if you had any problems in your care?" The study found that 48.6% of respondents indicated that they had experienced a problem during hospitalisation. Of these, 1,514 (30.5%) did not always feel comfortable speaking up. The authors concluded that creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience.
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Content ArticleThis report by Best Beginnings, Home-Start UK and the Parent-Infant Foundation highlights the impact Covid-19 and measures introduced to control its spread have had on babies. It highlights a “baby blindspot” in Covid-19 recovery efforts and a shortage of funding for voluntary sector organisations and core services like health visiting to offer the level of support required to meet families’ needs. The authors of the report spoke to mothers of babies born during the pandemic and surveyed professionals and volunteers who work with babies and their families.
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Content ArticleIn order to become competent clinicians, doctors need to appropriately calibrate their clinical reasoning, but lack of follow-up after transitions of care can present a barrier to this. This study in the Journal of Hospital Medicine aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners' self-efficacy. The authors concluded that structured feedback for overnight admissions is a promising approach to improve residents' diagnostic calibration, particularly given how often diagnostic changes occur.
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Content ArticleInfant mental health describes the social and emotional wellbeing and development of children in the earliest years of life. It reflects whether children have the secure, responsive relationships that they need to thrive. However, services supporting infant mental health are currently limited; only 42% of CCGs in England report that their CAMHS service will accept referrals for children aged 2 and under. This briefing by the Parent-Infant Foundation is aimed at commissioners looking to set up specialist infant mental health support.
