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Content ArticleTo improve their diagnosis and management skills, doctors need consistent, timely and accurate feedback, as it helps them become better calibrated, leading to more appropriate clinical decisions. Despite its benefits, clinicians do not consistently receive information on the subsequent clinical outcomes of patients they have diagnosed and treated, known as patient outcome feedback. This paper discusses challenges faced in developing systems for effective patient outcome feedback. The authors propose applying a sociotechnical approach using health IT to support these systems. The concepts they discuss are applicable not only to fragmented systems of care, but also to integrated health systems that plan to harness the benefits of integration for providing effective clinician feedback.
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Content ArticleReducing errors in diagnosis is the next big challenge for patient safety. This article highlights ways in which healthcare organisations can pursue learning and exploration of diagnostic excellence (LEDE). Building on current evidence and their recent experiences in developing such a learning organisation at Geisinger in Pennsylvania, the authors propose a 5-point action plan and corresponding policy levers to support the development of LEDE organisations.
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Content ArticleFor the first time since the 1990s, the Surgeons’ Hall Museums in Edinburgh has displayed a new pathology specimen—a transvaginal tape removed in April 2022 from a woman suffering complications of vaginal tape (or mesh) surgery performed in 2006. In this blog Louise Wilkie, the museums' Curator, explains how the device came to be displayed, the history of vaginal tape surgery and the controversy surrounding its introduction and regulation. She also highlights concerns about the subsequent treatment of women who experienced life-changing complications as a result of the procedure.
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Content ArticleThe Patients Association has put together a jargon buster dictionary designed to give straightforward explanations for many healthcare terms. The document was developed by the Patients Association's lived experience advisory panel, Patient Voices Matter. During its meetings, it became clear that members didn't always know the meanings of some of the words and terms they were hearing during consultations with doctors and other healthcare professionals. Letters from the NHS were identified as a source of a lot of jargon. You can also suggest words and phrases to add to the dictionary.
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Content ArticleA Learning Health System (LHS) is a model of how routinely collected health data can be used to improve care, creating ‘virtuous cycles’ between data and improvement. This requires the active involvement of health service stakeholders, including patients themselves. However, to date, research has explored patients being ‘data donors’ rather than considering patients as active contributors. This study in the journal Health Expectations aimed to understand how patients should be actively involved in a LHS.
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Content ArticleSerious case reviews from the past twenty years have repeatedly highlighted the absence of professional curiosity as a core failing in the actions of health and social care professionals. However, 'professional curiosity' as a term is still not commonly used amongst healthcare professionals and there is no shared understanding of its meaning. This paper published by Diabetes on the Net, critically reviews current research surrounding professional curiosity and discusses the main themes. explores how inter-agency working can promote professional curiosity by supporting healthcare professionals to overcome the complex barriers that may arise during safeguarding cases. It discusses the role of Children and Young People’s diabetes clinics as an ideal platform for utilising the benefits of professional curiosity.
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Content ArticleIn this article, Anubha Taneja Mukherjee, Group Member Secretary of Thalassemia Patients Advocacy, writes about patient safety issues surrounding blood donation and transfusion in India. She looks at several recent cases of children with thalassemia being infected with HIV while having blood transfusions, and highlights growing concern about lack of regulation and inconsistent testing of donated blood in India. She argues that blood banks should use additional screening such as the Nucleic Acid Amplification Test (NAT) to provide a safety net and ensure that blood containing infectious diseases—such as HIV, hepatitis B and C, syphilis and malaria—is not unwittingly given to patients.
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Content ArticleScrutiny of NHS chief executive officers (CEOs) has tended to focus on the generally short tenure of their position. The implications of high turnover have been assessed but there has been limited research looking at CEOs who remain in post for long periods, whether in the same organisations or in multiple ones. This study by researchers from the University of Manchester draws on interview data collected in 2019 with 10 long serving CEOs in the English NHS, with an average tenure of 17 years.
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Content ArticlePatient Voices Matter (PVM), a lived experience advisory panel set up by The Patients Association, has highlighted how important it is to make information accessible to all potential users. In this blog, Sarah Tilsed Head of Patient Partnership, and Ray, a member of PVM, talk about the impact of jargon on health inequalities and the accessibility of health services. They also discuss their presentation in August 2022 to the NHS Health Inequalities Improvement Network.
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Content ArticleHospital boards members are charged with developing appropriate organisational strategies and cultures and have an important role to play in safeguarding the care provided by their organisation. However, recent concerns have been raised over boards’ ability to enact their duty to ensure the quality and safety of care. This paper in BMC Health Services Research provides a critical reflection on the relationship between hospital board oversight and patient safety. It highlights new perspectives and suggestions for developing this area of study.
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Content ArticleThis infographic accompanies the TeamSTEPPS for diagnosis improvement course from the US Agency for Healthcare Research and Quality (AHRQ).
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Content Article
AHRQ course- TeamSTEPPS® for diagnosis improvement
Patient-Safety-Learning posted an article in Diagnosis
Diagnostic harm is an area of concern in healthcare quality and patient safety. A growing body of patient safety and care delivery research shows that diagnostic harm is both widespread and costly. TeamSTEPPS is an evidence-based program built on a framework composed of four teachable, learnable skills—communication, leadership, situation monitoring and mutual support. The TeamSTEPPS for Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error. On the course. teams will learn about how improved communication among all members of the team can help lead to safer, more accurate and more timely diagnosis in all healthcare settings. The course can be delivered virtually, in a classroom setting or as individual self-paced learning modules. Additional resources for trainees include: Team assessment tool for improving diagnosis Case study of the diagnostic journey of Mr. Kane Reflective practice tool Postcourse knowledge assessment -
Content ArticleThese tools and resources from the National Institute for Health and Care Excellence (NICE) accompany the NICE guidance on Hypothermia: prevention and management in adults having surgery. Resources available for download include: Audit and service improvement baseline assessment tool Implementation support advice document Education information Shared learning information Practical steps to improving the quality of care and services using NICE guidance
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Content ArticleThis report by pharmaceutical company ViiV Healthcare focuses on results from wave two of their Positive Perspectives study. It investigates how people living with HIV (PLHIV) rate their own health and how living with HIV impacts their lives and affects their outlook for the future. It also examines their interactions and relationships with healthcare professionals and their experiences with antiretroviral treatment. The report highlights the importance of open and active dialogue and shared decision making between PLHIV and their healthcare professionals in improving outcomes.
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Content ArticleHealth information technology (health IT) has potential to improve patient safety, but its implementation and use has had unintended consequences and has raised new safety concerns. This viewpoint article in BMJ Quality & Safety introduces a new framework—the health IT safety (HITS) framework—to provide a conceptual foundation for health IT-related patient safety measurement, monitoring and improvement.
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Content ArticleThis literature review in The Operating Theatre Journal examines why the decision was made not to class surgical fires as a 'Never Event', even though research has identified them as a preventable hazard. The author also examines steps that could be taken to further reduce the risk of surgical fires in the NHS and other health systems. You will need to create a free online account to view this article.
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Content ArticleThe Health and Care Act 2022 placed Integrated Care Systems (ICSs) on a statutory footing in July 2022, and trusts will play a critical role in delivering the key purposes of ICSs in order to benefit patients and service users. This briefing from NHS Providers: provides a brief overview of how provider collaboratives are developing across England. illustrates some of the emerging benefits that collaboratives are working to realise. explores how trust leaders see the role of provider collaboratives developing within ICSs. identifies some key enablers and risks trust boards need to consider.
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Content ArticleIn this episode of The Mind Full Medic podcast, host Cheryl Martin talks to Dr Chris Turner, a consultant in Emergency Medicine at University Hospitals of Coventry and Warwickshire. Chris is also the co-founder of Civility Saves Lives, an organisation dedicated to raising awareness of the impact behaviour has on individuals, teams and organisations. In this conversation, Chris discusses his own professional journey and experience as a healthcare leader and safety and quality lead. He talks about the challenging start to his consultant career, the powerful impact of a trusted mentor and critical friend, and how this experience has informed his future work. He also describes the spectrum of approaches to improving safety and quality in the challenging, complex healthcare environment, including the Safety I and Safety II approaches.
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Content Article
The 'So What' of maternity data (August 2022)
Patient-Safety-Learning posted an article in Maternity
This report from the Healthcare Quality Improvement Partnership (HQIP) aims to explore how the multiple national data sets and national audits are used in maternity services across the UK. Based on data from a survey of over 100 people working in a variety of roles across maternity services and a series of in-depth interviews with a diverse group of clinicians and methodologists working in this area, the report explores what data is being reviewed and how it might influence quality improvement, as well as the burden of data. -
Content ArticleThis study in the journal Health Policy uses an innovative methodology to provide further understanding of the implementation process in the English NHS, using the examples of two distinctly different National Institute for Health and Care Excellence (NICE) clinical guidelines. The authors conclude that NICE and other national health policy-makers need to recognise that the introduction of planned change ‘initiatives’ in clinical practice are subject to social and political influences at the micro level as well as the macro level.
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Content ArticleThis blog by global law firm Clyde & Co describes the background to the new Patient Safety Incident Response Framework (PSIRF) and how it will change the way that NHS services will investigate patient safety incidents. The authors offer an overview of the framework, its implementation and who it affects.
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Content ArticleThis guide by the Royal College of Physicians explains what a hip fracture is and answers questions about how patients will be cared for before and after a hip operation. It is written for patients and their families and carers. The guide covers aspects of hip fracture care such as: pain relief memory problems who should be involved in your care how soon an operation should take place eating and drinking bladder problems rehabilitation and physiotherapy following surgery when you will be able to go home future falls prevention bone strengthening medication
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Content ArticleThis letter accompanies the publication of the Patient Safety Incident Response Framework (PSIRF) by NHS England. The PSIRF forms a major part of the NHS Patient Safety Strategy and replaces the Serious Incident Framework (SIF) that has been in place since 2015. It aims to improve safety management across the healthcare system in England and to support the NHS to embed the key principles of a patient safety culture. In his letter, Dr Aiden Fowler, National Director of Patient Safety in England outlines how PSIRF was developed, describes how the transition from the SIF to PSIRF will take place and highlights the tools available to support organisations to implement the changes. The letter is addressed to: NHS trust and foundation trust chief executives, medical directors and nursing directors Integrated Care Board medical directors and nursing directors NHS England Regional Team medical directors and nursing directors NHS England regional direct commissioning leads
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Content ArticleNon-ventilator-associated hospital-acquired pneumonia (NVHAP) is one of the most common and deadly healthcare-associated infections, but it is not tracked, reported or actively prevented by most hospitals. This article in the journal Infection Control & Hospital Epidemiology highlights a national call to action to address NVHAP in the US. This national call to action includes: launching a national healthcare conversation about NVHAP prevention. adding NVHAP prevention measures to education for patients, healthcare professionals, and students. challenging healthcare systems and insurers to implement and support NVHAP prevention. encouraging researchers to develop new strategies for NVHAP surveillance and prevention.
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Content ArticleThis article and video tell the story of Rihan Neupane, a baby born prematurely in Dhapasi, Nepal, who was left in a vegetative state following a series of medical errors including a missed diagnosis of meningitis. His parents had chosen a private international hospital for their maternity care, but were let down by a series of medical errors including Rihan being mistakenly given a massive paracetamol overdose. Although external hospital safety inspectors found the hospital negligent on many counts, the hospital continued to deny any wrongdoing or responsibility for Rihan's condition. Rihan's father Sanjeev Neupane talks about his family's experience in the embedded video.
