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Patient-Safety-Learning

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Everything posted by Patient-Safety-Learning

  1. Content Article
    In order to prevent hypothermia during or after surgery, patients can be warmed before or during the induction of anaesthesia. If the patient is warmed before, this is known as prewarming, and if they are warmed at the same time that anaesthetics are given, this is known as cowarming. This study in the Journal of Anaesthesiology and Clinical Pharmacology aimed to investigate whether cowarming is as good as prewarming in preventing the occurrence of intraoperative hypothermia.
  2. Content Article
    This study in BMJ Open examines the impacts of the four episodes of industrial action by English junior doctors in early 2016. The authors looked at the impact of the strikes on A&E visits, outpatient appointments and cancellations, admitted patients and all in-hospital mortality. The study concluded that industrial action by junior doctors during early 2016 had a significant impact on the healthcare provided by English hospitals. It also found that t here were regional variations in how these strikes affected providers, and that there was not a measurable increase in mortality on strike days.
  3. News Article
    People no longer believe the NHS will treat them quickly if they fall ill, according to new polling showing wide dissatisfaction about the state of the health service. With hundreds of ambulances stacked outside overstretched A&E departments and patients languishing on record waiting lists, voters are far more likely to say the service has worsened than improved in the last year. Fifty-eight per cent are not confident they would receive timely treatment from the NHS if they fell ill tomorrow, with 36 per cent not confident at all and 22 per cent just not confident. Meanwhile, 45 per cent believe the service they receive has worsened in the past 12 months. Just over half think it has become harder to get an appointment with their local doctor while 41 per cent think their local GP service has worsened. Robert Ede, head of health and social care at the Policy Exchange think tank, said: “It is concerning to see that a majority of the public don’t believe they would receive timely treatment from the NHS if they became ill tomorrow. There is a risk that the perception of a service in crisis beds in and actually leads to a complete erosion in public confidence." Read full story (paywalled) Source: The Times (27 August 2022)
  4. Content Article
    This document sets out the Parliamentary and Health Services Ombudsman's (PHSO) strategy 2022-25 and outlines its vision to be a voice for improvement in public services, providing an independent, impartial and fair complaints handling service. The document describes how PHSO will achieve its three strategic objectives: People who use public services have a better awareness of the role of the Ombudsman and can easily access our service People we work with receive a high quality, empathetic and timely service, according to international Ombudsman principles We contribute to a culture of learning and continuous improvement, leading to high standards in public service
  5. Content Article
    This decriptive study in BMC Health Services Research aimed to increase understanding of how patient and family education affects the prevention of medical errors, and provide basic data for developing educational content. The authors surveyed patients, families and Patient Safety Officers to investigate the relationship between educational approaches and medical error prevention. Participants thought that educational contents developed through this study could prevent medical errors. The results of this study are expected to provide basic data for national patient safety campaigns and standardised educational content development to prevent medical errors.
  6. News Article
    Black and Asian people in England have to wait longer for a cancer diagnosis than white people, with some forced to wait an extra six weeks, according to a “disturbing” analysis of NHS waiting times. A damning review of the world’s largest primary care database by the University of Exeter and the Guardian discovered minority ethnic patients wait longer than white patients in six of seven cancers studied. Race and health leaders have called the results “deeply concerning” and “absolutely unacceptable”. The analysis of 126,000 cancer cases over a decade found the median time between a white person first presenting symptoms to a GP and getting diagnosed is 55 days. For Asian people, it is 60 days (9% longer). For black people, it is 61 days (11% longer). Michelle Mitchell, the chief executive of Cancer Research UK, which funded the research, said that while the differences are “unlikely to be the sole explanation for the inequalities in cancer survival”, at the very least “extended wait times may cause additional stress and anxiety for ethnic minority patients”. Read full story Source: The Guardian (28 August 2022)
  7. News Article
    Britain faces a low uptake of the Covid booster jab this autumn amid “vaccine fatigue” and complacency about the virus, the new Pfizer boss has warned. The booster campaign starts next week, with care home residents and the housebound the first to be invited. Over-75s and the clinically vulnerable will be able to book appointments from September 12, with a wider rollout for over-50s taking place in phases. Roughly 26 million in England will be eligible. Susan Rienow, who was appointed UK managing director at Pfizer in February, said: “We have to remain vigilant. I recognise there may be some vaccine fatigue in the population. But making sure that people are boosting their immunity, so that we can prevent people from being hospitalised, is going to be really important.” Read full story (paywalled) Source: The Times (28 August 2022)
  8. Content Article
    This article describes perceptions of the culture of safety in paediatric primary care in the US, and evaluates whether organisational factors and staff roles are associated with these perceptions. The authors found that perceptions of the culture of safety and quality in paediatric primary care practices were generally positive, but differences in perceptions did exist based on staff role.
  9. Content Article
    This US study in the journal Medical Care aimed to assess the accuracy of Nursing Home Compare's (NHC) pressure ulcer measures, which are chief indicators of nursing home patient safety. The authors identified hospital admissions for pressure ulcers and linked these to nursing home-reported data at the patient level. They then calculated the percentages of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay status, and race. Next, they estimated the correlation between an alternative claims-based measure of pressure ulcer events and NHC-reported ratings. The study found that pressure ulcers were substantially underreported in data used by NHC to measure patient safety. The authors call for alternative approaches to improve surveillance of health care quality in nursing homes.
  10. Content Article
    Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors of this narrative review in BMJ Quality & Safety aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature. They argue that securing improvement may be hard and slow and faces many challenges, but formal evaluations assist in recognising the nature of these challenges and help in addressing them.
  11. Content Article
    This study in JAMA Network Open aimed to investigate how often patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes they report. The results of the study showed that: 1 in 5 patients who read a note reported finding a mistake 40% perceived the mistake as serious the most common mistakes reported were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient and sidedness. The authors suggest that patients may perceive important errors in their visit notes, and inviting them to report mistakes may be associated with improved record accuracy and patient engagement in safety.
  12. Content Article
    This editorial in BMJ Quality & Safety looks at the need for urgent improvement in the test result management and communication process in primary care. The authors highlight the inconsistency in tracking and communicating test results and look at potential solutions to reduce the patient safety risks associated with test results. They look at the evidence surrounding automated alerts built into provider IT systems and giving patient direct access to test results through apps, highlighting the growing importance of patients in safeguarding their own care through actively pursuing test results.
  13. Content Article
    Medication safety has long been a major issue in long-term social care due to the number of medications taken by many older people. This editorial in BMJ Quality & Safety looks at why managing medications in care homes is so complex and highlights potential interventions to improve medication safety in long-term care settings.
  14. Content Article
    Health care providers that encourage patients and parents to be "the eyes and ears" of patient safety gain many insights into opportunities for improvement and risk prevention. However, in the world of quality improvement the voices of patients and their families often go unheard. Dale Micalizzi and Marie Bismark published this article in the journal Pediatric Clinics of North America to share their perspectives as mothers of children who have benefited from and been harmed by paediatric care.
  15. Content Article
    This report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) examines the quality of care provided to patients aged 16 years and over who were admitted to hospital following an out-of-hospital cardiac arrest (OHCA). The report is based on the findings of a study that looked at the clinical care delivered to patients from the time of an OHCA to discharge from hospital or death. The review of the clinical pathway included the community and emergency service response, hospital admission and inpatient care (in particular cardiac and critical care services). Data were also collected to assess organisational aspects of care within acute hospitals.
  16. Content Article
    Life expectancy for people with a mental illness diagnosis is 15–20 years less than those without, mainly because of poor physical health. This article in the Journal of Paramedic Practice highlights the fact that mental ill health affects a significant proportion of paramedics' patients, and argues that practitioners could assess and promote patients' physical health even though contact time is limited.
  17. Content Article
    This National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report reviews the quality of care of patients aged 16 and over who had a pulmonary embolism (PE), The study aimed to highlight areas where care could be improved in patients with a new diagnosis of acute PE. A retrospective case note and questionnaire review was undertaken in 526 patients aged 16 and over who had a PE, and who either presented to hospital or developed a PE whilst an inpatient for another condition. You can view and download the following documents: Full report Summary report Summary sheet Recommendation checklist Infographic Slide set Commissioners' guide Fishbone diagram Audit toolkit YouTube video: Know the Score
  18. News Article
    The Biden administration plans to offer the next generation of coronavirus booster shots to Americans 12 and older soon after Labor Day, a campaign that federal officials hope will reduce deaths from Covid-19 and protect against an expected winter surge. Dr. Peter Marks, the top vaccine regulator for the Food and Drug Administration, said in an interview on Tuesday that while he could not discuss timing, his team was close to authorizing updated doses that would target the versions of the virus now circulating. Even though those formulations have not been tested in humans, he said, the agency has “extremely good” data showing that the shots are safe and will be effective. “How confident am I?” he said. “I’m extremely confident.” Read full story Source: The New York Times (23 August 2022)
  19. Content Article
    This article in The Guardian aims to explain the major pressures the NHS will face in Autumn 2022. It identifies and explores the following threats: Covid Influenza Cost of living crisis Workforce shortages Pay
  20. Content Article
    The Government's Race Disparity Unit has published data relating to NHS staff reports of discrimination at work. The charts, tables and commentary on this page cover survey data from 2019, and the data from 2020 is available to download without commentary. 300 NHS organisations took part in the staff survey in 2019, including 229 NHS trusts.
  21. News Article
    Dental patients are still suffering from the fallout of the Covid-19 pandemic, as parts of England are left with only one NHS dentist for thousands of people. In North Lincolnshire, there were just 54 NHS dentists – equivalent to one for every 3,199 people – at the end of March, NHS Digital figures show. This means every NHS dentist in the area would have to work nine-hour days every working day of the year without holidays for each resident to receive one annual checkup on the NHS. Across England, 24,272 dentists treated some NHS patients in the year to 31 March – up 2.3% from the previous year, broadly in keeping with the general population increase in the same period, but lower than pre-pandemic figures for the three previous years. The chair of the British Dental Association, Eddie Crouch, said the service was “on its last legs” and the figures underlined the need for radical and urgent change. “The government will be fooling itself and millions of patients if it attempts to put a gloss on these figures,” said Crouch. “NHS dentistry is light years away from where it needs to be. Unless ministers step up and deliver much-needed reform and decent funding, this will remain the new normal.” Read full story Source: The Guardian (25 August 2022)
  22. News Article
    A coroner has expressed concern at the difficulty of getting face-to-face appointments with GPs and other health professionals after a 17-year-old boy suffering from mental health problems was found dead. Sean Mark, who described himself as an “anxious paranoid mess”, was desperate for help but felt “palmed off” when he asked for assistance, an inquest heard. He was found dead in his bedroom four months after a phone consultation with a GP and before he had spoken to anyone in person about his concerns. The area coroner, Rosamund Rhodes-Kemp, recorded a verdict of death by misadventure, saying she could not be sure Sean had intended to kill himself. Dr Robin Harlow, clinical director of the Willow Group, where Sean Mark was a patient, said it had increased the number of face-to-face meetings. When told that Sean felt palmed off, he said: “I would want him to be seen face to face at the second time, if not the first time. We have seen a lot more face-to-face appointments since then.” Read full story Source: The Guardian (23 August 2022)
  23. Content Article
    This article by The Decision Lab explains the Dunning-Kruger Effect, which occurs when a person’s lack of knowledge and skills in a certain area causes them to overestimate their own competence. By contrast, this effect also causes those who excel in a given area to think the task is simple for everyone, and underestimate their relative abilities as well. The article covers the following topics: Where this bias occurs Individual effects Systemic effects Why it happens Why it is important How to avoid it How it all started It also includes two real-world examples of the Dunning-Kruger Effect.
  24. Content Article
    This report by The Tony Blair Institute for Global Change sets out an action plan to save the NHS this winter. It highlights the pressures the health service faces, worsened by the Covid-19 pandemic, including a resurgent flu epidemic, the effect of the cost-of-living crisis, the unprecedented elective-care backlog and a depleted and exhausted workforce. The authors call for the Government to immediately: focus leadership minimise demand on the service improve patient flow and efficiency maximise capacity.
  25. News Article
    A report into the care of three women at a former mental health unit has recommended greater monitoring and scrutiny of private provision. The Norfolk Safeguarding Adults Board (NSAB) review focused on care given to women known as L, M and N, who lived at Milestones Hospital near Norwich. The women, in their 20s, were found to have visited accident and emergency 53 times, mostly due to self-harm. The unit shut down last year and the company that run it has been dissolved. Heather Roach, chair of NSAB, said: "When vulnerable patients are placed in hospitals like Milestones, it's vital that our whole system works together to keep them safe. This review has shown that there are gaps in the monitoring of private provision, particularly when patients are placed in Norfolk from out of our county." Read full story Source: BBC News (25 August 2022)
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