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Content ArticleThis paper by Professor Paul Bate, Emeritus Professor of Health Services Management at University College London, looks at the importance of considering context in healthcare initiatives. It introduces various frameworks for viewing context and looks at key themes in existing research. It concludes by looking at key questions for future research on context.
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Content ArticleThis article in The BMJ examines the case for vaccinating children under five against Covid, following the US recently recommending that children aged six months to five years should receive Covid-19 vaccines. It looks at the risks and benefits of vaccination for young children, citing recent Moderna and Pfizer trials. It highlights that children are more likely than adults to experience asymptomatic Covid-19 or very mild illness, and are much less likely to have severe disease requiring hospital admission. But for children with underlying health conditions, such as long term neurological disease, vaccination may be beneficial in preventing severe disease.
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Content ArticleNeonatal intensive care unit (NICU) admission among term neonates is associated with significant morbidity and mortality, as well as high healthcare costs. This study in the Journal of Clinical Medicine aimed to identify and quantify risk factors and causes of NICU admission of term neonates. The study looked at NICU admission for term babies at a maternity unit in Israel. The authors suggest that a comprehensive NICU admission risk assessment that uses an integrated statistical approach may be used to build a risk calculation algorithm for this group of neonates prior to delivery.
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Content Article
AYPH Youth health data website
Patient-Safety-Learning posted an article in Children, young people and families
This website from the Association for Young People's Health (AYPH) aims to provide useful data about young people’s health for healthcare professionals, researchers and other professionals working with young people. At its heart is a data compendium called ‘Key Data on Young People’s Health’ produced AYPH, which gives up to date national data on key health outcomes for 10-24 year olds. The website also include links to other resources and sources of data about the key issues facing young people. -
Content ArticleDefining whether a diagnostic error has occurred can be difficult, but in order to reduce harms from diagnostic errors, hospitalists must first understand how these errors occur and then develop practical strategies to avoid them. This article in the journal Annals of Internal Medicine explores these issues and highlights new opportunities for reducing diagnostic error in hospitals.
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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. Jordan talks to us about his journey from drama school to patient safety, how the new Patient Safety Incident Response Framework (PSIRF) will change the way the NHS looks at safety, and how his love of driving makes him think differently about his role. A transcript of the interview is also available below.- Posted
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Content ArticleThis report by the Academy of Medical Royal Colleges looks at the possibilities for establishing a system of staggered changeover start dates for trainee doctors. Evidence suggests that there is an increase in patient morbidity and mortality at the beginning of August each year, which corresponds with the time when trainee doctors rotate positions. The paper, produced by the Academy’s Staggered Trainee Changeover Working Group (STCWG), recommends that the most effective solution for safe trainee changeover is a roll forward model of staggering, where the more senior trainees rotate one month later. A survey of Foundation doctors demonstrated support for a system where all Specialty Training programmes start at the beginning of September, one month after the end of the Foundation Programme.
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Content ArticleThe fishbone diagram is a widely-used patient safety tool that helps to facilitate root cause analysis discussions. The authors of this article in the journal Diagnosis expanded this tool to reflect how both systems errors and individual cognitive errors contribute to diagnostic errors. They describe how two medical centres in the US have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets their patient safety and educational needs.
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Content ArticleThe Department of Health today published the 2021/22 Inpatient, Day Case and Outpatient Hospital Statistics for Northern Ireland. Analysed by HSC Trust, hospital and specialty, these Hospital Statistics publications outline: the number of inpatient and day case admissions. the number of attendances at consultant led outpatient services in Northern Ireland during 2021/22.
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Content ArticleThis report by Richard Norrie, director of the Statistics and Policy Research Programme at Civitas, aims to scrutinise the Race and Health Observatory (RHO) rapid evidence review into ethnic inequalities in healthcare published in February 2022. The report highlights inconsistencies in the review's use of research and data and argues that its conclusions do not reflect the full body of evidence available concerning race and health outcomes. The author suggests that the review makes a false assumption that the needs of all ethnic groups are the same, which leads to its potentially inaccurate conclusions about the prevalence and causes of health inequalities.
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Content ArticleIn this episode of the Driving Insights to Action podcast, patient safety advocates Soojin Jun and Sue Sheridan talk about the role of the World Health Organization's Global Patient Safety Action Plan in helping reduce medication errors in healthcare. They also share their personal experiences of family members' deaths as a result of avoidable harm in healthcare.
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Content ArticleThis NCEPOD report looks at the quality of care provided to patients with Parkinson’s disease (PD) aged 16 years and over who were admitted to hospital when acutely unwell. It highlights the findings of a review into the pathway of care for patients with Parkinson’s disease (PD) which explored multidisciplinary care and organisational factors in the process of identifying, screening, assessing, treating and monitoring their ability to swallow. You can view and download the following diagrams related to the report: Full report Summary report Summary sheet Recommendation checklist Infographic Slide set Commissioners' guide Fishbone diagram Recommendations Audit toolkit
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Content ArticleVideo and telephone consultations have, through the course of the pandemic, become a central of daily operations across the NHS. In this blog, Ben Gadd and Amanda Nash of University Hospitals Plymouth NHS Trust share their experiences about how they are being received and the potential lessons we can learn.
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Content ArticleThis article published by The Conversation looks at the pressures faced by ambulance services and emergency departments across Australia as a result of Covid-19. There has been an increase in 'ramping', where ambulances queue up outside hospitals. Ramping is a sign that the whole health system is under immense pressure. The article looks at the large amounts of funding Australian local governments are putting into ambulance services and emergency departments (EDs), but highlight that this will not solve the issues face by the health system if issues discharging patients into community and social care remain. It highlights a model developed in Leeds, UK, that has been adopted by the health service in Victoria, Australia, focused on solving more systemic issues. The Leeds model aims to improve patient flow in and out of the hospital and ensure that patients are quickly transferred from ambulances into EDs. Discharge coordinators organise the care patients need in the community after an ED or hospital stay. The authors also look at the role of community paramedics in keeping patients out of hospital and their potential to reduce financial and capacity pressure on health systems worldwide.
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Content ArticleThe Care Quality Commission (CQC) has introduced a new assessment framework that it will use to set out its view of quality and make judgements about health services. The framework is being introduced in phases, and the CQC has published it before it comes into use so that providers and other stakeholders can start to become familiar with it.
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Content ArticleThe Personalised Care Group at NHS England aims to help improve the choice and control that patients have over their health, as part of its NHS Long Term Plan commitments. These decision support tools will help people discuss their treatment choices with their healthcare professionals through shared decision making. The eight new tools cover the following conditions: Dupuytren’s contracture Carpal tunnel syndrome Hip osteoarthritis Knee osteoarthritis Further treatment for atrial fibrillation Cataracts Glaucoma Wet age-related macular degeneration
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Content ArticleRecent data shows that people aged 10–25 in the poorest areas of the UK will die earlier than those in richer areas. It’s also predicted that people aged 10–14 living in the most deprived areas will live 18 more years in ill health than their peers in the least deprived areas. In this blog for The Health Foundation, Association for Young People's Health (AYPH) policy fellow Rachael McKeown outlines data recently published by AYPH that shows the scale and complexity of young people’s health inequalities, and the need for action.
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Content ArticleDuring the Covid-19 pandemic, intensive Care Units (ICUs) all came under severe pressure, resulting in higher than usual mortality and complications rates, and longer stays. However, there was variation in outcomes among ICUs and this editorial in the journal Annals of Intensive Care discusses the concept of a resilient ICU. It looks at which metrics can be used to address the capacity to respond, sustain results and incorporate new practices that lead to improvement.
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Content ArticleClinical governance can be defined as ‘the framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high quality of care’. This article aims to provide an introduction to clinical governance based on UK practice. The article defines and examines how UK health systems priorities safe care, effective care, person-centred care and assured care.
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Content Article
PRSB - 111 referral standard (August 2022)
Patient-Safety-Learning posted an article in Processes
The Professional Record Standards Body (PRSB) has published the final draft standard for 111 referral, which defines the information that should be shared from 111 or 999 services when a person is referred on to another service. The standard applies to: all 111 and 999 service referrals to wherever the person goes next. referrals through 111 online, call handler or clinical assessment services and 999 services, and is not specific to any triage system. all age groups including children. The standard is UK-wide and was developed in consultation with a wide range of professionals from all four nations, including from 111 services, receiving services, IT suppliers and people who use services. It does not apply to transfers between 111 services (e.g. across a country border) or between 111 and 999 services. -
Content ArticleIn spring 2021, YouTube asked the National Academy of Medicine to bring together experts to develop principles for elevating credible health information online. In this interview with The Commonwealth Fund, Garth Graham, YouTube’s director and global head of health care and public health partnerships talks about how YouTube—which reaches two billion people each month—has been working with health systems in the US to create high-quality, engaging health content.
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Content ArticleThis article outlines the results of a recent investigation by the Parliamentary and Health Service Ombudsman (PHSO) which found that a 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray. The patient, known as Mr B, was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019 after being unwell for several days with abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities. The following day Mr B's condition deteriorated and he suffered a heart attack and died. The PHSO investigation found that the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life.
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Content ArticlePatient safety culture is the foundation of patient safety and refers to a healthcare organisation’s shared values, norms and beliefs that influence staff’s behaviour and actions. This study in BMJ Open Quality aimed to assess nurses’ reporting on the predictors and outcomes of patient safety culture and the differences between patient safety grades and the number of events reported. It aimed to fill a gap in research by looking at patient safety culture in terms of both predictors and outcomes. The author developed a cross-sectional comparative research design and recruited 300 registered nurses to take part in a survey on patient safety culture. The author found that nurses generally perceived patient safety culture as 'moderate', and identified areas that should be prioritised to improve patient safety culture. They concluded that assessing patient safety culture is the first step in improving hospitals’ overall performance and quality of services, and that improving patient safety practices is essential to improving culture and clinical outcomes.
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Content ArticleThe health and care system in the UK is under intense pressure and as a result, patient and public satisfaction with services has dropped significantly, prompting debate and discussion about the future of health and care services. In this article, Charlotte Wickens, Policy Adviser at The King's Fund, looks at five 'myths' perpetuated about the NHS by politicians and the media. She analyses the extent to which each myth can be backed up or debunked by the available data and evidence. The myths she analyses are: The NHS is a bottomless pit, demanding more and more money The NHS is inefficient GPs aren't working hard enough to meet demand for appointments The government has 'fixed' social care The NHS is being privatised
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EventuntilThe International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the 6th webinar of the medication without harm webinar series is "Medication Safety in Polypharmacy and Transitions of Care”. Register for the webinar The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm.
