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Patient_Safety_Learning

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Everything posted by Patient_Safety_Learning

  1. Content Article
    One year on from the launch of the Health Innovation Network's Chronic Pain Experience-Based Co-Design (EBCD) project, Natasha Callender, Senior Project Manager at the Health Innovation Network South London (HIN), and Natasha Curran, HIN Medical Director and Consultant in Pain Medicine share reflections on their learnings from working with people living with chronic pain. 
  2. Content Article
    Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors of this paper, published in The Joint Commission Journal on Quality and Patient Safety, sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.
  3. Content Article
    Suad Duale grew up as a Somali refugee. She is now a community activist, a clinician, a mother and a researcher. Every day she says she sees the Somali community suffering and being treated unfairly, which leads to a collective lack of trust in professionals, particularly in the health system. In her work, she tried to address this issue by bridging the gap between the community and health and social care professionals. Read the full article on the Kings Fund website via the link below.
  4. Content Article
    Published on Steve Turner's blog site, this article gives a summary of the The Protection for Whistleblowing Bill & the Office of the Whistleblower, and answers some frequently asked questions.
  5. Content Article
    Safety risks exist in all medical care settings, but emergency medicine professionals face particular challenges as they strive to deliver the safest, highest quality care to their patients. Massachusetts emergency departments rank high in a national review of ED quality and safety. Yet many frontline staff express concerns that the environment is not as safe as it needs to be for patients or staff. In response to these concerns from their members, leaders of the Massachusetts College of Emergency Physicians (MACEP) reached out to the Betsy Lehman Center to help facilitate work to improve safety in emergency departments across the state. The Massachusetts Emergency Nurses Association (MENA) and the Massachusetts Association of Physician Assistants (MAPA) joined as partners in the effort. Through this collaboration, the Betsy Lehman Center convened an expert panel to identify key risks to safety in emergency departments, recommend practical steps for mitigating these risks, and develop a toolkit to support implementation of the recommendations. Recognising the broad range of safety issues facing emergency medicine clinicians and staff, the expert panel focused on interventions that could be executed from “within the four walls” of the emergency department in three key areas: (1) crowding; (2) cognitive overload; and (3) care coordination.
  6. Content Article
    Over the past year, the Director of Patient Safety, the Risk and Governance Team, the Legal team, nursing and medical leaders, adult mental health services in Bedfordshire & Luton, as well as the Associate Director of Quality Improvement, have been deploying quality improvement (QI) methods to enhance the development and delivery of the organization’s patient safety strategy. Following sessions with staff, service users, and partner organizations, the strategy was constructed in the form of a Driver Diagram. Follow the link to find out more and to access the diagram.
  7. Content Article
    Healthcare has become increasingly dependent on, and supported by, technology and digital solutions. We've pulled together some key pieces of hub content to help readers take a closer look at some of the patient safety considerations.
  8. Content Article
    QualiScope is... a general public information service on the level of quality and safety of care measured by Haute Autorité de Santé (HAS) in all hospitals and clinics in France; access to all the results of the quality and safety indicators of care and certification of health establishments in France; a search engine and an interactive panorama allow access to data from more than 4 000 hospital sites by search by establishment name, geographical area, activity, certification result, indicator results, etc. ; data developed and measured independently by HAS, with robust methods ensuring their reliability and comparability between health facilities; tools for mapping, comparison, data visualisation or data exports to make information accessible and understandable to all.
  9. Content Article
    This webpage from the UK Civil Aviation Authority contains information for organisations regarding Safety Management Systems including: Evaluation tools Guidance and templates Gap analysis frameworks.
  10. Content Article
    In 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation. This research, published by Lund Universities Libraries, comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinising five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's categorisation regarding incident investigation models, which delineates three models: sequential, epidemiological, and systemic. The findings show that there are distinctions in both the nature and effects of the investigation reports. Investigations conducted pre-2017 exhibit characteristics of the sequential model due to a focus on what went wrong, (broken) components and measures that mostly aim at the sharp end operator (train drivers, conductors, train dispatcher) such as training and discussing specific findings of the investigations with those involved only.
  11. Content Article
    Secure and immediate access to health and care data helps to prevent avoidable delays in diagnosis and unnecessary repeat tests and examinations that can slow down the speed at which patients are able to begin treatment. In an emergency situation, the right information at the right time can be life saving. This NHS England webage looks improving individual care and patient safety, within the context of the Data Saves Lives: Reshaping health and social care with data strategy. Content includes: Video: Why do shared care records matter? Video: Why does data matter to adult social care? Case studies
  12. Content Article
    Quality improvement and patient safety (QIPS) practitioners aspire to improve care for all patients, caregivers and families using improvement methods. While teams are trained to carefully implement the science of improvement, less is known of how to effectively incorporate equity into QIPS work. In this editorial for BMJ Quality and Safety authors ask; should there be more projects focused specifically on equity, or should equity be embedded into all quality improvement? 
  13. Content Article
    Following the release of the Australian National Safety and Quality Digital Mental Health (NSQDMH) Standards in November 2020, the objective of this study, published in Australas Psychiatry, was to ensure effective implementation of the Standards. This included the development of an accreditation scheme to allow digital mental health services to be formally assessed against the Standards and provide service users with an assurance of safe and high-quality services. Conclusion: The NSQDMH Standards accreditation scheme provides an assurance of safety and quality for digital mental health service users.
  14. Content Article
    Data Saves Lives is a multi-stakeholder initiative with the aim of raising wider patient and public awareness about the importance of health data, improving understanding of how it is used and establishing a trusted environment for multi-stakeholder dialogue about responsible use and good practices across Europe. Read more on the Data Saves Lives website Read more on the European Patients forum website
  15. Content Article
    In this editorial for BMJ Quality and Safety, Richard Lilford looks at a A paper from Ferguson and colleagues. Lilford concludes by saying that the paper provides useful findings regarding locums and their impact on patient safety. "The paper should not be simply curated among the voluminous safety literature. It should be considered as a call to action by senior policy makers."
  16. Content Article
    One of the enduring lessons of the pandemic has been the pivotal role that nursing plays in health care--vital work that isn't widely understood or, sadly, appreciated. Sara Fung and Amie Archibald-Varley started the wildly popular The Gritty Nurse podcast to give voice to nurses all over the world, including more than 400,000 nurses in Canada. The authors have quickly become sought-after speakers and advocates for nurses and are called on regularly by the media to talk about a wide range of issues around the profession. In their first book, they take you to the front line of nursing to show the compassion, selflessness and dedication of professionals who not only give it all for their patients, but get up and do it over and over again.
  17. Content Article
    The Gritty Nurse Nursing Podcast examines hot topics related to health and healthcare. We shy away from nothing, discussing topics such as mental health, social justice, women's health and women's rights. Hosts Amie Archibald-Varley and Sara Fung are story-tellers and love hearing how healthcare has impacted individuals' lives. They want to discuss the good, bad and ugly . They also provide a platform for empowerment and shared experiences, where they represent voices that have been silenced, underrepresented and marginalized --so they can share their stories of hope, change and inspiration.
  18. Content Article
    In this article for Healthcare Quarterly, Leslee Thompson argues that Health Quality 5.0 moves people-centred, integrated health and social care systems to the forefront of our post-COVID-19 agenda – and that cannot happen without addressing our global workforce crisis. Building back a stronger, healthier workforce is the first of the five big challenges we address in our special series. Starting with the global health workforce crisis is fitting, given it is the most fundamental and formidable barrier to health and quality today. As we put the pieces of the Health Quality 5.0 puzzle together, a picture of a more resilient health system will emerge and a new leadership agenda to get there will take shape.
  19. Event
    until
    About this webinar In many pharmaceutical companies, human error is still addressed reactively through compliance by Deviation Management. While people are involved, they are NOT the root cause in the majority of deviations. There's an opportunity to set people up for success proactively in regards to risk prevention in a complex work environment through, for example: Recognition of risk and techniques for prevention of error. A roadmap for investigating repeated, human-related deviations. A means of integrating human performance into operational excellence, such as Gemba and leader standard work. Techniques for interviewing, coaching and improved communication. Recommendations for addressing system-related problems. Who would this be of interest to? Leaders and supporters of those that perform complex work in any regulated Good Manufacturing Practice (GMP) environment and anyone interested in human and organisational performance. About the speakers Bill Farmer has a BS in Microbiology and is an Associate Director for Deviation Management at Merck in North Carolina, USA. He's an experienced pharmaceutical scientist and has had many roles in technical and quality organisations. His philosophy to 'Help others, make it easier to do the 'right' thing, harder to do the 'wrong' thing, drives Bill to continuously improve the Merck Deviation Management Process. Julie Avery (chair) is former Global Lead for human factors at GSK, with over 20 years in Quality and Operational Excellence. As an independent practitioner, Julie now integrates human performance into existing systems strategically and tactically supporting business goals and KPIs. Julie leads the CIEHF Human Factors Pharmaceutical Manufacturing COP and is a Trustee of the CIEHF representing Associate Members. Register here
  20. Content Article
    6B is a technology and engineering consultancy. It has produced a list of all 214 NHS Trusts in England and the Electronic Patient Record (EPR) they have implemented (as of May 2024).
  21. News Article
    A mental health trust and a band seven ward manager it employed have denied manslaughter charges over a death on an inpatient ward. North East London Foundation Trust and Benjamin Aninakwa entered not guilty pleas to manslaughter by gross negligence at the Old Bailey on Friday (24 May). It is believed to be the first time a named NHS manager at a trust has faced corporate manslaughter charges, alongside the organisation that employed them. Read full story (paywalled) Source: HSJ, 29 May 2024
  22. Content Article
    In this paper, published by Healthcare, authors proceed in two steps. First, they expand the existing base of literature on the interpersonal aspect of a safety climate by presenting a conceptual model of psychological safety and joint problem-solving orientation and proposing how, individually and together, they promote safety improvement and worker retention in healthcare. Second, they conduct an exploratory test of these relationships using empirical data from a large healthcare organization in the US.
  23. Content Article
    In this editorial for BMJ Quality and Safety, Kate Kirk explains why staff well-being is the foundation to improving patient safety.
  24. Content Article
    This seminal study by Cabral et al delves into the transformative potential of artificial intelligence (AI) in oncology, highlighting its pivotal role in enhancing healthcare quality and safety. The study aligns with the broader discourse on AI’s capacity to revolutionise healthcare outcomes, drawing from insights previously proposed on the synergy between human expertise and AI across various medical disciplines.
  25. News Article
    A man discovered a medical specimen bag had been left inside his abdominal cavity after his hernia surgery, the BBC has found. The surgeon who carried out the procedure, at the Royal Sussex County Hospital in Brighton in 2016, also left behind part of Tom Hadrys's bowel that had been cut out during the operation. According to a hospital incident report seen by BBC Newsnight, the surgeon realised his mistakes while driving home from work. Sussex Police are investigating at least 105 cases of alleged medical negligence by two surgery teams at the University Hospitals Sussex NHS Foundation Trust. Read full story Source: BBC News, 24 May 2024
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