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Content ArticleReducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study, published in PLOS ONE, aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. Authors conclude: "We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement."
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Content ArticleThe mandated reporting of medication-related errors in community pharmacies including incidents resulting in inappropriate medication use and near misses intercepted before reaching the patient can be utilised as learning opportunities to aid in the prevention of future events. This study examined reporting uptake, trends, and initial learnings from medication errors reported by community pharmacists to the Assurance and Improvement in Medication Safety (AIMS) Program based in Ontario, Canada between April 1st, 2018, and June 30th, 2021. Key findings Community pharmacy engagement with the AIMS Program has grown since implementation. Commonly reported events involved the incorrect drug, concentration, or quantity. In most cases no patient harm was reported. Reporting by pharmacy teams will help develop strategies to prevent future events.
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Content ArticleNear misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED). This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED. It was published in the Journal of Patient Safety. Authors conclude that near-miss events are relatively common (22.7% of their sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.
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Content ArticleThis paper, published in the International Journal of Health Governance, discusses and analyses the need and benefits of a patient safety definition within the context of nursing. The predominant role of nurses due to the proportionate size and significant role along with the need for clarification of patient safety in nursing terms is recognised. Research evidence of nursing areas with safety issues and relevant nursing interventions are presented. Based on all findings, a research-based nursing specific patient safety definition is proposed. This definition includes three axes: What is patient harm? How this harm can be eliminated or reduced? Which are the areas of nursing practice that are identified to provide opportunity for patient harm? These axes include nursing specifications of the patient safety definition.
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Content Article
Footage from the Black Maternal Health Conference UK 2023 is now available for download. Sessions highlight the gaps within the system and disparities - and provide nuance, to further reiterate the importance of Black women receiving health care that is respectful, culturally competent, safe and of the highest quality. Hosted by Sandra Igwe, Chief Executive of The Motherhood Group. You can purchase the full recording, or specific sessions, from the event via the link below. -
Content ArticleIn this audio recording from the 2023 Chief Coroner's Conference at Central Hall Westminster, we hear Dr Georgia Richards present on the work of the Preventable Deaths Tracker. Dr Richards explains why this work was so necessary, how it can be used to reduce future avoidable deaths and why we need to ensure that the learning and data shared in coroner reports has impact on the ground.
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Content ArticleNational Education for Scotland research and evaluation work has shown wide variations in the standard of significant event analysis (SEAs) undertaken by frontline healthcare teams. The direct implication is that there are many missed opportunities to learn from and improve the safety of patient care. As a consequence, NES developed a robust educational model to enable clinicians, managers and healthcare teams to submit SEA reports for feedback from trained peer groups.
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Content ArticleA Human Factors approach to significant event analysis for more meaningful improvement implementation to minimise the risks of the event happening again. Enhanced SEA is a National Education Scotland innovation (funded by the Health Foundation 2012 SHINE programme) which aims to guide health care teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved. Taking this approach will help individual clinicians and care teams to openly, honestly and objectively analyse patient safety incidents, particularly more difficult or sensitive safety cases, by ‘depersonalising’ the incident and searching for deeper, systems-based reasons for why the significant event happened.
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Content Article
PSSD International (Post-SSRI/SNRI Sexual Dysfunction)
Patient_Safety_Learning posted an article in Medication
PSSD International are an international alliance of people experiencing an iatrogenic (meaning caused by a medication or medical treatment) disorder known commonly as Post-SSRI Sexual Dysfunction or Post SSRI/SNRI Sexual Dysfunction. This potentially permanent disorder arises during or after the use of SSRI (selective serotonin re-uptake inhibitor) and SNRI (Serotonin-norepinephrine re-uptake inhibitor) antidepressants. Though characterized by a reduction or removal of sexual functioning, common symptoms also include emotional blunting, cognitive dysfunction, genital numbness and sleep disruption. The causes of PSSD are poorly understood and there are no known reliable treatments. The disorder can arise from brief exposure to SSRIs or SNRIs and can persist for months, years or indefinitely. This page exists to bring together people suffering from this condition and advocate for recognition, research and greater transparency within psychiatry concerning the risks of antidepressants. -
Community PostInfiltration is when fluid or intravenous drugs are administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign, to improve awareness of infiltration and extravasation and reduce avoidable harm. Do you have insights to share on this topic? Perhaps you are a patient who has had an extravasation injury? Or a healthcare professional who has insights to share around making improvements? Share your thoughts below (you'll need to register for free here first).
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Content ArticleBecause hospitals exist for a long time and are expensive to build and to operate, it is crucial to use the abundant, available empirical evidence to guide design. “Evidence-based design” has documented how to make hospitals safer and less stressful. This article, published in The Conversation, looks at the challenges involved.
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Content ArticleWhen the Paralympian and television presenter Tanni Grey-Thompson found she was pregnant in 2001, she went to see her doctor. “The first thing I was offered was a termination,” she says, “because people like me shouldn’t be allowed to have children.” She changed hospitals and gave birth to Carys, but she says that for disabled people, “the relationship with the NHS can be quite mixed”. Read the full article, published in the Times, via the link below.
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Content Article
Sepsis: National Education Scotland resources
Patient_Safety_Learning posted an article in Deterioration and sepsis
This document brings together some of NHS Education for Scotland (NES) sepsis educational resources. Note: given the changes to the definition of sepsis, some of these resources may refer to previous, alternative terms, which are now not formally recognised. The management and need for urgent treatment remain unchanged, and resources will be updated, as appropriate. -
Content ArticleThis editorial commentary, published in the Journal of the Royal College of Physicians of Edinburgh, looks at the College's response to the Mid Staffordshire inquiry.
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Content ArticlePennsylvania hospitals are required to report patient safety events, but do you know why it’s so important? Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They also can be tools to trigger change facility wide, or even nationwide. This resource from the Patient Safety Authority allows you to click one of the categories or type keywords into the search field to find stories of event reports that inspired staff to make changes that improved patient care and safety throughout their hospital.
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Content ArticleCan the NHS effectively combine the aims of clearing the elective backlog and tackling health inequalities? It’s a question that systems and providers have been faced with since NHS England requested that recovery in the wake of the pandemic is managed inclusively. Some may think these aims are at odds with one another, while others will champion their unification. In the first stage of a new research project about inclusive approaches to reducing the backlog, The Kings Fund look at what we can learn from NHS boards about how this issue is playing out.
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Content ArticleTPXimpact was commissioned by the NHS Race & Health Observatory to deliver research that can shape future digital health recommendations to reduce ethnic inequality in the usage of healthcare apps such as the NHS App, NHSBT Give Blood app, and other current and future healthcare apps. As health inequalities are shaped by wider determinants of health, addressing them requires a response beyond digital and even beyond the NHS. This report focuses on the role digital can play in understanding and addressing ethnic health inequalities.
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Content ArticleNHS England working in partnership with integrated care system (ICS) leads and representatives, has devised actions to help systems develop plans that can support people who are taking medicines associated with dependence and withdrawal symptoms. The actions will support ICSs to deliver on their 4 key objectives of: improving outcomes in population health and healthcare tackling health inequalities in outcomes, experience and access enhancing productivity and value for money helping the NHS support broader social and economic development.
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Content ArticleThis discussion, published in HSJ, looks at the state of NHS waiting times in January 2023. All figures come from NHS England. The referral-to-treatment waiting list narrowly broke through previous records in January, edging up to 7,213,436 patient pathways. Waiting times rose too, with 8 per cent of the list waiting longer than 46.6 weeks, up from 46.3 weeks the previous month. Read the full blog and access the data via the link below.
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Content ArticleIn this podcast Martin Bromiley talks about his determination for more Human Factors in the medical domain and the formation of the Clinical Human Factors Group (CHFG).
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Content ArticleThis article, originally published in HindSight magazine, details a conversation between Steven Shorrock and with Manoj Kumar, consultant general surgeon with a background also in safety, human factors, and training. Manoj provides insights and perspectives on the realities of work in healthcare, and the team’s role in improvement.
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Content Article
Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety. -
Content ArticleSmart Pods is the first-ever Royal College of Art (RCA)/ Engineering and Physical Sciences Research Council (EPSRC) multi-disciplinary healthcare project. It has grown out of the College’s chartered commitment to engage with ‘social developments’ through design.
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Safe design of healthcare facilities (December 2006)
Patient_Safety_Learning posted an article in Design for safety
In April 2002, St Joseph’s Community Hospital of West Bend, a member of SynergyHealth, brought together leaders in healthcare and systems engineering to develop a set of safety-driven facility design recommendations and principles that would guide the design of a new hospital facility focused on patient safety. By introducing safety-driven innovations into the facility design process, environmental designers and healthcare leaders will be able to make significant contributions to patient safety. Request permission to view the resource in full via the link below. -
Content ArticleThe NHS is the closest thing we have to a national religion – or so it's often said. But many critics have claimed that the high value we place on our health system leads to widespread resistance to its reform. In the second of a series of mythbusting commentaries, Nigel Edwards shows this isn't the case – arguing that, in fact, the NHS has perhaps had too much reform, of the badly planned kind.
