In resource-constrained health care environments, it is important not to reinvent the wheel and waste money when existing, proven patient safety solutions already exist in other countries. Global patient safety knowledge sharing, and learning helps all countries, regardless of income level and this needs to be encouraged. Read More
NHS Improvement, which supports the NHS (National Health Service) and helps improve care for patients, have just published their latest report on Never Events occurring between April 1, 2018 and February 28 2019.
The report makes for uncomfortable reading, as Never Events are not reducing.
From 1999 to 2017, almost 218,000 people died in the United States from overdoses related to prescription opioids. Overdose deaths involving prescription opioids were five times higher in 2017 than in 1999, according to the CDC.
Previous research has indicated that patients who receive higher doses of prescription opioids have an increased risk of overdose and mortality. In response, several states have established Morphine Equivalent Daily Dose (MEDD) thresholds that convert opioid prescriptions to their equivalent dose in morphine and divides the total prescription by the number of days the prescription is intended to last, allowing for comparison among different opioid formulations and strengths. MEDD policies set thresholds for prescribers, which may only be exceeded in limited circumstances, such as when being prescribed to certain patient groups or as short-courses.
Sara Heins, PhD, an associate policy researcher at RAND Corporation, used policy surveillance to track MEDD policies through June 1, 2017 (data are available on LawAtlas.org). She published an article in Pain Medicine on March 13 that describes U.S. MEDD policies.
We asked Dr. Heins a few questions about her work and this recent publication. Read More
The independent regulator of health and social care in England, the Care Quality Commission (CQC) has just published a report on how the National Health Service (NHS) is progressing in the first year of implementing national guidance on learning from deaths.
The report follows on from another published in 2016 which detailed major failings and concerns about the way the NHS investigate and learn from the deaths of patients in their care. The 2019 report contains several case studies which detail experiences of implementing the national guidance. Read More
Mental Health Care in the National Health Service in England has always existed in the shadow of physical care in terms of funding and NHS-government health policy priorities.
Many in the past have termed it the “Cinderella” part of the NHS. This neglect has been chronicled in numerous reports over the years pointing to many problems which include chronic under funding, poor patient safety, abuses of patient rights, poor complaint handling, unnecessary restrictive care regimes, poor patient, health carer communication, and poor patient satisfaction. Read More
The National Health Service in England has been trying for many years to get its complaints system right, but it has never succeeded. A great number of reports have been published on the system over the years, some dating back for at least a quarter of a century.
Wait times and length of stay in emergency departments are a hot topic and often result in a variety of identifiable harms that include medical error and failures to meet quality care measures. Patients with psychiatric conditions, including suicidal ideations, risk for harm to others, or psychosis, are particularly vulnerable to increased emergency department (ED) lengths of stay. The length of ED holds for psychiatric patients can be three-fold that of similar holds for medical patients. Lack of access to appropriate care, comorbid medical illness, or violent behavior can all contribute to this.
Increased length of stay impacts the efficiency of the ED itself, increasing wait times, utilizing human resources and physical space. It has a more important impact, however, on the patient. Patients may be held in a small room with constant observation for days with little or no access to natural light, bathing facilities or contact with family or friends. They may be dressed in paper gowns, told when to eat, when to sleep and confined to their room for days at a time, emulating the conditions in a maximum security prison. Emergency Departments, through no fault of their own, are becoming holding cells for patients who are both vulnerable and often marginalized.
Recent studies have highlighted the inherent susceptibility for medication errors by anesthesia providers in the perioperative environment. In a prospective survey at Massachusetts General Hospital, investigators identified a concerning potential error rate of 1 in 20 medication administrations, many of which resulted in patient harm.
To those of us who toil daily in the trenches of the operating room, this come as no surprise, for we are the only type of healthcare provider that prescribes, dispenses, premixes, repackages, relabels and administers the medications, independently and without secondary verification or use of technologic support. In one sense this may seem to be an advantage, for if there are fewer intermediaries, such as pharmacists or registered nurses, there are fewer humans to make a mistake. On the other hand, more intermediaries or additional verification might identify previously unrecognized errors. Read More