Design for Patient Safety: A Review of the Effectiveness of Design in the UK Health Service

Volume 3 ◽  
2004 ◽  
Author(s):  
P. John Clarkson ◽  
James Ward ◽  
Peter Buckle ◽  
Dave Stubbs ◽  
Roger Coleman
Keyword(s):  
Patient Safety ◽  
Medical Error ◽  
Improve Patient Safety ◽  
Research Centre ◽  
Department Of Health ◽  
University Of Cambridge ◽  
Key Stakeholders ◽  
Consistent Picture ◽  
The Uk ◽  
The University

The Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the NHS. The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the health care system as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.

Reification and Modern Drama: an Analysis, a Critique, and a Manifesto

2016 ◽  
Vol 32 (3) ◽  
pp. 256-268
Author(s):  
Eva Urban
Keyword(s):  
Research Centre ◽  
Modern Drama ◽  
Northern Irish ◽  
Human Relationships ◽  
Irish Studies ◽  
University Of Cambridge ◽  
Political Drama ◽  
Irish Drama ◽  
The University ◽  
Postdoctoral Fellowship

Drawing on a close reading of Theodor Adorno's essay, ‘Education after Auschwitz’, in this article Eva Urban develops the argument that an analysis of the reification that reduces human relationships to mere business interactions has been a central concern of modern drama. The article offers an analysis of some of the ways in which this theme continues to be represented, interrogated, and challenged internationally in contemporary political plays and theatre performances across a range of genres and grounded in a variety of dramaturgical principles. It asks how drama, theatre-making, theatre-spectating, and theatre-participating can create dynamics necessary to enable a move from reified consciousness towards the development of critical autonomy and solidarity. A negotiation of the principles of critical consciousness and solidarity is problematic within economic structures that cause social, ethnic, and religious atomization and divisions. Her argument concludes with an outline for a manifesto for political drama and theatre practice to work against reification. Eva Urban is a lecturer and researcher in the English Department and an Associate of the Irish Studies Research Centre, CEI/CRBC, at the University of Rennes 2, France. She recently completed a British Academy Postdoctoral Fellowship at the University of Cambridge and is a Life Member of Clare Hall, Cambridge. The author of Community Politics and the Peace Process in Contemporary Northern Irish Drama (Peter Lang, 2011), she has also published articles in New Theatre Quarterly, Etudes Irlandaises, Caleidoscopio, and edited book collections.

scholarly journals The Roles of Music in Effecting Change: Considerations about Public Policy

2020 ◽  
Vol 3 ◽  
pp. 205920432093722
Author(s):  
Elaine C. King
Keyword(s):  
Public Policy ◽  
Culture Media ◽  
Digital Culture ◽  
The Political ◽  
Political Environment ◽  
Final Session ◽  
Managing Change ◽  
University Of Cambridge ◽  
The Uk ◽  
The University

The aim of this article is to consider questions, issues, and debates about music in public policy, a topic that featured in the final session of the Musics, Selves and Societies workshop at the University of Cambridge in June 2018. The first part of this article provides a backdrop by defining key terminology and describing the political environment in relation to music, specifically in the UK. It deciphers the scope of the Department for Digital, Culture, Media and Sport (DCMS) alongside public, professional, and charitable bodies as well as learned societies. The second part highlights three main areas of focus that were identified in the final session of the workshop: considerations about the value of music; considerations about the meaning of music; and considerations about policy-making. Each of these areas are discussed in turn before final remarks are put forward about steps for managing change.

Does UK medical education provide doctors with sufficient skills and knowledge to manage patients with eating disorders safely?

2018 ◽  
Vol 94 (1113) ◽  
pp. 374-380 ◽  
Author(s):  
Agnes Ayton ◽  
Ali Ibrahim
Keyword(s):  
Eating Disorders ◽  
Patient Safety ◽  
Eating Disorder ◽  
Postgraduate Training ◽  
Medical Training ◽  
Improve Patient Safety ◽  
Medical Schools ◽  
Junior Doctors ◽  
The Uk ◽  
Improve Patient

BackgroundEating disorders affect 1%–4% of the population and they are associated with an increased rate of mortality and multimorbidity. Following the avoidable deaths of three people the parliamentary ombudsman called for a review of training for all junior doctors to improve patient safety.ObjectiveTo review the teaching and assessment relating to eating disorders at all levels of medical training in the UK.MethodWe surveyed all the UK medical schools about their curricula, teaching and examinations related to eating disorders in 2017. Furthermore, we reviewed curricula and requirements for annual progression (Annual Review of Competence Progression (ARCP)) for all relevant postgraduate training programmes, including foundation training, general practice and 33 specialties.Main outcome measuresInclusion of eating disorders in curricula, time dedicated to teaching, assessment methods and ARCP requirements.ResultsThe medical school response rate was 93%. The total number of hours spent on eating disorder teaching in medical schools is <2 hours. Postgraduate training adds little more, with the exception of child and adolescent psychiatry. The majority of doctors are never assessed on their knowledge of eating disorders during their entire training, and only a few medical students and trainees have the opportunity to choose a specialist placement to develop their clinical skills.ConclusionsEating disorder teaching is minimal during the 10–16 years of undergraduate and postgraduate medical training in the UK. Given the risk of mortality and multimorbidity associated with these disorders, this needs to be urgently reviewed to improve patient safety.

Faculty Clinical Quality Goals Drive Improvement in University HealthSystem Consortium Outcome Measures

2012 ◽  
Vol 78 (7) ◽  
pp. 749-754 ◽  
Author(s):  
Kevin E. Behrns ◽  
Darwin Ang ◽  
Huazi Liu ◽  
Steven J. Hughes ◽  
Holly Creel ◽  
...  
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Clinical Score ◽  
Outcome Data ◽  
Faculty Members ◽  
Clinical Quality ◽  
Patient Safety Indicators ◽  
Before And After ◽  
The University ◽  
Hospital Acquired

Mortality, length of stay (LOS), patient safety indicators (PSIs), and hospital-acquired conditions (HACs) are routinely reported by the University HealthSystem Consortium (UHC) to measure quality at academic health centers. We hypothesized that a clinical quality measurable goal assigned to individual faculty members would decrease UHC measures of mortality, LOS, PSIs, and HACs. For academic year (AY) 2010–2011, faculty members received a clinical quality goal related to mortality, LOS, PSIs, and HACs. The quality metric constituted 25 per cent of each faculty member's annual evaluation clinical score, which is tied to compensation. The outcomes were compared before and after goal assignment. Outcome data on 6212 patients from AY 2009–2010 were compared with 6094 patients from AY 2010–2011. The mortality index (0.89 vs 0.93; P = 0.73) was not markedly different. However, the LOS index decreased from 1.01 to 0.97 ( P = 0.011), and department-wide PSIs decreased significantly from 285 to 162 ( P = 0.011). Likewise, HACs decreased from 54 to 18 ( P = 0.0013). Seven (17.9%) of 39 faculty had quality grades that were average or below. Quality goals assigned to individual faculty members are associated with decreased average LOS index, PSIs, and HACs. Focused, relevant quality assignments that are tied to compensation improve patient safety and outcomes.

scholarly journals Andrew Richard Lang. 9 September 1924—30 June 2008

2019 ◽  
Vol 67 ◽  
pp. 237-254
Author(s):  
André Authier
Keyword(s):  
Second World War ◽  
Magnetic Domains ◽  
X Ray ◽  
X Ray Crystallography ◽  
University Of Cambridge ◽  
The Usa ◽  
The Uk ◽  
The University ◽  
Port Sunlight ◽  
Second World

Andrew Lang will be remembered internationally for having developed the technique of X-ray topography which enables individual defects, such as dislocations, stacking faults, small angle boundaries and magnetic domains, to be imaged in many different types of materials. His interests spanned the whole range of dislocation studies and he made many important contributions to advanced instrumentation for X-ray crystallography, including pioneering experiments with a synchrotron radiation source. His career began during the last year of the Second World War when he was appointed to a research position at the Unilever Research Laboratories at Port Sunlight, Cheshire. He held research positions at the University of Cambridge, where he completed his PhD, and after a period at the Philips Laboratory in Irvington-on-Hudson in the USA, he obtained a tenured post at Harvard University. He returned to the UK in 1959 as a lecturer at Bristol University, where he was to remain for the rest of his life, being successively promoted to reader and then professor.

scholarly journals Parents’ Active Role and ENgagement in The review of their Stillbirth/perinatal death 2 (PARENTS 2) study: a mixed-methods study of implementation

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e044563
Author(s):  
Christy Burden ◽  
Danya Bakhbakhi ◽  
Alexander Edward Heazell ◽  
Mary Lynch ◽  
Laura Timlin ◽  
...  
Keyword(s):  
Patient Safety ◽  
Mixed Methods ◽  
Review Process ◽  
Parent Engagement ◽  
Improve Patient Safety ◽  
Parental Engagement ◽  
Mixed Methods Study ◽  
Bereaved Parents ◽  
The Uk ◽  
Improve Patient

ObjectiveWhen a formal review of care takes places after the death of a baby, parents are largely unaware it takes place and are often not meaningfully involved in the review process. Parent engagement in the process is likely to be essential for a successful review and to improve patient safety. This study aimed to evaluate an intervention process of parental engagement in perinatal mortality review (PNMR) and to identify barriers and facilitators to its implementation.DesignMixed-methods study of parents’ engagement in PNMR.SettingSingle tertiary maternity unit in the UK.ParticipantsBereaved parents and healthcare professionals (HCPs).InterventionsParent engagement in the PNMR (intervention) was based on principles derived through national consensus and qualitative research with parents, HCPs and stakeholders in the UK.OutcomesRecruitment rates, bereaved parents and HCPs’ perceptions.ResultsEighty-one per cent of bereaved parents approached (13/16) agreed to participate in the study. Two focus groups with bereaved parents (n=11) and HCP (n=7) were carried out postimplementation to investigate their perceptions of the process.Overarching findings were improved dialogue and continuity of care with parents, and improvements in the PNMR process and patient safety. Bereaved parents agreed that engagement in the PNMR process was invaluable and helped them in their grieving. HCP perceived that parent involvement improved the review process and lessons learnt from the deaths; information to understand the impact of aspects of care on the baby’s death were often only found in the parents’ recollections.ConclusionsParental engagement in the PNMR process is achievable and useful for parents and HCP alike, and critically can improve patient safety and future care for mothers and babies. To learn and prevent perinatal deaths effectively, all hospitals should give parents the option to engage with the review of their baby’s death.

scholarly journals Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Adam Sutherland ◽  
Denham L. Phipps ◽  
Stephen Tomlin ◽  
Darren M. Ashcroft
Keyword(s):  
Patient Safety ◽  
Medication Errors ◽  
Adverse Drug Events ◽  
Improve Patient Safety ◽  
Safety Issue ◽  
Cochrane Library ◽  
Drug Related Problems ◽  
Prescribing Errors ◽  
Theoretical Understanding ◽  
The Uk

Abstract Background Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety. Methods Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted. Results In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8–29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7–13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9–13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4–23). Administration technique errors represented 53% (IQR 52.7–67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1–46) of prescribed medication; 70.3% (Range 50–78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors. Conclusions Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.

5 Standard iv infusion concentration in paediatric and neonatal units: a national survey

2018 ◽  
Vol 103 (2) ◽  
pp. e2.45-e2
Author(s):  
Nanna Christiansen
Keyword(s):  
Patient Safety ◽  
National Survey ◽  
Response Rate ◽  
Improve Patient Safety ◽  
National Standards ◽  
List Type ◽  
National Patient Safety Agency ◽  
National Patient ◽  
National Consensus ◽  
The Uk

AimThe National Patient Safety Agency in the UK has advocated the use of standard concentration (SC) infusions to improve patient safety and care.1 National standards have been adopted for infusions in the adult critical care setting however practice in paediatric and neonatal settings still varies and presents a challenge.2,3 This study is part of a multi-professional collaborative working towards a national consensus on SC infusions in paediatric and neonatal care. The study aims to explore the practice of standardised concentration usage for Intravenous (IV) infusions in paediatric and neonatal units in the UK, specifically:How many units use standardised concentration for IV infusions.Evaluate the variation and overlap of continuous IV infusion concentrations in practice.Assess what devices are used to administer these infusions.How standardised infusions are provided.MethodThe study used a quantitative descriptive survey design via an online self-administered questionnaire. Paediatric and neonatal intensive care units in the UK were surveyed through pharmacy, nursing, and medical networks to describe current practice. Data was collected for 25 days and analysed using SPSS.ResultA total of 194 NICUs and 39 PICUs were surveyed. Responses were received from 71 units: NICU 46 (65%); PICU 17 (24%) and 8 other (11%), giving an overall response rate of 30.5%.Twenty-eight units (40%) have established SC for IV infusions, 18 units provided information on presentation of SC infusions. Forty-six different medication infusions were standardised. Considering the differences in concentration, weight-bands, diluents, volume and presentation, there were 273 variations for these drugs. Taking only the concentration into account, there were 137 variations presented. The average number of variations per medication was 3 (range 1 to 14).15 units (53.6%) use ‘smart’ pumps for administration of SC infusions and 3 (10.7%) use other computer software for infusion rate calculations. Infusions are most commonly prepared on wards (81.3%) or in pharmacy (12.3%).ConclusionThe study is limited by the response rate; however the results suggest that 59% of paediatric and neonatal units in the UK use conventional weight-based methods for IV infusions. A third of units have established some SC with a wide variation of concentrations in this sample. Just over half of the units use ‘smart’ pump technology and over three quarters of SC infusions are prepared on the ward.Further data collection is required to acquire a fuller picture of SC infusions used in UK PICUs and NICUs. This data can then be used as the basis of a national consensus statement on SC infusion, facilitating adoption across the NHS.ReferencesNPSA Patient Safety Alert 20: Promoting safer use of injectable medicines2007. London: The National Patient Safety Agency.MacKay MW, Cash J, Farr F, et al. Improving paediatric outcomes through intravenous and oral medication standardisation. J Pediatr Pharmacol Ther2009;14:226–35.Phillips MS, Standardising IV. Infusion concentrations: National survey results. Am J Health Syst Pharm2011;68:2176–82.

scholarly journals Blood-borne virus-related discrimination in dental services

1998 ◽  
Vol 21 (3) ◽  
pp. 92
Author(s):  
Sandra Meihubers ◽  
Phillip Godwin ◽  
Arie Rotem
Keyword(s):  
Dental Health ◽  
Dental Services ◽  
Family Services ◽  
Department Of Health ◽  
South Wales ◽  
Key Stakeholders ◽  
Geographical Regions ◽  
The University ◽  
Hiv Aids

While the risk of infection through occupational exposure to blood-borne viruses isa major concern of dental health care workers, the National HIV/AIDS Strategy and many health, AIDS and discrimination-related agencies have identified discrimination related to HIV/AIDS as a priority area for action. In 1995 the Commonwealth Department of Health and Family Services selected the School of Medical Education at the University of New South Wales to conduct a national project to reduce discrimination related to blood-borne viruses within dental services(Godwin, Meihubers & Rotem 1997). This paper provides an overview of the study and its major findings.The study focused on quality of care issues which may cause or manifest discrimination. Key stakeholders were invited to review policies, procedures,organisational arrangements and other systemic issues which influence the quality of oral health services to populations within selected geographical regions.

Gender Issues in Engineering Education: What Systemizing and Empathizing Have to Do With It

2017 ◽  
Author(s):  
Jan Fertig ◽  
Subha Kumpaty
Keyword(s):  
Engineering Education ◽  
Gender Issues ◽  
Fundamental Difference ◽  
Female Students ◽  
Relevant Research ◽  
Engineering Programs ◽  
University Of Cambridge ◽  
Males And Females ◽  
The Uk ◽  
The University

More than half of U.S. students entering college are female, but female students are still largely absent from engineering fields. The persistent absence of females in engineering may owe itself, at least in part, to a fundamental difference in cognitive approaches between males and females. Although there is a significant amount of cross-over, males are more likely than females to have a systemizing brain, which is associated with a drive to understand how the world works through the identification and creation of patterns and rules. Females are more likely to be born with an empathizing style, which lends itself to a natural aptitude for identifying others’ thoughts and emotions. This systemizing-empathizing dichotomy is based on the work of Simon Baron-Cohen at the University of Cambridge in the UK. Engineering programs are geared toward those with a higher SQ (systemizing quotient). This paper reviews relevant research on how systemizing-empathizing (S-E) theory applies to engineering education and examines current research on the reasons behind the dearth of females in engineering, finding that the contemporary engineering culture in college is also characterized by subtle forms of discrimination that systematically direct women away from engineering. Finally, some recommendations are made for how engineering programs might engage a broader base of students.

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