A safer place for patients: learning to improve patient safety

1 Every day over one million people are treated successfully by National Health Service (NHS) acute, ambulance and mental health trusts. However, healthcare relies on a range of complex interactions of people, skills, technologies and drugs, and sometimes things do go wrong. For most countries, patient safety is now the key issue in healthcare quality and risk management. The Department of Health (the Department) estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed, a rate similar to other developed countries. Around 50 per cent of these patient safety incidentsa could have been avoided, if only lessons from previous incidents had been learned. 2 There are numerous stakeholders with a role in keeping patients safe in the NHS, many of whom require trusts to report details of patient safety incidents and near misses to them (Figure 2). However, a number of previous National Audit Office reports have highlighted concerns that the NHS has limited information on the extent and impact of clinical and non-clinical incidents and trusts need to learn from these incidents and share good practice across the NHS more effectively (Appendix 1). 3 In 2000, the Chief Medical Officer’s report An organisation with a memory 1 , identified that the key barriers to reducing the number of patient safety incidents were an organisational culture that inhibited reporting and the lack of a cohesive national system for identifying and sharing lessons learnt. 4 In response, the Department published Building a safer NHS for patients3 detailing plans and a timetable for promoting patient safety. The goal was to encourage improvements in reporting and learning through the development of a new mandatory national reporting scheme for patient safety incidents and near misses. Central to the plan was establishing the National Patient Safety Agency to improve patient safety by reducing the risk of harm through error. The National Patient Safety Agency was expected to: collect and analyse information; assimilate other safety-related information from a variety of existing reporting systems; learn lessons and produce solutions. 5 We therefore examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. Key parts of our approach were a census of 267 NHS acute, ambulance and mental health trusts in Autumn 2004, followed by a re-survey in August 2005 and an omnibus survey of patients (Appendix 2). We also reviewed practices in other industries (Appendix 3) and international healthcare systems (Appendix 4), and the National Patient Safety Agency’s progress in developing its National Reporting and Learning System (Appendix 5) and other related activities (Appendix 6). 6 An organisation with a memory1 was an important milestone in the NHS’s patient safety agenda and marked the drive to improve reporting and learning. At the local level the vast majority of trusts have developed a predominantly open and fair reporting culture but with pockets of blame and scope to improve their strategies for sharing good practice. Indeed in our re-survey we found that local performance had continued to improve with more trusts reporting having an open and fair reporting culture, more trusts with open reporting systems and improvements in perceptions of the levels of under-reporting. At the national level, progress on developing the national reporting system for learning has been slower than set out in the Department’s strategy of 2001 3 and there is a need to improve evaluation and sharing of lessons and solutions by all organisations with a stake in patient safety. There is also no clear system for monitoring that lessons are learned at the local level. Specifically: a The safety culture within trusts is improving, driven largely by the Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (Appendix 7). However, trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture. b All trusts have established effective reporting systems at the local level, although under-reporting remains a problem within some groups of staff, types of incidents and near misses. The National Patient Safety Agency did not develop and roll out the National Reporting and Learning System by December 2002 as originally envisaged. All trusts were linked to the system by 31 December 2004. By August 2005, at least 35 trusts still had not submitted any data to the National Reporting and Learning System. c Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these are still not widely promulgated, either within or between trusts. The National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system. It published its first feedback report from the Patient Safety Observatory in July 2005

Thermal energy storage material thermophysical property measurement and heat transfer impact

The thermophysical properties of salts having potential for thermal energy storage to provide peaking energy in conventional electric utility power plants were investigated. The power plants studied were the pressurized water reactor, boiling water reactor, supercritical steam reactor, and high temperature gas reactor. The salts considered were LiNO3, 63LiOH/37 LiCl eutectic, LiOH, and Na2B4O7. The thermal conductivity, specific heat (including latent heat of fusion), and density of each salt were measured for a temperature range of at least + or - 100 K of the measured melting point. Measurements were made with both reagent and commercial grades of each salt

Playas of inland Australia

[Abstract] Playas, mostly in the form of salinas, are characteristic of the Australian arid zone. Many are associated with lunettes in sebkha complexes or assemblages and can be attributed to the deflation of bare alluvial flats. Many playas are structurally controlled. Lake Eyre, for example, occupies a downfaulted segment of the crust, and many other playas large and small are associated with faults. Lakes Frome, Callabonna, Blanche, and Gregory each displays a linear shoreline, but also and arguably, all are located on a regional structural arc. Lake Gairdner occupies a valley probably blocked by faulting. Others may be caused by preferential weathering along fracture zones, some linear but others arcuate. Many salinas are developed in dismembered rivers channels, the position and pattern of which are structurally determined. But many owe their existence to the interaction of several of these factors. The various salts precipitated in playas constitute a significant resource, regional and local, past, present and future

Anomalous hydrodynamics and "normal" fluids in rapidly rotating BECs

In rapidly rotating bose systems we show that there is a region of anomalous hydrodynamics whilst the system is still condensed, which coincides with the mean field quantum Hall regime. An immediate consequence is the absence of a normal fluid in any conventional sense. However, even the superfluid hydrodynamics is not described by conventional Bernoulli and continuity equations. We show there are kinematic constraints which connect spatial variations of density and phase, that the positions of vortices are not the simplest description of the dynamics of such a fluid (despite their utility in describing the instantaneous state of the condensate) and that the most compact description allows solution of some illuminating examples of motion. We demonstrate, inter alia, a very simple relation between vortices and surface waves. We show the surface waves can form a "normal fluid" which absorbs energy and angular momentum from vortex motion in the trap. The time scale of this process is sensitive to the initial configuration of the vortices, which can lead to long-lived vortex patches - perhaps related to those observed at JILA.Comment: 4 pages; 1 sentence and references modifie

Exact vortex nucleation and cooperative vortex tunneling in dilute BECs

With the imminent advent of mesoscopic rotating BECs in the lowest Landau level (LLL) regime, we explore LLL vortex nucleation. An exact many-body analysis is presented in a weakly elliptical trap for up to 400 particles. Striking non-mean field features are exposed at filling factors >>1 . Eg near the critical rotation frequency pairs of energy levels approach each other with exponential accuracy. A physical interpretation is provided by requantising a mean field theory, where 1/N plays the role of Planck's constant, revealing two vortices cooperatively tunneling between classically degenerate energy minima. The tunnel splitting variation is described in terms of frequency, particle number and ellipticity.Comment: 4 pages,4 figure

School-based Understanding of Human Rights in Four Countries: A Commonwealth Study

Teaching/Communication/Extension/Profession,

Dust attenuation in 2<z<3 star-forming galaxies from deep ALMA observations of the Hubble Ultra Deep Field

17 pages, 7 figures, accepted version to be published in MNRASWe present the results of a new study of the relationship between infrared excess (IRX ≡ L IR/L UV), ultraviolet (UV) spectral slope (β) and stellar mass at redshifts 2 < z < 3, based on a deep Atacama Large Millimeter Array (ALMA) 1.3-mm continuum mosaic of the Hubble Ultra Deep Field. Excluding the most heavily obscured sources, we use a stacking analysis to show that z ≃ 2.5 star-forming galaxies in the mass range 9.25 ≤ log(M*/M ⊙) ≤ 10.75 are fully consistent with the IRX-β relation expected for a relatively grey attenuation curve, similar to the commonly adopted Calzetti law. Based on a large, mass-complete sample of 2 ≤ z ≤ 3 star-forming galaxies drawn frommultiple surveys, we proceed to derive a new empirical relationship between β and stellar mass, making it possible to predict UV attenuation (A1600) and IRX as a function of stellar mass, for any assumed attenuation law. Once again, we find that z ≃ 2.5 star-forming galaxies follow A1600-M* and IRX-M* relations consistent with a relatively grey attenuation law, and find no compelling evidence that star-forming galaxies at this epoch follow a reddening law as steep as the Small Magellanic Cloud (SMC) extinction curve. In fact, we use a simple simulation to demonstrate that previous determinations of the IRX-β relation may have been biased towards low values of IRX at red values of β, mimicking the signature expected for an SMC-like dust law. We show that this provides a plausible mechanism for reconciling apparently contradictory results in the literature and that, based on typical measurement uncertainties, stellar mass provides a cleaner prediction of UV attenuation than β. Although the situation at lower stellar masses remains uncertain, we conclude that for 2 < z < 3 star-forming galaxies with log(M*/M ⊙) ≥ 9.75, both the IRX-β and IRX-M* relations are well described by a Calzetti-like attenuation law.Peer reviewe