4,486 research outputs found
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
A systematic review of dramatherapy interventions which are used to support adult participants’ mental health in forensic settings
T-PHOT version 2.0: improved algorithms for background subtraction, local convolution, kernel registration, and new options
We present the new release v2.0 of T-PHOT, a publicly available software
package developed to perform PSF-matched, prior-based, multiwavelength
deconfusion photometry of extragalactic fields. New features included in the
code are presented and discussed: background estimation, fitting using position
dependent kernels, flux prioring, diagnostical statistics on the residual
image, exclusion of selected sources from the model and residual images,
individual registration of fitted objects. These new options improve on the
performance of the code, allowing for more accurate results and providing
useful aids for diagnostics.Comment: 7 pages, 8 figure
Playing at the edges, navigating sexual boundaries, and narrating sexual distress; Practices and perspectives of sexuality and gender diverse people who use GHB
Background: Research addressing sexualised use of GHB to date has largely focussed on gay and bisexual men's GHB use in the context of chemsex, this research has highlighted risks and experiences associated with sexual violence. No studies have included people of diverse sexualities and genders and documented reported practices to ensure mutually gratifying and consensual sex in the context of sexualised drug use (SDU). Methods: Semi-structured interviews were conducted with 31 people from sexuality and gender diverse communities living in Australia who reported three or more occasions of GHB use in the previous 12 months. Participants were asked about their use of GHB for sex, their experiences of GHB sex and their approaches to negotiating sexual boundaries. Data were analysed thematically. Results: Most participants valued the sexual possibilities enabled by disinhibitory components of GHB and were cognisant of respecting other's sexual boundaries in the context of GHB sex. Participants reported strategies to ensure communication prior to and throughout GHB sex. However, several participants narrated experiences of GHB sex that they felt were distressing and, in some circumstances, sexually violent. In most instances participant's resisted terminology of sexual violence or non-consent as descriptors of their experience and none reported accessing sexual violence services. Conclusion: Positive strategies to facilitate sexual communication prior to and throughout GHB sex should be reflected in health promotion and service level responses to promote affirmative and continuous consent among people who use GHB for sex. Education initiatives to help people engaged in SDU to recognise and respond to sexual violence if it occurs ought to be prioritised
The relationship between dust and [C I] at z = 1 and beyond
© 2018 The Author(s) Published by Oxford University Press on behalf of the Royal Astronomical Society.Measuring molecular gas mass is vital for understanding the evolution of galaxies at high redshifts (z ≳ 1). Most measurements rely on CO as a tracer, but dependencies on metallicity, dynamics, and surface density lead to systematic uncertainties in high-z galaxies, where these physical properties are difficult to observe, and where the physical environments can differ systematically from those at z = 0. Dust continuum emission provides a potential alternative assuming a known dust/gas ratio, but this must be calibrated on a direct gas tracer at z ≳ 1. In this paper, we consider the [C I] 492-GHz emission line, which has been shown to trace molecular gas closely throughout Galactic clouds and has the advantages of being optically thin in typical conditions (unlike CO), and being observable at accessible frequencies at high redshifts (in contrast to the low-excitation lines of CO). We use the Atacama Large Millimetre/submillimetre Array to measure [C I], CO(4–3), and dust emission in a representative sample of star-forming galaxies at z = 1, and combine these data with multiwavelength spectral energy distributions to study relationships between dust and gas components of galaxies. We uncover a strong [C I]–dust correlation, suggesting that both trace similar phases of the gas. By incorporating other samples from the literature, we show that this correlation persists over a wide range of luminosities and redshifts up to z ∼ 4. Finally, we explore the implications of our results as an independent test of literature calibrations for dust as a tracer of gas mass, and for predicting the C I abundance.Peer reviewedFinal Published versio
- …