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

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