CPSSQ Events
CPSSQ News
19 November 2009
Study finds deaths rise when junior doctors changeover
Researchers from the Dr Foster Unit have published a study which shows a small but statistically significant increase in the number of patients who die each year when junior doctors start work in the first week of August. The widely-reported study found a 6% increase in likelihood of death in patients in this period, although the team were unable unable to draw firm conclusions about the reasons for the increase.
BBC news story including Radio 4 interview with Dr Paul Aylin
6 October 2009
Study finds high rates of drug errors in nursing homes
A study published today in Quality And Safety In Health Care has found that seven out of 10 care home residents are subject to drug errors. The study, which has received widespread press coverage, was led by Prof Nick Barber at the School of Pharmacy, and included other CPSSQ researchers Bryony Dean Franklin and Maria Woloshynowych.
The findings are based on a random sample of 256 residents in 55 care homes located in West Yorkshire, Cambridgeshire, and central London. Each care home resident was taking an average of eight medicines each. One or more drug errors were made in seven out of 10 (69.5% or 178) cases, with the average number of mistakes just under two for each resident. Interviews with residential care home staff, doctors, and pharmacists were used to uncover potential causes, which included in adequate medicines training; interrupted drug rounds; poor team work between the care home, GP practice, and the pharmacy; poor record keeping; and complicated administrative systems.
Full paper
Press Coverage
26 August 2009
CPSSQ successfully wins EU research grant
The CPSSQ is one of the successful partners who have secured a €3 million grant from the EU for a major international research project. The project, which also involves partners Sweden, the Netherlands, Portugal and Norway and is led by the King’s Patient Safety & Service Quality Research Centre(King’s PSSQ) is a three-year study, starting in 2010, to explore the relationships between the organisational and cultural characteristics of hospitals, and how these impact upon clinical effectiveness, patient safety and experience in European countries.Data will be collected in two hospitals in each of the five partner countries, with additional studies of two particular clinical areas in one hospital in each country.
Whilst there is a good understanding of the types of quality improvement undertaken in healthcare, less is known of the organisational and cultural processes that determine the effectiveness of these methods. By examining the relationship between these processes and quality on different levels – from the national healthcare system through to the hospital, to the frontline clinical team – in each of the five partner countries, the study will unveil how the dynamics and interactions between these different levels impact on sustained quality of hospital care.
The research will enable the team to deliver effective solutions to hospital leaders, based on the realities of implementing quality improvement programmes. The findings will be used to design and disseminate an evidence-based Quality and Safety Guide for Hospitals to guide hospitals on implementing effective organisation-wide quality and safety improvement initiatives.
In parallel, a Framework for Assessing Hospital Quality will also be compiled, enabling purchasers of hospital services and governments throughout the EU to monitor and assess the effectiveness, safety and patient experience of hospital care.
18 June 2009
Patient Safety Award Winners announced
The winners of the CPSSQ award for best patient safety and quality project at Imperial College Healthcare NHS Trust have been announced. The judges, Professor Mervyn Maze and Sally Heywood were so impressed with the high quality applicants that the decided to name two joint winners: Dr Maisse Farhan, consultant in emergency medicine for her study on improving handover in the emergency department of St Mary’s; and to the Anti-infective Policy Implementation Group (APIG) for their work on improving prudent anti-infective prescribing on the MAU. The judges praised all the entries as topical and innovative entries, but according to Sally Heywood “these two stood out because they were multi professional as well as improving patient safety”.
The applicants have each received a £500 contribution to attend a relevent conference of their choice, and the award certificates were presented by Professor Lord Ara Darzi at the Safety and Quality Symposium on 18th June. Kandarp Thakkar, a pharmacist who is part of the APIG said “On behalf of the Anti-infective Policy Implementation Group, I am absolutely delighted and extremely proud on receiving the CPSSQ Patient Safety Award. As I am sure everyone is aware, infections and anti-infective use is currently a very high profile area within the NHS and to contribute positively to this area is a very satisfying feeling. Patient safety, research and innovation are at the heart of this project which fits in nicely with the vision of us as the UK’s first AHSC.”
Dr Brown accepting the certificate on behalf of Dr Maisse Farhan from Lord Ara Darzi
Some members of the Anti-infective Policy Implementation group at the Safety and Quality Symposium
Project details:
20th May 2009
CPSSQ Programme Lead Nominated for Health and Social Care Award
An innovative project to reduce infection risk and improve the patient experience by minimising ward moves was shortlisted in this year’s regional Health and Social Care Awards. The bed management and infection prevention and control teams at Imperial College Healthcare NHS Trust were finalists in the patient safety category at NHS London’s red-carpet ceremony held at Bafta. The teams worked together in a unique way to keep unnecessary bedmoves to a minimum. The project group developed appropriate patient pathways for the duration of a hospital stay in each clinical speciality at all of the Trust’s hospitals.
Bed allocation is now based on
these pathways and every
month, each clinical programme
group (CPG) reports ward move
information to the Trust board.
Dr Alison Holmes, director of
infection prevention and control at the Trust and CPSSQ Programme Lead,
led the project, working
alongside Gavin MacDonald, site operations manager.
Dr Holmes said: “Our
approach of closely combining
bed management and infection
prevention and control to
improve patient safety and
experience is unique and we are
delighted this has been
recognised at the regional
awards ceremony. “As a result of this and other
bed management initiatives,
ward closures have reduced and
the number of C. difficile cases is
27 percent lower than the
reduction target set by the
Department of Health.”
7 April 2009
CPSSQ Researcher Wins Prize
Susy Long has been awarded the British Geriatrics Society award for the best Scientific Presentation Poster, the Fergus Anderson Prize, for her poster illustrating her interview study on staff perceptions of risks to older people.
The £200 prize is awarded each year for the best poster presented at the Spring Meeting by a member of the Society who is not a consultant. Susy will be presented with the winning certificate at the next BGS Autumn meeting in Harrogate at the Annual General Meeting on the 9th October 2009.
Elderly Care Research Projects
12 March 3009
Visit from House of Commons Health Committee
MPs from the House of Commons Health Committee visited Charing Cross Hospital today, hosted by Ann Jacklin, Visiting Professor, and Bryony Dean Franklin, Professor of Medication Safety. The MPs asked to visit the hospital to view innovations in the use of technology to improve patient safety, following evidence submitted by Professors Bryony Dean Franklin and Nick Barber to the ongoing Health Committee enquiry into Patient Safety.
The MPs today were shown a pharmacy-based dispensing robot, an automated pharmacy-based CD cabinet, and a closed loop system comprising electronic prescribing, electronic medication administration records, ward-based automated dispensing and barcode patient verification.
The Health Committee is the Government Select Committee whose terms of reference are to examine the expenditure, administration and policy of the Department of Health and associated public bodies.
18th February 2009
The Royal Pharmaceutical Society Launch Safety Policy Document
The RPSGB have set out an ambition for Britain to be the safest place in the world to receive medicines. This well-received report examines the current state of knowledge about
medication safety in the UK and considers the role of the RPSgB, the future professional body for pharmacy and of pharmacists working across great Britain in improving medicines safety. The report’s research team are all members of the CPSSQ: Charles Vincent, Nick Barber, Bryony Dean Franklin and Susan Burnett.
5th February 2009
New Patient Safety Award for ICHNT Staff
A new award is being sponsored by the Imperial CPSSQ for the best quality and safety project in the Trust.
The prize is a £500 contribution towards a relevant conference of the winner’s choice and the successful entry will be publicised widely across the Trust, including the CPSSQ website and annual report.
Projects can be either a research study or a service improvement project designed to improve the safety of patients and the quality of care they receive and must be complete to be eligible.
The award is open to all Trust staff. To enter, send a short report on your project (maximum 2000 words) to Sandra Iskander by 31st March 2009.
Report submission headings
- Aim(s) and objectives
- Methods
- Results
- Discussion
- Outcome and impact on patient safety
For further information please contact Sandra Iskander. The winner will be announced by 1st May.
15th January 2009
Surgical Safety Checklist Reduces Morbidity and Mortality
A paper published today in the New England Journal of Medicine has shown that using a simple surgical checklist improves patient safety. Eight hospitals, including Imperial College Healthcare NHS Trust working with researchers from the CPPSQ, piloted the checklist as part of the WHO Safe Surgery Saves Lives programme. The results have shown that implementation of the checklist has been associated with a significant reduction in rates of death and complications.
12 January 2009
House of Commons Patient Safety Inquiry
Members of the CPPSQ have been contributing to the House of Commons Health Committee's inquiry into Patient Safety. Professor Charles Vincent has been acting as an advisor to the inquiry, and so has helped to shape the terms of reference and advised on the evidence collection process. Professor Bryony Dean Franklin will be giving evidence to the committee this week about her area of expertise, medication safety. Further evidence sessions are planning as part of the committee’s investigation, and so the completion date for this inquiry has not yet been announced.