Improving the safety and experience of transitions from hospital to home: a cluster randomised controlled trial of an intervention to involve older people in their care (Your Care Needs You).

Background: Transitions from hospital to home are risky for older people. The role of patient involvement in supporting safe transitions is unclear.

Objective: To assess the clinical effectiveness of an intervention to improve the safety and experience of care transitions for older people.

Evaluating an intervention to improve the safety and experience of transitions from hospital to home for older people (Your Care Needs You): a protocol for a cluster randomised controlled trial and process evaluation.

Background: Older patients often experience safety issues when transitioning from hospital to home. The 'Your Care Needs You' (YCNY) intervention aims to support older people to 'know more' and 'do more' whilst in hospital so that they are better prepared for managing at home.

Methods: A multi-centre cluster randomised controlled trial (cRCT) will evaluate the effectiveness and cost-effectiveness of the YCNY intervention.

Doing involvement: A qualitative study exploring the 'work' of involvement enacted by older people and their carers during transition from hospital to home.

Context: Being involved in one's care is prioritised within UK healthcare policy to improve care quality and safety. However, research suggests that many older people struggle with this.

Design: We present focused ethnographic research exploring older peoples' involvement in healthcare from hospital to home.

Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project.

Background: The Patient Safety Huddle (PSH) is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. Despite growing interest and application of huddles as a mechanism for improving safety, evidence of their impact remains limited. There is also variation in how huddles are conceived and implemented with insufficient focus on their fidelity (the extent to which delivered as planned) and potential ways in which they might influence outcomes.

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives.

Background: Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home.

Get Parkinson's medications on time: the Leeds QI project.

Parkinson's disease (PD) is a common neurodegenerative disease. Delayed administration of PD medications is associated with increased risk of life-threatening complications including choking, aspiration pneumonia and neuroleptic malignant syndrome. In 2016, the spouse of a patient with PD wrote to Leeds Teaching Hospitals Trust (LTHT) to highlight that multiple medication delays and omissions had occurred during his recent admission.

Sustaining the commitment to patient safety huddles: insights from eight acute hospital ward teams.

Background: A recent initiative in hospital settings is the patient safety huddle (PSH): a brief multidisciplinary meeting held to highlight patient safety issues and actions to mitigate identified risks.

Aim: The authors studied eight ward teams that had sustained PSHs for over 2 years in order to identify key contributory factors.

Methods: Unannounced observations of the PSH on eight acute wards in one UK hospital were undertaken.

Partners at Care Transitions: exploring healthcare professionals' perspectives of excellence at care transitions for older people.

Introduction: Hospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs.

Partners at Care Transitions (PACT) xploring older peoples' experiences of transitioning from hospital to home in the UK: protocol for an observation and interview study of older people and their families to understand patient experience and involvement in care at transitions.

Introduction: Length of hospital inpatient stays have reduced. This benefits patients, who prefer to be at home, and hospitals, which can treat more people when stays are shorter. Patients may, however, leave hospital sicker, with ongoing care needs.

Intraindividual variability and falls in older adults.

Objective: We investigated whether a simple measure of reaction time (RT) intraindividual variability (IIV) was associated with falls in older adults. Falls and fall-related injuries represent a major cost to health care systems, it is therefore critically important to find measures that can readily identify older adults at greater risk of falling.

Method: Cognitive and motor function were investigated in 108 adults aged 53 to 93 years (M = 73.

Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change.

At Leeds Teaching Hospitals NHS Trust doctors type an electronic discharge advice note (eDAN) which includes a prescription for discharge medication, before a patient can be discharged from hospital. In 2014 staff on the Medical Admissions Unit for Older People identified significant delays in the completion of this document, with an average completion time of 138 minutes. This caused patient harm and exacerbated bed management problems as patients remained in hospital longer than necessary to obtain their discharge medication.

The role of emotion in patient safety: Are we brave enough to scratch beneath the surface?

Healthcare professionals work in emotionally charged settings; yet, little is known about the role of emotion in ensuring safe patient care. This article presents current knowledge in this field, drawing upon psychological approaches and evidence from clinical settings. We explore the emotions that health professionals experience in relation to making a medical error and describe the impact on healthcare professionals and on their professional and patient relationships.

Discovering Innovation at the Intersection of Undergraduate Medical Education, Human Factors, and Collaboration: The Development of a Nasogastric Tube Safety Pack.

Problem: Significant deficiencies exist in the knowledge and skills of medical students and residents around health care quality and safety. The theory and practice of quality and safety should be embedded into undergraduate medical practice so that health care professionals are capable of developing interventions and innovations to effectively anticipate and mitigate errors.

Approach: Since 2011, Leeds Medical School in the United Kingdom has used case study examples of nasogastric (NG) tube patient safety incidents within the undergraduate patient safety curriculum.

Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline.

Background: Clinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals - but the behaviour change component is often overlooked.

Improving mid stream urine sampling: reducing labelling error and laboratory rejection.

A urine sample is vital in older patients with pyrexia or acute confusion, and commonly directs clinicians towards a source of infection. Not only can the organism be identified, but sensitivities to antibiotics can also guide prescribing. A high number of urine samples were not being processed on the medicine for older people wards at St.

Impact of prescribed medications on patient safety in older people.

Appropriate prescribing for older adults presents unique challenges to the prescriber. An understanding of the scale of the problems and contributing factors is essential when designing interventions to improve patient safety. The altered pharmacology of ageing, the existence of multiple medical conditions and the exclusion of elderly patients from many trials render this subgroup of the population particularly vulnerable to underprescribing and overprescribing.

Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine.

Patient safety is a major priority for health services. It is a multi-disciplinary problem and requires a multi-disciplinary solution; any education should therefore be a multi-disciplinary endeavour, from conception to implementation. The starting point should be at undergraduate level and medical education should not be an exception.

Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review.

Objectives: to estimate the extent, preventability and consequences of adverse clinical events in elderly and non-elderly patients.

Design: a two-stage structured, retrospective, patient case-note review.

Setting: a large NHS hospital in England.

Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital.

Objectives: To estimate the extent, nature and consequences of adverse events in a large National Health Service (NHS) hospital, and to evaluate the reliability of a two-stage casenote review method in identifying adverse events.

Design: A two-stage structured retrospective patient casenote review.

Setting: A large NHS hospital in England.