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Content ArticleHuge numbers of patients suffer avoidable harm in US hospitals each year as a result of unsafe care. In this blog, published in the Harvard Business Review, the authors argue that these numbers could be greatly reduced by taking four actions: Make patient safety a top priority in hospitals’ practices and cultures, establish a National Patient Safety Board, create a national patient and staff reporting mechanism, and turn on EHRs machine learning systems that can alert staff to risky conditions.
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Content ArticleIn this blog for The Health Foundation, the authors make five recommendations for strengthening NHS management and leadership: Support providers and systems to tackle variation in management practice Improve access to training and development opportunities Ensure training equips managers and leaders with the skills they need today Tackle the reporting burden and 'priority thickets' facing managers Ensure the role of managers and leaders is better understood and valued
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Content ArticleThis webpage provides an overview of how human factors affect outcomes in surgical emergencies. It includes: An introduction to human factors Video exploring the case of Elaine Bromiley Explanation of human error and the Swiss Cheese Model Table of factors that reduce human error 'What if?' video showing how simple changes could have resulted in a different outcome in Elaine Bromiley's case Practical tips for managing the paediatric airway in a critically ill child
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Content Article
Safe to speak up? NHS Staff Survey Results 2021
Patient Safety Learning posted an article in Culture
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In this blog, Patient Safety Learning analyses the results of the NHS Staff Survey 2021, specifically focusing on responses relating to reporting, speaking up and acting on safety concerns. It reflects on the importance of staff feeling able to speak up about patient safety incidents and the implications when this is not the case. It describes the NHS’s current approach to creating a patient safety culture and emphasises the need for NHS England and NHS Improvement, in partnership with the National Guardian and Care Quality Commission, to bring forward robust and specific commitments to drive this work forward. -
Content ArticleRaDonda Leanne Vaught faced criminal charges over a fatal medication error she made in 2017. Her trial has raised important questions over medical errors, reporting and process improvement, as well as who bears responsibility for widespread use of tech overrides in hospitals. There is debate over whether automated dispensing cabinet overrides are a reckless act or institutionalised as ordinary given the widespread use of IT workarounds among healthcare professionals. The Nashville District Attorney's Office described this override as a reckless act and a foundation for Ms. Vaught's reckless homicide charge, while some experts have said cabinet overrides are used daily at many hospitals.
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Content Article
Learning from Coroner's reports
Patient Safety Learning posted an article in Coroner reports
When a patient dies because of preventable avoidable harm it is crucial that we learn from the event and implement changes to ensure it does not reoccur. Implementing the findings and recommendations of Coroner’s Prevention of Future Deaths (PFD) reports can play a key role in this. This blog reflects on a recent discussion at a Patient Safety Management Network (PSMN) meeting about PFD reports and how their insights can be used for learning and improvement. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. You can find out about the network here.- Posted
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Content ArticleThis independent external quality assurance review looks at the independent investigation into the care and treatment of mental health service user Mr M at Greater Manchester Mental Health NHS Foundation Trust.
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Content ArticleIncident reporting is an important aspect of clinical care. It highlights safety issues that need addressing and supports clinicians in learning how to keep our patients safe from avoidable harm. Sian Rodger, patient education and health coaching lead at London Spinal Cord Injury Centre shares with the Nursing Times how nurses are learning from incident reporting at her trust.
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Content ArticleThis article in the Journal of Patient Safety & Quality Improvement examines the impact of the Covid-19 pandemic on patient safety reporting and procedures in 33 healthcare settings in Indonesia. The authors found that: patient safety data was recorded and reported less often during 2020, partly due to fewer hospital attendances. the pandemic has had a significant positive impact on hospital staff's compliance with handwashing policies. surgical procedures were less accurate during 2020, as surgical staff sought to reduce infection risk by missing safety procedures such as the surgical checklist.
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Content ArticleThis guidance from the General Medical Council sets out the how doctors should raise and act on concerns about patient care, dignity and safety.
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Content ArticleThis webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust
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Content ArticleThis study in the International Journal of Radiation Oncology, Biology and Physics assesses the impact of the early Covid-19 pandemic on incident learning through evaluation of events reported to the Radiation Oncology Incident Learning System® (RO-ILS) in the USA. The authors conclude that reporting to RO-ILS declined during the early Covid-19 pandemic, especially in hotspot areas, suggesting that resources and time were diverted away from incident reporting to address other critical needs. However, three of the five top reporting practices that stopped reporting during early Covid have since reported events after the analysis timeframe, suggesting the decline may be temporary.
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Content ArticleThis systematic review in Nursing Open synthesises the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute care hospitals. The review included nine studies and found that nurses with positive safety attitudes reported: fewer patient falls and medication errors fewer pressure injuries and healthcare-associated infections fewer mortalities fewer physical restraints and vascular access device reactions higher patient satisfaction. The authors also found that effective teamwork led to a reduction in adverse patient outcomes. They conclude that a positive safety culture results in fewer reported adverse patient outcomes, and that nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
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Content ArticleDiagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. This study in BMC Emergency Medicine sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015. The authors identified the priority areas for intervention to reduce the occurrence of diagnostic error. The study found that system modifications are needed to support clinicians in assessing patients and interpreting investigations. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.
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Content ArticleNumerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
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Content ArticleThis editorial in BMJ Quality & Safety suggests that individual doctors' conduct, performance and responsibility are important factors in improving patient safety. The authors argue that although a 'systems approach' is important, it is necessary to examine the role of individuals within those systems. They highlight recent research that points to small numbers of individual doctors who contribute repeatedly to patient dissatisfaction and harm, and to difficult working environments for other staff. They suggest that identifying and intervening with these individuals plays a role in the wider systems approach to patient safety. They also highlight an urgent need for further research into identifying and responding to problematic clinicians.
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Content ArticleThis paper by Biophorum, a membership organisation for the biopharmaceutical industry, looks at how companies in the sector can adopt a human performance approach to operations. It highlights the need to move away from a focus on reducing human error and towards integrating fundamental systems changes that will enhance human performance.
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Content ArticleThis report provides an overview of the work of Healthcare Inspectorate Wales (the independent inspectorate and regulator of healthcare in Wales) during 2020-21. It discusses National Reviews undertaken in this period and trends emerging from its quality checks of health services. It also highlights areas of innovation, new methods of public and staff engagement and the delivery of care in new settings as a result of the COVID-19 pandemic.
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Content ArticleThis article, published in the BMJ Quality & Safety, discusses the value of incident reporting systems. Reporting systems, both local and national, are overwhelmed by the volume of reports they receive and fall short in defining recommendations for improving healthcare safety. Focusing incident reporting systems on the local learning process of healthcare providers could mitigate many of the problems that have been attributed to reporting systems.
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Content ArticleThis study, published in the International Journal for Quality in Health Care, examined the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. It highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
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Content ArticleThis article, published by the BMJ, discusses mandatory and voluntary medical error reporting programmes and comments that voluntary reporting by practitioners is usually more useful.
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Content ArticleThis manual by the Healthcare Quality Improvement Partnership provides an overview of the basic clinical audit process for non-clinician members of a clinical audit team. Topics include: What is Clinical Audit? How to Set Objectives How to Select an Audit Sample Clinical Audit Confidentiality and Ethics Comparing Performance Against Criteria and Standards Writing an Audit Report Implementing Change and Action Plans
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Content ArticleThis summary, published by the Health and Safety Executive, outlines the legal necessity of reporting and recording incidents in the workplace. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) require employers to report to the relevant enforcing authority and keep records of work-related deaths, accidents and injuries.
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Content Article
SKYbrary: Safety occurrence reporting (2 October 2020)
Becky T posted an article in Implementation of improvements
This article, published on SKYbrary, discusses the importance of correct safety reporting in the aviation industry. Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies; the aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware. Although for the aviation industry, some of the principles can be applied to healthcare. -
Content Article
In this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture.
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