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Showing results for tags 'Near miss'.
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News Article
Physician associates accused of illegally prescribing drugs and missing diagnoses
Patient Safety Learning posted a news article in News
Physician associates have attempted to illegally prescribe drugs at dozens of NHS trusts and missed life-threatening diagnoses, a dossier claims. Doctors working across the country claim patients’ lives have been put at risk by physician associates (PAs) who they say have failed to respond appropriately to medical emergencies – alleging more than 70 instances of patient harm and “near misses”. The Telegraph has seen responses from more than 600 doctors to a survey on PAs run by Doctors’ Association UK (DAUK), a campaign group. The data suggest that at over half of England’s hospital trusts, doctors are being replaced by PAs on the rota, despite associates only completing a two-year postgraduate course and having no legal right to prescribe. A spokesperson from the Department of Health said their role “is to support doctors, not replace them”. The Telegraph has interviewed more than a dozen surveyed doctors, as well as other clinicians worried about patient safety. At Dudley Group NHS Trust, one junior doctor said a PA had missed an “obvious heart attack” on an ECG, having “just signed it as if it was normal”. A clinician in primary care alleged PAs repeatedly misdiagnosed a patient’s metastatic cancer as muscle ache – despite blood results that were “tantamount” to a cancer diagnosis. They said: “The patient could have been saved eight months of pain; their life could have been prolonged.” Read full story (paywalled) Source: The Telegraph, 27 January 2024- Posted
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NHSE to catalogue ‘harm and near misses’ where BMA rejects derogations
Patient Safety Learning posted a news article in News
The NHS will start recording harm caused to patients during strike action where exemptions have been rejected by the British Medical Association (BMA). BMA council chair Phillip Banfield yesterday accused NHS England of the “weaponisation” of the strike “derogation” process, saying trusts had this week submitted more of the requests, which would permit some striking doctors to return to work, and were not providing information needed to determine if they were justified. NHS England wrote back to Professor Banfield, insisting it was only trying to prioritise safety, but also saying it would revise its own approach to derogation requests. This will include: asking trusts whose requests were rejected by the BMA “to compile a picture” of the impact on services; reinforcing requirements to report patient safety incidents during strikes and after mitigation requests, so “we can evidence harm and near misses which might have been avoided”. The letter says: “We have consistently asked local medical and other clinical leaders to consider applying to the BMA for patient safety mitigations where they have significant concerns for patient safety that cannot be mitigated through other options available to them, and where they can make a strong evidential case that the return of a limited number of junior doctors would address these risks. “We have done this, in part, because we have received a number of reports over previous periods of action that some teams have been put off seeking patient safety mitigations because of their prior experience of having applications rejected, or not receiving a response in time. We are sure you would agree that this is an unsatisfactory position, and that where patient safety concerns exist, these should always be escalated appropriately.” Read full story (paywalled) Source: HSJ, 4 January 2024- Posted
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Content ArticleA patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time. This NHS England document provides an overview of patient safety incident investigation stages, tips and suggested structure for analysis.
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Content Article
Near misses or great catches? A blog by Emma Walker
Patient Safety Learning posted an article in In health care
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Content ArticleJust like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns a company’s safety philosophy into a clear reality. This article, published by Safety Management Group (SMG), looks at the importance of reporting 'good catches' and the positive impact this can have on safety culture and behaviour.
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Content Article
Near-miss and good-catch reporting
Patient_Safety_Learning posted an article in Quality and safety reports
In this article, published by Incident Prevention, authors define what a 'near miss' or 'good catch' is and look at why it is so important to report them. -
Content ArticleA good catch in healthcare is recognised as an employee interception of a potential safety event before a patient is harmed. Both near misses and good catches present healthcare organisations with opportunities for learning to reduce harmful events, which is why reporting near misses in healthcare should be a priority for all organisations, regardless of type or size. It is important that all employees can recognise common examples of good catches in healthcare that prevent patient harm before it reaches the patient. This article, published by Performance Health Partners, includes five situations in which harm can likely occur when no action is taken. It also looks at how to establish a good catch program and how to recognise staff for reporting.
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Content ArticleWales' national policy on patient safety incident reporting and management.
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The Family Oops and Burns First Aid eBook
Kristina Stiles posted an article in Recommended books and literature
'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.- Posted
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News ArticleA struggling trust has been warned by regulators that it could see its junior doctors removed, after concerns about clinical supervision and safety at a hospital whose A&E closes at night. NHS England inspectors who visited Cheltenham General Hospital found emergency patients – including potential surgical patients – became the responsibility of the overnight medical team when its accident and emergency closed in the evening. One night, 26 patients had been handed across, the inspectors were told, and some patients were felt to be inappropriate for medical referral. A surgical registrar could be telephoned at Gloucester Royal Hospital about surgical patients. They were told that although there were no incidents of serious harm, there had been many “near misses” and juniors felt “unsafe and unsupported in terms of consultant clinical supervision, overall clinical/nursing staffing support or logistically in managing patients in this setting or arranging transfers”. Read full story (paywalled) Source: HSJ, 7 July 2023
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Content ArticleIn this blog, After Action Review (AAR) specialist Judy Walker shares an account of a successful AAR that took place amongst a surgical team. The AAR was called after a near-miss where the anaesthetist was prevented from injecting spinal block medication into the wrong side of a patient's spine by an operating department practitioner (ODP). The story demonstrates the benefits of AAR, including accelerated learning, a no-blame approach, flattening staff hierarchy and a significant reduction in the time it takes to investigate an incident.
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Content ArticleNear misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED). This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED. It was published in the Journal of Patient Safety. Authors conclude that near-miss events are relatively common (22.7% of their sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.
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News ArticleHundreds of patients with metallic implants narrowly avoided death or serious injury after being wrongly referred for MRI scans, an investigation revealed yesterday. The powerful magnets used in the machines can displace and damage metallic items such as pacemakers, ear implants and aneurysm clips. Doctors should question patients and check medical records before requesting a scan because of the risk of injury. But hospitals in England recorded 315 near-misses from April 2020 to March 2022 involving patients sent for an MRI. An MRI scan at Mid Yorkshire Hospitals Trust was ditched after staff confirmed the skin over the patient’s pacemaker had begun heating up. Another patient – at Wrightington, Wigan and Leigh Trust – told staff about a metal plug implanted in their nose only after the scan had begun. Many of the incidents involved forms being filled out incorrectly on behalf of elderly and disoriented patients. At East Kent Hospitals University Trust, a patient described as ‘not compos mentis’ was given the all-clear by a care home nurse and again by a clinician for MRI – only for staff to realise at the last moment that metal clips were implanted in their chest. Information about the incidents was obtained using freedom of information requests. Helen Hughes of Patient Safety Learning, said: "It is vital that near-misses are regularly reported, their causes understood, and that this learning is acted on to prevent future avoidable harm." Read full story Source: MailOnline, 15 October 2022
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Content ArticleOn 24 October 2019 coroner Lydia Brown commenced an investigation into the death of Asher William Robert Sinclair, age 3. The investigation concluded at the end of the inquest on 24 January 2022. The conclusion of the inquest was: His medical cause of death was: 1a Hypoxic ischaemic brain injury 1b out of hospital cardiac arrest 1c displaced tracheal tube (trachael tube dependant) II Neonatal enterviral myocarditis and encephalitis (trachael ventilator dependant and cardiac pacemaker). Asher died on 8th October 2019 in Great Ormond Street hospital when his life support mechanisms were withdrawn.
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Content ArticleSafety in aviation and maritime domains has greatly improved over the years, but there is no room for complacency. This is especially the case as we approach systems with ever more automation and use of remote control in both industries. It is also more complicated because ‘human error’ is often seen as the root cause, when usually it is the system that leads people into mistakes, and seafarers and flight crew alike so often save the day. Accidents, incidents and near misses all offer us valuable lessons from which to improve safety, to do better next time. Yet in the aftermath of adverse events, the wish to blame someone, which makes sense of something that was never intended to happen, might make us lose sight of the real causes of accidents, leading to more tragedy and loss. The key to learning is using the right tool with which to understand what happened and why. This means going beyond the surface ‘facts’ and suppositions, seeing beneath the ‘usual suspects’ of factors that yield little in terms of how to prevent the next one. The SHIELD (Safety Human Incident & Error Learning Database) taxonomy has been developed by reviewing a number of existing taxonomies - in this case, a set of related terms for describing human performance and error - to derive a means of objectively classifying events in a way that helps us develop safety countermeasures afterwards. Whilst it can analyse single events it is particularly insightful when looking - and learning - across related events
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Content ArticleIn this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.
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Content ArticleThis study, published in the Journal of Patient Safety, looks at how preventable adverse events and near misses are identified, based on data from an acute care hospital in western Sweden. It examines how many events are identified through structured record review, web-based incident reporting and daily safety briefings, and the different types of events identified by each method. Reflecting on its findings, the authors suggest that health care organisations should adopt multiple methods to get a comprehensive review of the number and type of events occurring in their setting.
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Content ArticleThis Chartered Institute of Ergonomics and Human Factors (CIEHF) webinar explores near misses in three different sectors and how controls can, or cannot, be developed to prevent future events.
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EventuntilThis free webinar will explore near misses in three different sectors and how controls can, or cannot, be developed to prevent future events. It will start with an introduction to the concept of near misses in healthcare and the challenges faced in learning from these near misses to improve safety. You will then hear how near misses are approached in rail and nuclear and how controls are developed in their processes. At this event, you’ll: Gain valuable insights from all three sectors: healthcare, rail and nuclear. Hear discussion about defining near misses with respect to controls. Learn how to build barriers in systems. Who will this be of interest to? This webinar will be of interest to anyone involved in the management of safety events in their industry/ organisation, and especially human factors practitioners, safety investigators, policy leads and regulators. Register
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Content ArticleThe Japan Council for Quality Health Care (JQ) has been conducting various activities, such as the Project to Collect Medical Near-Miss/Adverse Event Information and the evaluation of medical services provided at hospitals, in order to maintain public confidence in healthcare services and improve the quality of the services. In response to rising awareness and expectations of the general public as well as medical institutions concerning promotion of patient safety and medical adverse event prevention, the JQ has been actively engaged in the said activities. The JQ Division of Adverse Event Prevention has been undertaking the Project to Collect Medical Near-Miss/Adverse Event Information to prevent medical adverse events and to promote patient safety since 2004. As a neutral third-party organisation, the JQ has been publishing collected medical near-miss/adverse event information and the analyses of data in the form of periodic reports, annual reports and monthly fax newsletters for medical professionals, administrative organisations and the general public. The reports can also be browsed on JQ's website.
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Content Article
CORESS reports
Patient Safety Learning posted an article in Surgery
CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments.- Posted
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Content ArticleAHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety.
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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 ArticleThis study, published in the Journal of Advanced Nursing, investigates the processes through which personnel understaffing and expertise understaffing jointly shape near misses among nurses during the Covid-19 pandemic. It looks at survey data collected from 120 nurses in the United States of America working in hospitals during the pandemic. The authors conclude that the challenges created by understaffing of nurses have been amplified by the pandemic. They suggest that understanding the mechanisms through which safety outcomes are affected by understaffing can help healthcare organisations be better prepare for safety challenges that may arise when staffing shortages are experienced.
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