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Found 74 results
  1. Content Article
    Practice staff should use the GP e-form to report all patient safety incidents and near misses whether they result in harm or not. These reports are used by to spot any emerging patterns of similar incidents or anything of particular concern. This will help protect patients by raising awareness of the risks through shared learning with general practices and other health providers across the country.
  2. Content Article
    This blog highlights: The juxtaposition of how work is carried out by healthcare staff compared to the work that policy makers are 'imagining' healthcare workers are doing. The need for healthcare staff to be part of patient safety solutions.
  3. Content Article
    Published by wbur, an American news station, this account from a doctor tells the story of his father's admission to hospital. Dr. Ashish Jha lists a catalogue of errors that took place over those few days, notes how common these mistakes are and argues we should be less tolerant of poor patient safety in healthcare.
  4. Content Article
    The All Party Parliamentary Group (APPG) for Whistleblowing was launched in July 2018 to look at the case for an Independent Office for the Whistleblower. The APPG have set an ambitious workplan aiming to take back the UK’s lead on this legislation, proposing to deliver world class, gold standard draft legislation – a global solution to a global problem. The objectives of the APPG for Whistleblowing are: Influencing policies and decisions that affect whistleblowers globally. Drafting legislation to ensure effective protection for whistleblowers. Commissioning and publishing research, based on our work with whistleblowers and relevant groups and stakeholders across all sectors. Engaging our supporters in campaigns to influence decisions affecting whistleblowers. Giving whistleblowers safe platforms to speak out on issues affecting them. Promoting positive social attitudes towards whistleblowing. Encouraging MPs to promote positive recognition for whistleblowers. Supporting and upskilling MPs and their staff to identify and manage constituent whistleblower cases.
  5. Content Article
    A thought-provoking blog about what it's like nursing in the emergency department (ED) when there are no beds. 
  6. Content Article
    This blog has been written by a healthcare worker and demonstrates the reality of what it is like caring for patients and families while being chronically low on staff. They describe the impact this has on staff morale and the impact it has on patients, patients family members and the relationship between staff and patients.
  7. Content Article
    The Healthcare Safety Investigation Branch (HSIB) latest report highlights that mislabelling of blood samples could pose a deadly risk to patients. The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death.
  8. Content Article
    More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across Canada. Watch this short video, produced by the Canadian Patient Safety Institute (CPSI) to hear more about his experience. 
  9. Content Article
    Helen Haskell, co-chair of the WHO Patients for Patient Safety Advisory Group, brings the patient leader perspective to her take on World Patient Safety Day in this essay published in the BMJ.
  10. Content Article
    No one should be harmed while receiving healthcare. And yet globally, at least five patients die every minute because of unsafe care. The World Health Organization (WHO) will focus global attention on patient safety and launch a campaign in solidarity with patients on the very first World Patient Safety Day on 17 September 2019. Watch the WHO Director General’s statement calling for patients, healthcare workers, policy makers to “Speak up for Patient Safety!”.
  11. Content Article
    Action Against Medical Accidents (AvMa) is a UK charity for patient safety and justice. AvMA supports people affected by avoidable harm in healthcare; to help them achieve justice; and to promote better patient safety for all.
  12. Content Article
    This article describes the qualitative methodology developed for use in CIRAS (Confidential Incident Reporting and Analysis System), the confidential database set up for the UK railways by the University of Strathclyde. CIRAS is a project in which qualitative safety data are disidentified and then stored and analysed in a central database. Due to the confidential nature of the data provided, conventional (positivist) methods of checking their accuracy are not applicable; therefore a new methodology was developed – the Applied Hermeneutic Methodology (AHM). Based on Paul Ricoeur’s ‘hermeneutic arc’, this methodology uses appropriate computer software to provide a method of analysis that can be shown to be reliable (in the sense that consensus in interpretations between different interpreters can be demonstrated). Moreover, given that the classifiers of the textual elements can be represented in numeric form, AHM crosses the ‘qualitative–quantitative divide’. It is suggested that this methodology is more rigorous and philosophically coherent than existing methodologies and that it has implications for all areas of the health and social sciences where qualitative texts are analysed.
  13. Content Article
    Interesting article, by the Patient Safety Network, around how patients can be involved in the solution and the cause of some patient safety incidents.
  14. Content Article
    In this thought paper published by The Health Foundation, Dr Rebecca Lawton and Dr Gerry Armitage look at ways to involve patients in clinical safety and the readiness of patients and health professionals to adopt new roles. They discuss the importance of involving patients in the development of patient engagement and involvement strategies. Genuine patient involvement in their own care requires a fundamental cultural shift in the relationship between patients and clinicians. 
  15. Content Article
    Staff at C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, Michigan are adopting a new approach to safety. By picking up near misses, close calls, deviation off protocol and investigating each one via a daily huddle, they are able to enable change system wide.
  16. Content Article
    This action plan was produced by the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group following a treatment delay for a patient in intensive care.
  17. Content Article
    Near misses or good catches present organisations with learning opportunities. Using data comparisons run by the Pennsylvania Patient Safety Authority, this article by Wallace et al. highlights how good catch programmes can contribute to significant reductions in harmful events and offers insights from risk managers and patient safety officers regarding elements that are necessary to establish successful good catch initiatives and the culture to support them.
  18. Content Article
    This document by the Care Quality Commission (CQC) sets out what needs to be reported to the CQC if working within social care.
  19. Content Article
    Herbert W. Heinrich was a pioneering occupational safety researcher, whose 1931 publication, Industrial Accident Prevention: A Scientific Approach [Heinrich 1931] was based on the analysis of accident data collected by his employer, a large insurance company.
  20. Community Post
    Do any areas of healthcare capture ALL near misses and act on them? What systems do you use?
  21. Community Post
    How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?
  22. Content Article
    Cataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entirely preventable. Read the Healthcare Safety Investigation Branch's report on the insertion of an incorrect intraocular lens.
  23. Content Article
    Both national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
  24. Content Article
    Healthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
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