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Showing results for tags 'Patient harmed'.
Found 1,337 results
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Content ArticleA "Fair and Just Culture" supports learning from unsafe acts that result in potential or real harm as a way to prevent future errors. A fair and just culture strikes a balance between a punitive culture and a blame free culture. Differentiating acceptable from unacceptable behaviour associated with harmful events requires a consistent approach to determine culpability of individuals against system flaws that contribute to unsafe acts. More than one unsafe act by more than one individual can contribute to an event. For optimal learning and fair treatment of staff, each act should be considered individually using the same structured approach.
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Content Article
WHO Global Patient Safety Action Plan 2021–2030 (Final version)
Mark Hughes posted an article in WHO
The Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure. In the last 10 years the number of patients treated in outpatient clinics has nearly doubled. Many minor surgical procedures can now be carried out in an outpatient clinic, whereas in the past they would have been carried out in an inpatient theatre setting. The high number of patients treated in an outpatient clinic requires efficient management. Clinical consultation and delivery of the required intervention often needs to be completed within a 15-20-minute appointment. In a single outpatient waiting area there may be patients arriving for different clinical interventions. Staff need to make sure that all patients are seen in the right place, at the right time and (if required) receive the right procedure. Outpatients are not provided with any physical means that staff can use to identify them. This is different to inpatients where a wristband is worn following an initial check of the patient’s identity. Checking the identity of a patient in an outpatient department typically relies on staff speaking to patients. There is a risk of patients being missed or misunderstood due to the environment, work demands, language or cultural barriers.
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Content ArticleImproving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper from Tase et al. examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare.
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Content ArticleSue Hignett and Paul Bowie propose taking a much-needed professional approach to patient safety through an accredited learning pathway to integrate safety into clinical systems and develop healthcare safety specialists and experts
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Content ArticleThis article, published in Mayo Clinic Proceedings, looks at how outsourcing in health care has become increasingly common as health system administrators seek to enhance profitability and efficiency while maintaining clinical excellence. However, outsourcing clinical services often results in lower quality patient care, including patient harm, and compromises the values of the organisation.
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Content Article
Bleed Out: HBO documentary (2018)
Patient Safety Learning posted an article in Investigations and complaints
Medical error is the third leading cause of death in the U.S. After a routine partial hip replacement operation leaves the mother of filmmaker and comedian Steve Burrows in a coma with permanent brain damage, what starts as a personal video diary becomes a citizen’s investigation into the state of American healthcare. -
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In this personal account, hub member Sophie talks about the trauma she experienced after a painful contraceptive device (IUD) fitting, and the impact this has had on her subsequent experience of medical procedures. She argues that damaging narratives around female pain cause harm to patients in multiple ways and have consequences that reach far beyond the initial experience of pain.- Posted
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Content ArticleThis study in The Journal of Minimally Invasive Gynecology applied a structured human factors analysis to understand the factors that contribute to vaginal retained foreign objects (RFOs). Trained human factors researchers looked at 45 incidents that occurred between January 2000 and May 2019 at an academic medical centre in Sothern California. The narrative of each incident was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). The authors of the study concluded that the top two contributing factors in vaginal RFO incidents were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.
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Content ArticleThe Health Protection Agency has suggested that one in ten hospital patients experiences an incident that puts their safety at risk, around half of which could be prevented, and the RCN has identified the need to reduce nurses’ paperwork considerably. This article reports a successful project that set out to tackle these two issues by developing a risk-based nursing assessment system that is simple to use, reduces unnecessary paperwork and reduces the risk of harm to patients. It outlines how the initiative was introduced, as well as obstacles encountered during the process. The risk-assessment tool received positive feedback from nursing staff as it reduces paperwork while providing a risk-based assessment of care needs.
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Content Article
The bleeding edge (2018)
Patient-Safety-Learning posted an article in Medical devices (new)
This documentary takes a look at the fast-growing medical device industry and reveals how the rush to innovate can lead to devastating consequences for patients. -
Content ArticleIn this episode of BBC Panorama, Reporter Deborah Cohen investigates how medical devices can cause harm to patients, and the lack of support and redress available when things go wrong.
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Content ArticleA surgical fire is one that occurs in, on or around a patient undergoing a surgical procedure and is an internationally recognised patient safety issue. On 16 December 2021, Members of Parliament held a general debate on preventing surgical fires in Westminster Hall. In this article, the Association for Perioperative Practice (AfPP) sets out its response to issues raised in the debate.
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Content ArticleThis paper, published in the Journal of Health Services Research & Policy, examines the potential of combining insights from patient complaints and staff incident reports for a more comprehensive understanding of the causes and severity of harm. In their conclusion, the authors state that this study demonstrates the value of using patient complaints to supplement, test and challenge staff reports, including to provide greater insight on the many potential factors that may cause unsafe care.
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Content ArticleHealthcare leaders are bringing renewed attention to patient safety issues that have been overshadowed by another year of the COVID-19 pandemic. Becker's Hospital Review asked patient safety experts the following question: "If you could fix one patient safety issue overnight, what would it be and why?" Read the answers Cynthia Barnard, Vice President of Quality at Northwestern Memorial Healthcare (Chicago), Patricia McGaffigan, Vice President of Safety Programs at the Institute for Healthcare Improvement, Ana Pujols McKee Vice president and CMO and Chief Diversity, Equity and Inclusion Officer at The Joint Commission and Gary Stuck, CMO at Advocate Aurora Health gave.
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Content ArticleThis is a debate from the House of Commons on 16 December 2021 on the issue of preventing surgical fires in the NHS.
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Content ArticlePatient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe. Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not, to the National Reporting and Learning System (NRLS). You can find out how to do this from the link below.
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Content ArticleThis report from the Department of Health and Social Care sets out the Government’s response to the Independent Inquiry into the Issues raised by Paterson.
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Content Article
This is the fourth of a short series of blogs in which we take a look back at our work in five areas of patient safety during 2021. In this blog we consider the need for greater patient engagement to support improvements to patient safety. Throughout our work, Patient Safety Learning seeks to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable. -
Content Article'Kicking the Hornet’s Nest' is a documentary that looks at power morcellation, a popular gynaecologic procedure used to perform hysterectomies. The documentary demonstrates how the practice has been inadvertently spreading cancer in patients for decades. It includes first-person testimonies and archival footage and follows two married, Harvard-affiliated whistle-blowers who have been personally impacted by the procedure, as they campaign to expose the controversial practice and prevent future needless deaths.
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Patient Safety Learning and the Safer Healthcare and Biosafety Network (SHBN) are undertaking a project, working with patient safety experts and frontline staff, to produce a manual to support staff after a serious safety incident. As part of this work, we are asking healthcare staff to complete a short survey relating to experiences of a serious safety incident. -
Content ArticleThis report looks at how the inaccurate use of the skin cleaning agent chlorhexidine in neonatal care caused severe chemical burns to a baby.
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Content ArticleThis report looks at an incident where a neonate suffered an oesophageal perforation following endotracheal and nasogastric tube insertion.
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Content ArticleThis report highlights the risk of patient overdose when converting tacrolimus (a medicine used following organ transplantation) from an oral to intravenous route.
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NHS England: Ceftazidime as a 24-hour infusion
Becky T posted an article in Medication administration
Through its core work to review patients safety events, recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a patient safety issue where the antibiotic ceftazidime was infused over 24 hours.
