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Showing results for tags 'Patient safety incident'.
Found 683 results
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NHS England: Our National Patient Safety Alerts
Patient-Safety-Learning posted an article in NHS England
This webpage provides links to all recent NHS England national Patient Safety Alerts and sets out the criteria for issuing a Patient Safety Alert. -
Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
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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 ArticleTwo years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. Swarm is a form of safety incident huddle that takes place as close as possible in time and place to the incident, allows blame-free investigation and leads to prompt action. This article describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust.
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Content ArticleJudy Walker, iTS Leadership, presented at the recent Patient Safety Management Network drop-in session on After Action Reviews. View the presentation below.
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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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In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, highlights a recent discussion at a meeting of the Patient Safety Management Network about how After Action Reviews (AARs) can help promote learning and patient safety improvement. -
Content ArticlePatient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring. The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents.
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Transvaginal mesh timeline (7 December 2017)
Patient-Safety-Learning posted an article in Women's health
This blog sets out a timeline of the major landmarks for transvaginal surgical mesh since its first approval in 1996. -
Content ArticleIn this blog for medical education website Intensive, Chris Nickson shares advice on running a 'hot debrief' after a critical incident. A hot debrief is a short conversation that allows staff involved in an incident to gather as a team and share their perspectives and concerns, as well as coming up with ways to prevent similar incidents happening again. This blog details practical methods for planning, facilitating and concluding a hot debrief and provides resources for further reading.
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Content ArticleThese tools and worksheets have been produced by NHS England to assist staff in conducting patient safety incident investigations. NHS England stresses that patient safety investigation is an important and complex task and should only be undertaken by those who have attended training and gained skills and experience from specialists in the field.
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Content ArticleThis guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.
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Content ArticleThis template has been published to guide local PSIRP early adopter organisations in prioritising investigation quality over quantity. NHS providers should follow this template when developing their local patient safety incident response plan.
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Content ArticleThe Serious Incident framework describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again. This framework explains the responsibilities involved when dealing with serious incidents and includes actions staff are required to take, and the tools available. It is designed to inform staff providing and commissioning NHS funded services in England who may be involved in identifying, investigating or managing a serious incident. It is relevant to all NHS-funded care in the primary, community, secondary and tertiary sectors, including private sector organisations providing NHS-funded services. At some point in 2022, the Serious Incident framework will be replaced by the Patient Safety Incident Response Framework
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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 new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
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Patient safety is fundamental to the delivery and outcomes of effective health care. But what happens when things go wrong? What can we learn from the data and how does nursing ensure effective incident reporting takes place to protect patients and staff? Chair of Patient Safety Learning and Datix expert Jonathan Hazan joins us to discuss how data is key to patient safety and the importance of a just culture in health care. Nursing Matters is presented by PNC Chair Rachel Hollis and PNC member Alison Leary. -
Content ArticleExternal clinical harm reviews aim to give assurance to patients, patient groups, commissioners and the public as to whether any patients have been harmed as a result of an incident, as well as to avoid future harm to patients. This handbook by Dr Henrietta Hughes, NHS Medical Director for London North, Central and East, outlines an approach to conducting clinical external harm reviews. It identifies the factors which make external clinical harm panels successful and provides example agendas and terms of reference for the process.
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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. -
Content ArticleBev Curtis, Medical Device Safety Officer (MDSO) at Harrogate & District NHS Foundation Trust, describes the role of the MDSO in this presentation.
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Content ArticleThis paper from Samson et al. discusses the properties of complex systems and a systems approach to incident investigation, describes the differences between reactive and proactive safety approaches and describes some of the system-focused models applied to patient safety incident investigations.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.
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Content ArticleMedication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. The Pennsylvania Patient Safety Reporting System (PA-PSRS) was queried and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020.
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Content ArticleA trocar is a hollow device used during minimally invasive surgery that serves as an entry port for optical scopes and surgical equipment. Insertion of this device into the body is determined using anatomical landmarks taking into consideration the patient’s history and physical attributes, e.g., scars or abdominal size. Insertion of the first trocar is the time of highest risk of injury. Intestinal and vascular injuries are two potentially life-threatening injuries that can occur. This is a retrospective review of trocar-related events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between 1 January 2014 and 30 June 2020, which identified 268 events.
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In his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe.
