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Showing results for tags 'Patient safety incident'.
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Content Article
Screening incidents: thinking differently
PatientSafetyLearning Team posted an article in Improving patient safety
In this blog, Suzette Woodward, an international expert on patient safety, advises Public Health England on its review of the screening incident guidance, setting out her thoughts on how learning from safety incidents could be strengthened. -
Content ArticleThis first webinar of Global Patient Safety Webinar Series 2021 introducing the “WHO Patient Safety Incident Reporting and Learning Systems: Technical report and guidance” which was released on 17 September 2020 on World Patient Safety Day. The webinar presented an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems. A recording of the webinar is available below.
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Content ArticleIn this episode of VISION ZERO Podcast, Dr Abdulealah Alhawsawi interviews Susan Sheridan, a family member of two medical error victims and a global patient safety advocate. In this podcast they explore how we can prevent such medical errors and harm from happening again and the importance of patient / family empowerment.
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Content Article
Uppsala Monitoring Centre: VigiBase
Patient Safety Learning posted an article in Adverse interactions
VigiBase is the Uppsala Monitoring Centre (UMC)’s starting-point for the journey from data to wisdom about safer use of medicines and wise therapeutic decisions in clinical practice. It is the driving-force at the heart of the work of UMC and the WHO Programme. The purpose is to ensure that early signs of previously unknown medicines-related safety problems are identified as rapidly as possible. VigiBase is the unique WHO global database of individual case safety reports (ICSRs). It is the largest database of its kind in the world, with over 20 million reports of suspected adverse effects of medicines, submitted, since 1968, by member countries of the WHO Programme for International Drug Monitoring. It is continuously updated with incoming reports. -
Content ArticleThe MDU’s Michael Devlin argues in this BMJ Opinion article that the never events policy has had a limited effect on patient safety and welcomes a reassessment by the Healthcare Safety Investigation Branch.
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Content ArticlePennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.6 million acute care event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world. This report analyses the serious events and incidents from the database.
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Content ArticleTraditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these two methods might not overlap. This is a retrospective observational study from Anderson et al. of all hospitalisations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event identified by surgery faculty and residents for review by departmental M&M conference or administrative data. The authors analysed the degree to which these two processes captured PSI-defined events and reasons for exclusion by each process. The study found that surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.
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Content ArticleThis international review from the Health Information and Quality Authority highlights the considerable variation in place across countries in relation to patient safety reporting. It is clear however, that the coordination and triangulation of patient safety intelligence for risk profiling is extremely important. Incidents need to be combined with other quality and patient safety sources of information.
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Content ArticlePreventable adverse events are an ongoing challenge in healthcare. International studies demonstrate that 3%–17% of admissions are associated with an adverse event (defined as an injury caused by healthcare management resulting in prolonged hospitalisation, disability on discharge or death). Approximately half of the adverse events are preventable. Little is known about adverse events in the Irish healthcare system.Therefore, recommendations on improving patient safety at a national level are being made on limited information. The aim of the Irish National Adverse Events Study (INAES) from Rafter et al. was to quantify the frequency and nature of adverse events in acute hospitals in the Republic of Ireland for the first time using an internationally recognised retrospective patient chart review methodology.
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Content Article
What to do when complications occur (3 January 2018)
Patient Safety Learning posted an article in Processes
In this article, Cruikshanks and Bryden outline the process that should take place after an adverse event has occurred.- Posted
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want— mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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Content ArticleDiagnostic delays for endometriosis can occur as many of the symptoms are very similar to other common medical conditions. During 2018 and 2019, there were 24 incidents reported to the MDU (a medical defence organisation) which involved endometriosis. A common factor in these incidents involved a complaint or claim following an allegation of a missed or delayed diagnosis. A delayed diagnosis can lead to prolonged pain and suffering and may cause other physical and psychological problems for the patient, such as infertility, anxiety and depression. Failure to diagnose endometriosis or a delay in diagnosis is not necessarily negligent, but a claimant may have a case if they can demonstrate that a doctor's management fell below the expected standard - for example, by not adequately examining the patient, or by not considering the diagnosis when a patient presents with those signs and symptoms as described in the NICE guidance. MDU offers advice in this blog to help reduce the risk of a delayed or missed diagnosis of endometriosis.
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Content ArticleThis was a debate in the House of Lords on the 2 March 2021 concerning the UK Government's plans regarding a redress scheme for those harmed by sodium valproate, stemming from recommendations in the First Do No Harm Report by the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege (also known as the Cumberlege Review).
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Content ArticleAt the age of 15, Helen Haskell's son, Lewis, died due to treatable surgical complications. Following a routine elective surgery, he developed signs of sepsis, a life-threatening response to infection. Like most patients in postsurgical distress, Lewis deteriorated slowly. As he became weaker and weaker over the course of many hours, his bedside caregivers downplayed the significance of his mounting pain and unstable vital signs. Finally, his blood pressure became undetectable and he went into cardiac arrest, from which he could not be saved. His death, like thousands of others, was preventable. In this article, Helen discusses the erosion of patient safety reporting at the United States' CMS. Each year, CMS proposes changes to quality reporting programmes. Longstanding evidence-based patient safety measures, especially those used to detect harm to patients, are gradually being removed. These measures are largely extrapolated from hospital records and do not add to the workload of hospital staff. But they are embarrassing to hospitals, and hospital representatives lobby against them. The trend of downgrading patient safety is concerning.
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Content ArticleWorking together and maximising the benefits of intelligent technology can have a truly transformative impact on clinical negligence claims, writes Molly Kent, a patient safety specialist at Radar Healthcare, in this HSJ article. Claims essentially arise out of dissatisfaction, usually with a process, service or poor patient journey. Each claim represents an individual’s story – no two cases will be identical, just as no two patients are identical. Molly argues, however, that it’s when we bring the information from claims together that we can truly learn. Rather than looking at each case in its own silo, we should be building the big picture, and considering things like systems of internal control, human factors, communications, audit and education.
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Content ArticleIn this article in the Pharmaceutical Journal, Carolyn Wickware asks if liquid morphine should be reclassified. She cites research that Oramorph or oral morphine sulphate solution was directly linked to the cause of death in 13 reports since 2013.
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Content ArticleIn this short film, Susanna Stanford and Sarah Seddon share a positive message about managing adverse events in healthcare. Drawing together the patient and clinician perspectives, they discuss how clinicians and other healthcare professionals can prepare for the inevitability of things going wrong, and how both patients and clinicians need the same things in the aftermath of adverse events.
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Content ArticleIn this short film, Susanna Stanford and Sarah Seddon share a positive message about managing adverse events in healthcare. Drawing together the patient and clinician perspectives, they discuss how clinicians and other healthcare professionals can prepare for the inevitability of things going wrong, and how both patients and clinicians need the same things in the aftermath of adverse events.
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Content ArticleA National Patient Safety Alert has been issued on the elimination of bottles of liquefied phenol 80%. The alert has been issued by the NHS England and NHS Improvement National Patient Safety Team, British Orthopaedic Society, The Association of Coloproctology Great Britain and Ireland, and Royal College of Podiatry.
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Content ArticlePennsylvania is the only state that requires healthcare facilities to report all events that cause harm or have the potential to cause harm to a patient. These patient safety events are reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), which is the largest repository of patient safety data in the United States and one of the largest in the world, with over 3.9 million acute care records. This article, published in Patient Safety, shows details of the PA-PSRS acute care data along with longitudinal and categorical insights that can be used to improve patient safety.
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Content ArticleA new national NHS Learn from patient safety events service (previously called the patient safety incident management system – PSIMS – during development) is in the final stages of development as a central service for the recording and analysis of patient safety events that occur in healthcare. NHS England has now commenced the public beta stage, where some organisations can begin using the system, instead of the NRLS. LFPSE is replacing the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), to offer better support for staff from all health and care sectors.
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Content ArticleIn this study, published in the Journal of Patient Safety and Risk Management, the authors explore and compare types and longitudinal trends of hospital adverse events in Norway and Sweden in the years 2013-2018 with special reference to the adverse events that contributed to death. They found that 13.2% of hospital admissions in Norway and 13.1% in Sweden were associated with an adverse event, with 0.23% of admissions in Norway and 0.26% in Sweden associated with an adverse event that contributed to death. In addition to the similar rates in adverse events between the two countries, the authors also found that there was no significant change in the level adverse events or fatal adverse events in either country over the six-year time period.
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Content Article
HSIB maternity programme year in review 2020/21 (August 2021)
Mark Hughes posted an article in HSSIB investigations
This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken. -
Content Article
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This study, published in the Journal of the Royal Society of Medicine, analyses safety incidents on acute medical wards in the NHS over a period of 10 years. A total of 377 reports of severe harm or death were confirmed, with the most common types of incident the result of diagnostic errors, medication-related errors and failures monitoring patients. -
Content ArticleThis report describes the impact of patient adverse events and near misses, including their use of incident reporting systems and the organisational support available.
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