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Showing results for tags 'Patient safety incident'.
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Content ArticleIntrahospital transport is a common occurrence for many hospitalised patients. Critically ill children are an especially vulnerable population who experience preventable adverse events at least once a week, on average. Transporting these patients throughout the hospital introduces additional hazards and increases the risk of adverse events. The transport process can be decomposed into a series of steps, each incurring specific risk. These risks are numerous and few of these risks are specific to the transport process. There is a paucity of literature available on paediatric intrahospital transport and related adverse events. Elliot et al. recently reviewed the Wake Up Safe database, a paediatric anesthesia quality improvement initiative across member institutions to disseminate information on best practices, for paediatric perioperative adverse events associated with anaesthesia-directed transport. The authors present several examples of airway and respiratory events taken from the database and discuss the complexity of the transport process.
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Content Article
Why didn’t you report it? A blog by Emma Walker
Patient Safety Learning posted an article in Good practice
A minor accident makes Emma Walker reflect on the safety culture of the NHS. -
Content ArticleA key benefit of the new Learn from Patient Safety Events (LFPSE) service is its introduction of machine learning to hugely enhance the NHS’s capabilities for processing and analysing records of patient safety events. This podcast discusses how we plan to introduce machine learning in LFPSE, how this will support the NHS to improve patient safety, what changes staff will see as a result, our longer-term ambitions, and how providers can get involved in shaping this exciting new revolution in patient safety learning.
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Content ArticleThis study aimed to operationalise and use the World Health Organization's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths.
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Content ArticleThe Royal United Hospital Bath NHS Trust project tested different ways to communicate with staff about patient safety, to encourage the reporting of incidents and to promote a learning culture.
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Content ArticleLearn from Patient Safety Events (LFPSE) presentation from Southern Health NHS Foundation Trust.
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Content ArticleIn the first in a series of blogs looking at the range of investigation methods used by HSIB, Nichola Crust reflects on how Appreciative Inquiry can be used to examine patient safety and identify opportunities for learning.
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Content ArticleStandardised data and integration of systems are vital for full traceability, improving patient safety, and enabling swift action in healthcare incidents. The PIP breast implant scandal was not the first and transvaginal mesh will not be the last. In fact, the next national patient safety scandal is likely manifesting today. “There needs to be better processes to ‘track and trace’ patients who have received a device when a problem arises,” says Professor Sir Terence Stephenson, Nuffield professor of child health at UCL Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England, in the Scan4Safety 2020 report. “Clear strategies and channels are needed to inform patients, the public and clinical professionals to help improve safety.” One common denominator among such incidents is the lack of traceability – limited visibility of the devices used, when and where they are used and, most importantly, in or on which patients. This is where standardised data comes into play. There is no shortage of data in the NHS. However, the ability to standardise and share that data between systems and organisations is something the health service as a whole still lacks. Today, achieving full traceability remains a key challenge for the NHS, with repercussions that continue to have a detrimental effect on patient care.
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Content ArticleSignificant Event Audit (SEA) ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided. This guidance from the Royal College of General Practitioners (RCGP) aims to enable primary care teams to conduct an effective SEA with the aim of improving care for all patients.
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Content ArticleEnsuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult.
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Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist -
Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content Article
The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
Content ArticleThis mixed-methods study in the Journal of Multidisciplinary Healthcare examined how health staff in Indonesian hospitals perceived open disclosure of patient safety incidents (PSIs). The authors surveyed 262 health workers and interviewed 12 health workers. In the quantitative phase they found a good level of open disclosure practice, a positive attitude toward open disclosure and good disclosure according to the level of harm. However, in the qualitative phase they found that most participants were confused about the difference between incident reporting and incident disclosure. The authors concluded that a robust open disclosure system in hospitals could address several issues such as lack of knowledge, lack of policy support, lack of training and lack of policy. They also suggest that the government should develop supportive policies at the national level and organise initiatives at the hospital level in order to limit the negative implications of disclosing situations.
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Content ArticleThe implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals.
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Content Article
NHS Patient Safety Syllabus v. 2.1 (June 2022)
Patient Safety Learning posted an article in Training & education
The Academy of Medical Royal Colleges and the University of Warwick have developed this NHS Patient Safety syllabus to complement it as the basis for education and training for staff throughout the NHS. -
Content ArticleThe Patient Safety Authority (PSA) is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires acute care facilities to report all incidents of harm (serious events) or potential for harm (incidents). Long-term care facilities report infections into the Pennsylvania Patient Safety Reporting System (PA-PSRS). The PSA analyses those reports to prevent recurrence—either by identifying trends unapparent to a single facility or flagging a single event that has a high likelihood of recurrence— and disseminates that information through multiple channels. Here is the PSA's 2022 Annual Report.
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Content ArticleJudy Walker summarises four tools that can be used for the Patient Safety Incident Response Framework (PSIRF), explaining what they are and the strengths and weaknesses of each: SWARM Huddle MDT Review After Action Review Patient Safety Incident Investigation (PSII).
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Content ArticleThe Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare, supporting the NHS to improve learning from the 2.5 million+ patient safety events recorded each year. All healthcare staff are encouraged to record patient safety events to support national and local improvement to make care safer for patients. This short video from NHS England introduces LFPSE.
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Content ArticleThe Dutch Hospital Patient Safety Program started in 2008. It initially ran for five years, and its aim was to decrease adverse events by 50% in all Dutch hospitals. A second National Safety Program launched in 2020. This focuses on reflection, interprofessional collaboration and explaining process variation in daily practice. It also looks to foster more patient involvement and shared decision making. The ultimate aim is to reach a significant reduction in preventable patient harm. This webinar provides an overview of patient safety in the Netherlands and discusses these two initiatives and their implementation, outcomes and ongoing impact.
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Content ArticleThis factsheet explains more about how the new independent Health Service Safety Investigations Body (HSSIB) will function
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News ArticleRegistered nurses (RNs) at US Prime Healthcare’s West Anaheim Medical Center (WAMC) will hold an informational picket today to protest chronic short staffing and its impact on safe patient care. Nurses say that the hospital should cancel elective surgeries because those beds and nurses are needed for other emergent patients. RNs in all medical departments are short-staffed, putting patient safety in jeopardy. “Nurses are under incredible pressure to care for patients beyond the state’s mandated safe staffing ratios due to the staffing crisis in our hospital,” said John Olarte, RN at WAMC. “The employer should be making beds available by canceling elective surgeries for the foreseeable future. Save those beds for the patients who most need them and at the same time give the RNs a chance to truly care for these patients by not forcing nurses to take patients that don’t need to be in the hospital right now. The public needs to know that the hospital is not doing everything they can to help the nurses care for patients.” “There is a staffing crisis because RNs are leaving,” said Sofia Rivera, RN in the emergency department at WAMC, “To attract and retain quality nurses — just staff the floors so the RNs do not have to pick up multiple extra shifts due to the revolving door of RNs in this hospital.” Nurses say they want a strong contract so they can recruit and retain RNs and they want to establish a health and safety committee to ensure they have a voice on issues of nurse safety and patient care. They have been in contract negotiations since May 2021. Their contract expired in June 2021. “We are getting slaughtered in the ER,” said Rasha Tran, RN. “Ambulances are just leaving their patients in the ER instead of waiting for an available bed because they are waiting too long. I don’t even know how we can sustain this demand to care for so many patients. It means less care for each patient. Continuing elective surgeries means that a regular bed is not available for a patient in the ER who is now is being held for hours or days before they are admitted. Even before this most recent Covid surge, nurses have been picking up extra 12-hour shifts to help our coworkers, often without a break for meals or rest periods.” Read full story Source: National Nurses United, 11 February 2022
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News Article
Why America needs a National Patient Safety Board
Patient Safety Learning posted a news article in News
Within hours of the catastrophic Fern Hollow bridge collapse in Pittsburgh, USA, the National Transportation Safety Board was on the scene, finding answers to “Why?” and “How can we keep this from ever happening again?” What could be more obvious than the value of having a team of experts on the alert — and empowered with the authority — to provide promising solutions to dangerous situations? Transportation industries embraced the recommendations because they know what its corporate mission and obligation to the public is: to get people from place to place as efficiently and safely as possible. Sadly, we cannot say the same for health care, says Karen Wolk Feinstein. There is no single federal agency entrusted with a sole mission: to make health care as safe as possible by investigating solutions to major threats. Therefore, there has been comparatively little progress to protect patients from medical mistakes. We don’t understand well enough the preconditions and root causes of adverse events, making it difficult to prevent harm before it happens; we haven’t deployed the safety technology and analytics we have available; and we often don’t share existing lessons learned or actionable solutions, says Karen. That’s why a coalition of US experts, including leaders from hospitals, insurers, patient safety groups, consumer advocates, foundations, universities, technology companies and employers has formed to promote the establishment of an independent, nonpunitive federal agency dedicated to finding data-driven solutions to the problem of medical error. A National Patient Safety Board, modelled after the National Transportation Safety Board, would identify patient safety events, study the root causes of these events and issue recommendations to prevent future lapses. More than 80% of the NTSB’s recommendations are acted upon. Imagine if this occurred in health care: How many lives could be saved? How much needless suffering could be prevented? Read full story Source: Pittsurgh Post-Gazette, 10 February 2022 -
News Article
Lincolnshire hospitals declare 'critical incident' over staff shortages
Patient Safety Learning posted a news article in News
A critical incident has been declared at four Lincolnshire hospitals because of staff shortages due to COVID-19. United Lincolnshire Hospitals NHS Trust said it was taking "additional steps to maintain services" at all its hospitals in Lincoln, Boston and Grantham. The trust's medical director, Dr Colin Farquharson, said there were "significant staffing pressures due to absence related to COVID-19". But he said essential services "remain fully open". According to a leaked email seen by The Sunday Times, the trust declared a critical incident on Saturday night "due to extreme and unprecedented workforce shortages". It issued an "urgent appeal" for clinical and non-clinical staff to offer extra time supporting colleagues "over the next 72 hours". It also asked staff to "consider limiting social contacts with people outside of work". Original tweet on Twitter: Read full story Source: BBC News, 3 January 2022
