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Showing results for tags 'Patient safety incident'.
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EventWHO Patient Safety Flagship: A Decade of Patient Safety 2020-2030 is pleased to invite you to the 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, the World Patient Safety Day. This webinar will present an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems. The Global Patient Safety Network Webinar Series 2021 aim at introducing ongoing activities of WHO Patient Safety Flagship, with the objective of sharing knowledge and experiences on important topics on patient safety. This webinar series is open to everyone who has interest in patient safety. Learning objectives Understand the benefit and challenges in implementing patient safety incident reporting and learning systems. Learn about the WHO technical report and guidance on patient safety incident reporting and learning systems. Consider how to set up patient safety incident reporting and learning systems. Register
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Event
Aiming for zero patient safety incidents or errors
Sam posted an event in Community Calendar
This virtual masterclass, facilitated by Mr Perbinder Grewal, will focus on patient safety and how to setup a proactive safety culture. It will look at what patient safety is and how to setup and improve the safety culture. It will look at Human Factors and how to mitigate some of the common errors. Can we have a system with zero patient safety incidents or errors? Further information and book your place or email kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org for code -
EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which has now been published for the early adopter sites as introductory guidance. NHS Improvement will then work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only and using learning from the pilot sites, resources and guidance will be developed to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin introducing the new framework from Autumn 2020, with full NHS-wide roll out complete by Summer 2021 (these timings are subject to change due to Covid-19). The conference will also update delegates on best practice in Learning from Deaths the role of the Medical Examiner. There will be an extended focus on learning from serious incidents, ensuring the investigation findings lead to change and improvement. Register
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Content Article
In this blog, Patient Safety Learning reflects on a recent letter by Keith Conradi to the Secretary of State for Health and Social Care, highlighting concerns about a lack of interest and attention in the activities of the Healthcare Safety Investigation Branch (HSIB) at the highest levels of the Department of Health and Social Care (DHSC) and NHS England.- Posted
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Content ArticleIn two videos, Mark Fewster, Head of Product and Innovation at Radar Healthcare, talks to Marcos Manhaes, NHS Improvement, and Paul Ewers, Milton Keynes University Hospitals NHS Trust, about the journey from the National Reporting and Learning System (NRLS) to Learn from Patient Safety Events (LFPSE) and the future benefits the NHS could see.
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Content ArticleFrail older adults are often at increased risk of patient safety incidents including rehospitalisation and overtreatment. In this study, published in BMC Geriatrics, researchers in the United States assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, they found that frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
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Content ArticleThis study, published in the Journal of Patient Safety, looks at how preventable adverse events and near misses are identified, based on data from an acute care hospital in western Sweden. It examines how many events are identified through structured record review, web-based incident reporting and daily safety briefings, and the different types of events identified by each method. Reflecting on its findings, the authors suggest that health care organisations should adopt multiple methods to get a comprehensive review of the number and type of events occurring in their setting.
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Content ArticleThe duty of candour is a general duty to be open and transparent with people receiving care from you. It applies to every health and social care provider that CQC regulates. The duty of candour requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them. The regulation also defines ‘notifiable safety incidents’ and specifies how registered persons must apply the duty of candour if these incidents occur. This document from the Care Quality Commission (CQC) gives the background to the duty of candour and explains the statutory and professional duties of candour.
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Content ArticleThese professional standards describe good practice and good systems of care for reporting, learning, sharing, taking action and review as part of a patient safety culture. The accompanying guidance and information support the implementation of the standards. These professional standards are for pharmacists, pharmacy technicians and the wider pharmacy team across the United Kingdom. This may also be of interest to the public, to people who use pharmacy and healthcare services, healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
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Content ArticleThis cross-sectional study in JAMA Network Open looked at patients in the USA with pneumonia who are admitted to hospitals with higher risk-standardised readmission rates. It aimed to assess whether these patients have higher rates of adverse events. The authors found that patients with pneumonia admitted to hospitals with high all-cause readmission rates were more likely to develop adverse events during hospitalisation. This strengthens the evidence that readmission rates reflect the quality of hospital care for pneumonia.
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Content ArticlePharmacists and pharmacy technicians across different settings work hard to provide person-centred, safe and effective care to patients. But, in reality sometimes things go wrong. The way that professionals respond to these situations is key to supporting the people affected and improving patient safety for the future. This guidance from the General Pharmaceutical Council aims to provide you with guidance on how to implement the Duty of Candour.
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Content Article
Extravasation: a patient safety priority
Patient Safety Learning posted an article in Extravasation
Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. This leaflet describes the risks posed by extravasation to patients, the extent of the problem in the NHS and what is currently being done to reduce the risk of avoidable harm. The leaflet sets out the action to prevent, recognise, treat and report extravasation which is urgently needed. It emphasises the importance of all suspected extravasation injuries being reported and investigated, with reviews undertaken to learn and take action to prevent harm to future patients. -
Content ArticleReducing stress is an organisational imperative since workplace pressures continue to be one of the main causes of short and long-term absence. According to research undertaken by CIPD based on responses from 804 organisations, 79% of respondents report some stress-related absence in their organisation over the last year. Healthcare settings have an even higher rate of absence due to stress, yet there is reason to be optimistic that this could start to change when a new policy from NHS England is implemented, which recommends the use of After Action Review (AAR). In this blog, Judy Walker explains how AARs can play a key role in reducing stress for those who have been involved in clinical incidents.
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Content ArticleAdverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human error. The aim of this study from Meyer et al. was to determine the incidence, nature and severity of adverse events in neurosurgery, and to investigate the contribution of human error. They found that adverse events occur frequently in neurosurgery. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reforms. The high frequency of human performance deficiencies contributing to adverse events shows that there is potential to further eliminate avoidable patient harm.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Claire talks to us about her role as a Patient Safety Lead and why she thinks the new Patient Safety Incident Response Framework will make her work more practical and patient-centred. She also describes why she set up the Patient Safety Management Network and highlights why patient safety roles would benefit from more standardisation across trusts.- Posted
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Content ArticleThis ITV documentary tells the story of how surgeon Ian Paterson duped his patients into believing they had cancer and performed unnecessary surgeries on them, before he was caught and jailed for 20 years in 2017. It features personal accounts of patients who were harmed by Paterson while he worked in NHS and private practice. Further reading: Report of the independent Inquiry into the issues raised by Paterson (4 February 2020) Patient Safety Learning’s response to the Paterson Inquiry (11 February 2020) Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson (16 December 2021)
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Content ArticleLucie Musset, Senior Product Manager, and Hugh Archibald, Product Manager, at NHS England and NHS Improvement present on the new Learn from patient safety events (LFPSE) service (formerly known as PSIMS).
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Content ArticleReporting to the National Reporting and Learning System (NRLS) is largely voluntary, to encourage openness and continual increases in reporting to facilitate learning from error. Increases in the number of incidents reported reflects an improved reporting culture and should not be interpreted as a decrease in the safety of the NHS. Equally, a decrease cannot be interpreted as an increase in the safety of the NHS. This report covers the early stages of the COVID-19 pandemic in England, from April 2020 through to the end of March 2021, when cases had declined rapidly. The number of incidents reported from April 2020 to March 2021 was 2,109,057, and represent a small decrease of 6.1% compared to April 2019 to March 2020 (2,246,622).
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Content Article
How healthcare employers can alleviate staff burnout using technology
Anonymous posted an article in Staff safety
In this blog, Hannah Wilkinson, Head of People & Culture at Radar Healthcare, describes five ways health tech companies can alleviate burnout across the workforce, following recently reported news that as many as 400 staff are leaving the NHS each week due to the effects of stress. -
Content ArticleAccording to new data released by the NHS, a total of 379 medical malpractices called ‘Never Events’ were recorded between 1 April 2021 and 28 February 2022. The term is defined by the service as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” See below Statista's chart representing the data.
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Content ArticleThis study from McQueen et al. explored what ‘good’ patient and family involvement in healthcare adverse event reviews may involve. Nineteen interviews were conducted with patients who had experienced an adverse event during the provision of their healthcare or their family member.
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Content ArticlePresentation slides from NHS England and NHS Improvement's Tracey Herlihey, Head of Patient Safety Incident Response Policy, Lauren Mosley, Head of Patient Safety Implementation and Matthew Fogarty, Associate Director of Patient Safety (Policy and Strategy) on the Patient Safety Incident Response Framework (PSIRF).
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Content ArticleThe Japan Council for Quality Health Care (JQ) has been conducting various activities, such as the Project to Collect Medical Near-Miss/Adverse Event Information and the evaluation of medical services provided at hospitals, in order to maintain public confidence in healthcare services and improve the quality of the services. In response to rising awareness and expectations of the general public as well as medical institutions concerning promotion of patient safety and medical adverse event prevention, the JQ has been actively engaged in the said activities. The JQ Division of Adverse Event Prevention has been undertaking the Project to Collect Medical Near-Miss/Adverse Event Information to prevent medical adverse events and to promote patient safety since 2004. As a neutral third-party organisation, the JQ has been publishing collected medical near-miss/adverse event information and the analyses of data in the form of periodic reports, annual reports and monthly fax newsletters for medical professionals, administrative organisations and the general public. The reports can also be browsed on JQ's website.
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Content ArticleAcciMap graphically maps the multiple contributing factors to an accident and their inter-relationships onto the following six levels: Government policy and budgeting. Regulatory bodies and associations. Local health economy planning and budgeting (including hospital management). Technical and operational management. Events, processes and conditions. Outcomes.
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Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.
