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Showing results for tags 'Patient safety incident'.
Found 683 results
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Content ArticleIn 2010, the US Department of Health and Human Services Office of Inspector General (OIG) reported the first national incidence rate of patient harm events in hospitals—27% of hospitalised Medicare patients experienced harm in October 2008. During that month, hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly half of these events were preventable. OIG conducted a new study to update the national incidence rate of patient harm events among hospitalised Medicare patients in October 2018. This work included calculating a new rate of preventable events and updating the cost of patient harm to the Medicare programme.
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Content ArticleThis study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England’s national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used. AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen.
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Content ArticleThe Safety Engineering Initiative for Patient Safety (SEIPS) is arguably the best known and most published systems-based Human Factors framework in healthcare worldwide. Developed by Professor Pascale Carayon and colleagues in the University of Wisconsin, the SEIPS framework is partly based on Donabedian’s well-known Structure-Process-Outcome model of healthcare quality. SEIPS is strongly grounded in a Human Factors based systems approach.
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Content ArticleAs a team, this worksheet can be used as a prompt to highlight the various system-wide factors that contribute to the issue at hand (e.g. implementing a new way of working; managing change or learning from a safety incident); seek to understand how these factors relate and interact to produce outcomes (desirable or undesirable).
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Content ArticleIn this webinar, MISHC Research Fellow Philippa Dodshon analyses research into practitioners’ experiences with incident investigation to determine how they can be used to enhance organisational learning and reduce the prospect of repeat accidents.
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Patient Safety Authority Annual Report 2021
Sam posted an article in International patient safety
The Patient Safety Authority (PSA) share its 2021 annual report, highlighting the agency’s expansion of education and reporting efforts to improve patient safety throughout the commonwealth. 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). -
Content ArticleThe purposes of the Canadian Medication Incident Reporting and Prevention System (CMIRPS) programme are to:Coordinate the capture, analysis and dissemination of information on medication incidents;Enhance the safety of the medication use system for Canadians.Support the effective use of resources through the reduction of potential or actual harm caused by preventable medication incidents.The goals of the CMIRPS information system are to:Collect data on medication incidents.Facilitate the implementation of reporting of medication incidents.Facilitate the development and dissemination of timely, targeted information designed to reduce the risk of medication incidents (e.g. ISMP Canada Safety Bulletins).Facilitate the development and dissemination of information on best practices in safe medication use systems.
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Content ArticleClinical governance can be defined as ‘the framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high quality of care’. This article aims to provide an introduction to clinical governance based on UK practice. The article defines and examines how UK health systems priorities safe care, effective care, person-centred care and assured care.
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Content ArticleFrom April 2023 the new Health Services Safety Investigations Body will require doctors to be candid about errors that have led to patient harm. But can medics trust that material given in this “safe space” won’t be used against them?
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Content ArticlePatients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organisations where safe care is delivered consistently over time, which is in most cases. In this article, Ioana Popescu discusses patient safety in Canada. While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary.
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Content ArticleRepeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period. The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
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Content ArticleSerious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study from Mary Dixon-Woods and colleagues aimed to use the Human Factors Analysis Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports.
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Content ArticleInvestigations of healthcare harm often overlook the valuable insights of patients and families. This review from Lauren et al. aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.
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Content ArticleBob Hanscom, J.D., is retiring this week after a nearly 30-year career championing patient safety improvement. He has been Vice President of Risk Management and Analytics at Coverys since 2013 and earlier held similar positions at CRICO and CRICO Strategies. He was Vice President of Clinical Services at Lahey Clinic from 1993 to 1998 and prior to that practiced law.
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Content ArticleA systematic review and meta-analysis from Hodkinson et al. examines the association of physician burnout with the career engagement and the quality of patient care globally. A joint team of British and Greek researchers analysed 170 previous observational studies of the links between burnout among doctors, their career engagement and quality of patient care. Those papers were based on the views and experience of 239,246 doctors in countries including the US, UK and others in Africa, Asia and elsewhere globally. This meta-analysis provides compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organisations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care. Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency. Read accompanying BMJ editorial here.
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Content ArticleImproving health care quality and ensuring patient safety is impossible without addressing medical errors, so it is important to accurately estimate incidence rates and implement the most appropriate solutions to reduce medical errors. This systematic review in the journal Frontiers in Medicine aimed to identify interventions that have the potential to decrease medical errors. The authors concluded that although many interventions have been suggested and tried, patient safety has not significantly improved. They call on policymakers to focus more on implementing selected interventions effectively.
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Content ArticleThis letter accompanies the publication of the Patient Safety Incident Response Framework (PSIRF) by NHS England. The PSIRF forms a major part of the NHS Patient Safety Strategy and replaces the Serious Incident Framework (SIF) that has been in place since 2015. It aims to improve safety management across the healthcare system in England and to support the NHS to embed the key principles of a patient safety culture. In his letter, Dr Aiden Fowler, National Director of Patient Safety in England outlines how PSIRF was developed, describes how the transition from the SIF to PSIRF will take place and highlights the tools available to support organisations to implement the changes. The letter is addressed to: NHS trust and foundation trust chief executives, medical directors and nursing directors Integrated Care Board medical directors and nursing directors NHS England Regional Team medical directors and nursing directors NHS England regional direct commissioning leads
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Content ArticleThis literature review in The Operating Theatre Journal examines why the decision was made not to class surgical fires as a 'Never Event', even though research has identified them as a preventable hazard. The author also examines steps that could be taken to further reduce the risk of surgical fires in the NHS and other health systems. You will need to create a free online account to view this article.
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This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here -
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Nuffield Trust: Safety culture in the NHS (25 August 2022)
Mark Hughes posted an article in Culture
A good safety culture in healthcare is one that includes value and respect for diversity, strong leadership and teamwork, openness to learning, and staff who feel psychologically safe. In this article the Nuffield Trust use data from the NHS Staff Survey to look at safety culture in the NHS. -
Content ArticleIn 2019, the Korean National Patient Safety Incidents Inquiry was conducted in the Republic of Korea to identify the national-level incidence of adverse events. This study determined the incidence and detailed the characteristics of adverse events at 15 regional public hospitals in the Republic of Korea. The authors concluded that a review of medical records aids in identifying adverse events in medical institutions and helps prioritise actions to reduce their incidence.
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Content ArticleNHS England’s Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. A Patient Safety Specialist in the North East of England has shared their 'plan on a page’ with the hub to help others prepare for the implementation of PSIRF. You can download the attachment below. Further reading: Applying the After Action Review for the PSIRF – some real life examples
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Content ArticlePeople increasingly provide feedback about healthcare services online. These practices have been lauded for enhancing patient power, choice and control, encouraging greater transparency and accountability, and contributing to healthcare service improvement. Online feedback has also been critiqued for being unrepresentative, spreading inaccurate information, undermining care relations, and jeopardising professional autonomy. Through a thematic analysis of 37 qualitative interviews, this paper explores the relationship between online feedback and care improvement as articulated by healthcare service users (patients and family members) who provided feedback across different online platforms and social media in the UK.
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Content ArticleSafety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organsation. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value.
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Content ArticleOn the 21 July 2022 NHS Resolution’s Safety and Learning team, in partnership with the National Infusion and Vascular Access Society, hosted a virtual forum on extravasation injury claims. The intention of this event was to raise awareness of these injuries and help spread learning and process review across health providers.
