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Showing results for tags 'Patient safety incident'.
Found 683 results
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Content ArticleReducing the risk of patient harm during the process of healthcare delivery is at the forefront of policy and practice. A considerable number of empirical studies and systematic reviews have examined the prevalence, causes and consequences of patient safety incidents and harms. However, a key limitation in the current patient safety literature is that existing reviews examine patient harm in general but there is less emphasis on understanding the burden of preventable patient harm, which in the interest of improvement is of particular importance. The primary aim of this study from Panagioti et al. was to identify the most common types of preventable patient harm and to examine the prevalence and severity of the identified harm. The authors also aimed to examine differences in the prevalence, types and severity of preventable harm across different healthcare settings and across studies published more recently, using more robust research designs and based in the UK.
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Content ArticleThe dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. This short paper from Susan Burnett and Charles Vincent, outlines the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalised health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
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Content ArticleThis overview considers how the NHS has performed over the current parliament in relation to patient safety. It looks at data relating to reported incidents and harm, episodes of care free of certain types of harm, and patient and staff perceptions of safety.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to the use of a flush fluid and blood sampling from an arterial line in people who are critically ill in hospital. As its ‘reference case’, the investigation uses the experience of Keith, a 66 year old man who during a stay in a clinical care unit had blood samples taken from an arterial line which were contaminated with the flush fluid containing glucose. As a result he received incorrect treatment which led to his blood glucose levels being reduced to below the recommended limit.
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Content ArticleAdverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study from St Clair et al. used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs.
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Content ArticleThe purpose of the Learn from patient safety events (LFPSE) service (previously known during development as the Patient Safety Incident Management System - PSIMS) is to enable learning from patient safety events – incidents, risks, outcomes of concern and also things that went well. Our ability to protect future patients from harm depends on promoting a culture that welcomes and encourages the recording of events. It is essential to abide by these principles to ensure that we continue to successfully learn from patient safety events and reduce harm. This document sets out the circumstances in which LFPSE data are the appropriate data source to be used and describes their appropriate use. These principles emphasise the purpose and characteristics of LFPSE data, and promote consistency across data users. It is essential that users of LFPSE data understand and represent it appropriately, as inappropriate presentations of LFPSE data could discourage recording.
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Content ArticleAs organisations continue to adapt to a faster pace of change and seek to achieve their organisational purpose, it’s essential that the resources and time needed to change are minimised. Improving performance by learning effectively from mistakes is a vital part of the change process but the method of learning employed is critical. In this LinkedIn post, Judy Walker discusses the application of After Action Reviews (AARs).
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Content ArticleCognition is the mental process of knowing, including awareness, perception, reasoning and judgement, and is distinct from emotion and volition. Cognitive processes include mental shortcuts, which speed up decision making. However, cognitive bias occurs when the shortcut causes inferences about other people and/or situations to be drawn in an illogical fashion. There is a tendency to display bias in judgements that are made in everyday life, indeed this is a natural element of the human psyche. Jumping to a conclusion, tunnel vision, only seeing what is expected/wanted, being influenced by the views of others, all are recognisable behaviours. However, whilst such biases may be commonplace and part of human nature, it is essential to guard against these in forensic science, where many processes require subjective evaluations and interpretations. The consequences of cognitive bias may be far-reaching; investigators may be influenced to follow a particular line of enquiry or interpretation of a finding that may be incomplete, or even wrong. Simply because there is a risk of a cognitive bias does not imply that it occurs. The problem is that as it is a subconscious bias it is unlikely that an individual will know either way and therefore it is wise that all practitioners understand the issue and take proportionate steps to mitigate against it.
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Content ArticleEffective incident investigation is an integral part of the provision of a safe blood transfusion service, with the aim to prevent recurrence of adverse events and harm to patients. Determining how an incident has taken place allows understanding of the gaps or failures within the system and identification of effective corrective and preventive measures that can be implemented to reduce risk of recurrence. Consideration of human factors supports a more sophisticated understanding of the factors that cause incidents, optimising human performance through better understanding of human behaviour and the factors that influence this behaviour, thus improving patient safety.
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Content ArticleThis annual report sets out how NHS Resolution's dispute resolution strategy has continued to drive down litigation against the NHS in England in 2021-22. 77% of claims made by patients were resolved in 2021/22 without court proceedings, continuing the year-on-year reduction for the last five years, and in line with the organisation's strategy to keep patients and healthcare staff out of court. NHS Resolution achieved this reduction through a range of dispute resolution approaches and continued cooperation across the legal market. It emphasises that the reduction in litigation has not been at the expense of a rigorous approach to investigation.
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Content ArticleThe Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups.
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Content ArticleWest Suffolk is first of a small number of trusts in England that are part of a pilot programme recently launched by NHS Improvement and NHS England called the Patient Safety Incident Response Framework (PSIRF). A national initiative, it is designed to further improve the quality and safety of the care we provide through learning from patient safety incidents. PSIRF outlines how providers should respond to patient safety incidents, and how and when an investigation should be carried out. It includes the requirement for the publication of a local Patient Safety Incident Response Plan (PSIRP), which sets out how trusts will continually improve the quality and safety of the care they provide, as well as the experience which patients, families and carers have when using our services. Find out more about what West Suffolk NHS Foundation Trust are doing.
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Content ArticleOn the 18 October it was announced that NHS Trusts have been given an optional six-month extension to implement Learn From Patient Safety Events (LFPSE). There are a lot of messages being talked about and there has been some confusion over what this means. So, what do organisations need to have in place by 31 March 2023 and what has changed? In this blog*, Radar Healthcare cover some of the key information.
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Content ArticleThe Royal College of Emergency Medicine’s Safety Resources hub has information and resources about alerts, safety resources, safety in the Emergency Department and safety events. This page is managed by the Safer Care Committee, which is part of the Quality in Emergency Care Committee (QECC). The QECC has produced a series of strategy documents, explaining the role of RCEM, and these committees, in improving patient care.
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Content ArticleVisual of the Learning from Patient Safety Events (LFPSE) implementation timeline.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) third annual conference took place on 21 September 2022. Presentations and videos from the day are now available to view and download below. Although it tied in with the World Health Organization’s World Patient Safety Day theme of medication safety, our speakers also covered: how we can drive system level change practical sessions based on our HSIB investigation education courses maternity safety insights themed around inclusivity of care opportunities for sharing and learning from Norway’s healthcare safety investigation body, UKOM.
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Content ArticleIf you want to find out what the new Patient Safety Incident Response Framework is all about, and how it will support the NHS to learn and improve, this video provides a helpful introduction.
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Content ArticleThis German study in the Journal of Patient Safety aimed to analyse the strength of safety measures described in incident reports in outpatient care. 184 medical practices were invited to submit anonymous incident reports to the project team three times in 17 months. The authors coded the incident reports and safety measures, classifying them as as “strong” (likely to be effective and sustainable), “intermediate” (possibly effective and sustainable) or “weak” (less likely to be effective and sustainable). The study found that the proportion of weak measures was high, which indicates that practices need more support in identifying strong patient safety measures.
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Content ArticleA themed review may be useful in understanding common links, themes or issues within a cluster of investigations or incidents. It will seek to understand key barriers or facilitators to safety using reference cases (e.g. individual datix incidents or previous investigations).
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Content ArticleSafety in aviation and maritime domains has greatly improved over the years, but there is no room for complacency. This is especially the case as we approach systems with ever more automation and use of remote control in both industries. It is also more complicated because ‘human error’ is often seen as the root cause, when usually it is the system that leads people into mistakes, and seafarers and flight crew alike so often save the day. Accidents, incidents and near misses all offer us valuable lessons from which to improve safety, to do better next time. Yet in the aftermath of adverse events, the wish to blame someone, which makes sense of something that was never intended to happen, might make us lose sight of the real causes of accidents, leading to more tragedy and loss. The key to learning is using the right tool with which to understand what happened and why. This means going beyond the surface ‘facts’ and suppositions, seeing beneath the ‘usual suspects’ of factors that yield little in terms of how to prevent the next one. The SHIELD (Safety Human Incident & Error Learning Database) taxonomy has been developed by reviewing a number of existing taxonomies - in this case, a set of related terms for describing human performance and error - to derive a means of objectively classifying events in a way that helps us develop safety countermeasures afterwards. Whilst it can analyse single events it is particularly insightful when looking - and learning - across related events
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Content ArticleWhen something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.
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Content ArticleHospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study from Richie et al. retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
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Content ArticleIn this blog, Melanie Ottewill, National Investigator and Senior Investigation Science Educator at HSIB, shares some key messages from a recent seminar delivered by Tracey Herlihey, Head of Patient Safety Incident Response Policy and Lauren Mosley, Head of Patient Safety Implementation at NHS England. The seminar looked at the new Patient Safety Incident Response Framework (PSIRF) published in August 2022. PSIRF fundamentally shifts how the NHS responds to patient safety incidents for learning and improvement, promoting a proportionate approach to responding to patient safety incidents. It focuses on ensuring resources allocated to investigating and learning are balanced with those needed to deliver improvement. Melanie describes the cultural shift needed to implement PSIRF so it really makes a difference, and talks about the important of compassionate engagement.
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Content ArticleThis study in the Journal of the American Medical Informatics Association aimed to evaluate the feasibility of using Unified Medical Language System (UMLS) semantic features for automated identification of reports about patient safety incidents by type and severity. UMLS was compared with results produced by bag-of-words (BOW) classifiers on three testing datasets. The authors found that UMLS-based semantic classifiers were more effective in identifying incidents by type and extreme-risk events than classifiers using bag-of-words (BOW) features.
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EventuntilWhen things go wrong - doctors in the dock series provides a unique opportunity to hear real patients discuss their experience of medical errors. Well-known witnesses of clinical errors will talk about their first-hand experiences, what happened, how they and their family had to deal with them, and how they have dealt with the aftermath in the most constructive way possible. Gain more experience and insight about the best way to deal with clinical errors as professionals, and from a patient perspective, and convert them into an opportunity for improvement for all involved, even leading to very successful careers. Register
