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Showing results for tags 'Patient safety incident'.
Found 683 results
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EventThe NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This virtual conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements. The conference will also discuss the role of Medical Examiners which were introduced in April 2019, providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and to improve patient safety. Register hub members can receive a 20% discount. Email info@pslhub.org to receive the discount code.
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Content ArticleWhen a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. The Canadian Patient Safety Institute (CPSI) provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
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Content ArticleThis report represents the collective work of the National Patient Safety Consortium to identify, for the first time, a list of 15 never events for hospital care in Canada. Never events are patient safety incidents that result in serious patient harm or death and that are preventable using organisational checks and balances. Never events are not intended to reflect judgment, blame or provide a guarantee; rather, they represent a call-to-action to prevent their occurrence. But a list of never events won’t solve anything on its own. For it to have meaning, we need to take deliberate steps to identify when they occur, and harness the knowledge in hospitals across the country to prevent never events from happening. The Canadian Patient Safety Institute (CPSI) encourages a culture of continuous quality improvement — where mistakes are openly reported, disclosure occurs routinely and open discussion and problem solving are encouraged — with patients and families as full and active participants.
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Content ArticlePatient safety has been considered the heart of healthcare quality. This study from Najjar et al. in Safety in Health aimed to explore relationships between patient safety culture and adverse event rates at unit levels in Palestinian hospitals, and provide insight on initiatives to improve patient safety. The study confirms the idea that a more positive patient safety culture is associated with lower adverse events in hospitals at the departmental levels in Palestine. Further analysis should include a more representative sample to examine the causal relationship between patient safety culture and adverse events incidents.
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Content ArticleThe aim of this study from Choi et al. was to investigate the scope and severity of the second victim problem among nurses in South Korea by examining the experiences and effects of patient safety incidents (PSIs) on them. The study found a considerable number of nurses experienced psychological difficulties due to PSIs at levels that could interfere with their work. The effect of PSIs on nurses with direct experience of PSIs was greater compared with those with indirect experience. There need to be psychological support programmes for nurses to alleviate the negative effects of PSIs.
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Content ArticleKeith Conradi, Chief Investigator at the Health Service Investigation Branch, presented at the Patient Safety Learning Conference on HSIB’s challenges and achievements in its first year.
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Content ArticleIn this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production.
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Content ArticleWhen things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems to turn to those proximal to the consequence, whom we judge to have failed to control the hazard in question. The notion of ‘just culture’ has developed over the past decade or so in response to this and is highly valued by front line staff. Just culture is, however, borne of the Safety-I mindset. Since the advent of ‘just culture’, the Safety-II perspective has emerged. Safety-II defines safety not as avoiding that things go wrong but as ensuring that things go right. Safety-II views the human not as a hazard, but as a resource necessary for system flexibility and resilience. In light of this, it has been proposed that the idea of just culture should be abandoned. If we take a Safety-II view, ‘just culture’ might indeed seem unnecessary. Steve Shorrock explores this further in his latest blog.
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Content ArticleIn these presentation slides, Paul Gantt and Ron Gantt, Safety Compliance Management, discuss human error and its effect on occupational safety. They identify the role of error traps in human error, how an organisation can identify and eliminate error traps to prevent incidents and they review case studies involving human error.
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Content ArticleThe Canadian Patient Safety Institute (CPSI) outlines the process in Canada if you have a question or a concern about the healthcare services you have received.
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Content ArticlePresentation slides for topic 5 of the WHO Multi-professional Patient Safety Curriculum Guide. The learning objective from this topic is to understand the nature of error and how healthcare providers can learn from errors to improve patient safety.
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The human error trap (7 June 2017)
Patient Safety Learning posted an article in Error traps
Phillip Ragain, director of training and human performance at The RAD Group, explains why it wrong to focus on human error when an incidence occurs. A majority of incident investigations correctly identify employees who made mistakes or deviated from policies and procedures, but this distracts from other causal factors and preclude better corrective actions. In his blog, Philip discusses how leaders can avoid the human error trap. -
Content ArticleThis document from the World Health Organization (WHO) is to urge the readers to understand the purpose, strengths and limitations of patient safety incident reporting. Data derived from incident reports can be very valuable in understanding the scale and nature of harm arising from health care, provided that the properties of the data are reviewed carefully and conclusions are drawn with caution. The use of incident reporting systems for true learning in order to achieve sustainable reductions in risk and improvements in patient safety is still work in progress. It can be and has been done, but not yet on the scale and with the speed that compares with some other high-risk industries. That is what we must all strive for. This technical guidance will help the journey to a position where we can show patients and their families how we used this learning to give them care that is safe and dependable, every time they need it.
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Content ArticleThis blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
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Content ArticleRoot cause analysis (RCA) is a widely used method deployed following adverse events in health care. Using a range of information-gathering and analytical tools (such as interviews, the "five whys" technique, fishbone diagrams, change analysis, and others), RCA seeks to understand what happened and why and to identify how to prevent future incidents. In this PSNet Case and Commentary, Mohammad Farhad Peerally and Mary Dixon-Woods discuss a case where a hospital planned to perform a root cause analysis (RCA) to investigate an adverse event which resulted in an individual blamed and no interventions to prevent similar errors or address systems issues were ever implemented.
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Content ArticleThe No Fault Compensation Review Group were asked by the Cabinet Secretary for Health and Wellbeing to consider the potential benefits for patients in Scotland of a no fault compensation scheme for injuries resulting from medical treatment, and whether such a scheme should be introduced alongside the existing clinical negligence arrangements. This report sets out the approach they adopted together with their findings, conclusions and recommendations which help and inform consideration of what is required to ensure that the compensation scheme in operation in Scotland meets the needs of those involved.
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Content ArticleAfter two weeks of evidence by experts in medical ethics the Infected Blood Inquiry finishes its review of Newcastle, reviews a single case from Cardiff and moves onto its first evidence from those involved with the Haemophilia Society. Professor Brian Edwards reflects on the evidence in this NHSManagers.Net article. See also the weekly updates on the inquiry from The Haemophilia Society.
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Content ArticleThe UK-wide inquiry is looking into what has been described as the worst treatment disaster in the history of the NHS. Thousands of patients across the UK were infected with HIV and hepatitis C via contaminated blood products in the 1970s and 1980s. The Haemophilia Society updates give a weekly summary of inquiry news when public hearings take place.
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Content Article
Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Content ArticleA sub-group of rare but serious patient safety incidents, known as ‘never events,’ is judged to be ‘avoidable.’ There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of ‘preventable harm’ with zero tolerance ‘never events,’ especially around the lack of evidence for such harm ever being totally preventable. Bowie et al. consider whether the ideal of reducing preventable harm to ‘never’ is better for patient safety than, for example, the goal of managing risk materialising into harm to ‘as low as reasonably practicable,’ which is well-established in other complex socio-technical systems and is demonstrably achievable. They reflect on the ‘never event’ concept in the primary care context specifically, although the issues and the polarised opinion highlighted are widely applicable. Recent developments to validate primary care ‘never event’ lists are summarised and alternative safety management strategies considered, e.g. Safety-I and Safety-II.
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Content ArticleIn Spring 2021, a new national Patient Safety Incident Management System (PSIMS) will enter its public beta stage. The new system will be phased in to replace the current National Reporting and Learning System (NRLS). Its aim is to maximise the NHS’s ability to learn from when things go wrong. In this, the first in a series of blogs from Lucie Mussett, PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer., PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer.
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Why learn from everyday work? (Steven Shorrock, 2020)
Sam posted an article in Improving patient safety
For a few reasons – especially regulatory requirements – the majority of effort when it comes to safety management concerns abnormal and unwanted outcomes, and the work and processes in the run up to these. We need to learn from incidents – for moral, regulatory and practical reasons. But incidents alone don’t tell us enough about the system as a whole. If we view incidents as the tip of the iceberg in terms of total hours of work or total outcomes, then what lies beneath? Steven Shorrock explores this in an article for HindSight. -
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Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this article. -
Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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Content Article‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. The latest national report from the Healthcare Safety Investigation Branch (HSIB) says that 'Never Events' should not be defined as such if they don’t have strong enough barriers in place to stop them happening.It recommends that seven Never Events on a list of 15 should be removed until better barriers are in place. They are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships.
