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Showing results for tags 'Patient safety incident'.
Found 683 results
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Content Article
Ehi Iden, hub topic lead for Occupational Health and Safety: OSHAfrica, reflects on a patient safety incident early on in his career. -
Content ArticleAcute respiratory distress syndrome (ARDS) and respiratory failure are characterised by hypoxemia (i.e., low levels of blood oxygen). Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from 1 January 2010, through 30 June 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.
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Content ArticleThis report from the Healthcare Safety Investigation Branch (HSIB) outlines the most important factors for supporting staff in the wake of safety incidents, against the backdrop of the COVID-19 pandemic. The report reinforces the importance of effective staff support for those suffering high levels of psychological harm, as it has a direct impact on patient care. While focusing on patient safety incidents overall, the report also provides valuable insight that could help organisations develop their own programmes of support for any situation. The report features a first-hand account from a junior doctor which charts the impact that a patient safety incident had on his life and his experiences of support. Excerpts from the story emphasise the importance of creating a ‘normalised’ culture around accessing support.
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Content ArticleThe aim of this project from Hollis et al. was to improve engagement with the incident reporting process and to encourage staff to raise issues and create a proactive culture of quality improvement. This project demonstrates that a relatively simple intervention can have effect significant positive cultural change in an organisation over a small period of time. By giving frontline staff a mechanism to record issues it is possible to develop a positive culture of grass roots change. Incident reporting can act as a vehicle not only to improve patient safety but more broadly to generate ongoing ideas for quality improvement within an organisation.
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Content ArticleThe Care Quality Commission (CQC) has published the second report of Professor Glynis Murphy’s independent review of its regulation of Whorlton Hall between 2015 and 2019. CQC commissioned Professor Murphy to conduct an independent review to look at whether the abuse of patients at Whorlton Hall could have been recognised earlier by the regulatory process and to make recommendations for how CQC can improve its regulation of similar services in the future. In addition, CQC asked Professor Murphy to conduct a review of international research evidence to look at how abuse is detected within services for adults with a learning disability and autistic people and how such detection can be improved. The first report of Professor Murphy’s review made a number of recommendations for CQC to strengthen its inspection and regulatory approach for mental health, learning disability and/or autism services. This second report outlines the progress that CQC has made to implement the recommendations. This includes publication of the final report of its review of restraint, seclusion and segregation; work on closed cultures and the development of a tool for rating support plans.
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Content ArticleIn the summer of 2019, following a televised Panorama programme showing abusive care of people with learning disabilities and/or autism in Whorlton Hall (an independent hospital in the north of England), the Care Quality Commission (CQC) requested an independent review of its inspections of Whorlton Hall. Professor Glynis Murphy was appointed to conduct the review.
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Content ArticleNHS Resolution received 2,600 claims for needlestick injuries for incidents occurring between 2012 – 2022. Needlestick injuries can be costly to investigate and increase the risk blood-borne infections. Fortunately, the harm and cost of most needlestick injuries are largely avoidable. NHS Resolution has created two new resources to share the learning from these claims and help organisations identify how to prevent future injuries.
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Content ArticleSuzette Woodward is a Senior Advisor for the Department of Health and Social Care and NHS Resolution. She is one of the authors of Being fair: Supporting a just and learning culture for patients and staff following incidents in the NHS. These slides and accompanying commentary give an idea of the content of the report and it’s purpose.
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Content Article
The Patient Safety Learning hub has provided the vehicle through which I’ve shared my personal journey as I sought to establish and embed a second victim support initiative at the trust where I worked until my recent retirement. Four years ago SISOS was set up to ensure that colleagues affected by safety incidents received emotional support as soon as possible. A lot of lessons have been learned along the way and positive actions taken. These are my personal thoughts. -
Content Article
House of Commons Debate - Ockenden Review
Mark Hughes posted an article in Other reports and inquiries
This debate begins with a statement by the Minister for Mental Health, Suicide Prevention and Patient Safety, Nadine Dorries MP, responding to the publication of the first report by the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust. It is followed by questions from MPs in the chamber and the Minister's responses. -
Content ArticleA short article from NHS Education for Scotland about Significant event analysis (SEA). Enhanced SEA is a well-established safety improvement tool in general practice. However, there is good evidence to suggest that many SEAs are poorly conducted by practice teams, leading to missed opportunities to make health care safer.
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Content Article
Rebuilding Shattered Lives
Patient Safety Learning posted an article in Legal matters
People who suffer an injury caused by the negligence of someone else need, and have a right, to rebuild their lives. Going through a personal crisis – whether it is short-term or life-changing – is bad enough without being made to feel ashamed about making a claim. People who have been injured needlessly must have access to justice and the care and support they need on the road to recovery. Injured people deserve our empathy and understanding. As a nation we should be focused on what genuinely injured people need, rather than on myths about their motivation, and misconceptions about the specialist lawyer s who fight for their rights and help put them on the road to recovery. ‘Rebuilding Shattered Lives’ tells the real story of personal injury and of people who need expert support to help them build brighter futures. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
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Content Article
Patient Safety Authority: Bed safety
Patient Safety Learning posted an article in Patient safety in health and care
In the past, healthcare workers considered bed rails a useful device to prevent patient falls from bed. While bed rails have their benefits, their use or misuse may also place patients at significant risk, resulting in death or serious injury. Entrapment is an occurrence involving a patient who is caught, trapped, or entangled in the hospital bed system, which includes the spaces in or around the bed rail, hospital bed mattress, or hospital bed frame. Entrapped body parts associated with risk for severe injury include the head, neck, and chest. Awareness of this risk must be heightened across the healthcare continuum. The Patient Safety Authority has collated guidelines, resources and educational tools on bed safety. -
Content ArticleSix monthly summaries of how the NHS reviewed and responded to the patient safety issues you reported.
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Content ArticleData workbooks and explorer tool based on incidents reported by NHS providers in England to the National Reporting and Learning System (NRLS). Every six months the NHS publish official statistics as a breakdown by NHS trust of the incidents reported to the NRLS. The Organisation patient safety incident reports (OPSIR) provide data by NHS trust and gives NHS providers an easy-to-use summary of their current position on patient safety incidents reported to the NRLS. This includes information on patient safety incident reporting and the characteristics of their incidents. The information in these reports should be used alongside other local patient safety intelligence and expertise, and supports the NHS to deliver improvements in patient safety. As well as the OPSIR, the NHS also publish the National patient safety incident reports which set out the number of patient safety incidents reported to the NRLS from a national perspective and describe their patterns and trends.
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Content ArticleArterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There are several examples of glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has lead to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal.
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Content ArticleIn 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in their intensive care unit (ICU), Leslie et al. surveyed current practice in arterial line management and determined whether these recommendations had been adopted. They contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented – use of sodium chloride 0.9% as flush fluid, two‐person checking of fluids before use – and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two‐person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. This survey provides evidence of continuing risk to patients.
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Content ArticleSusan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
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Content ArticleIn 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
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Content ArticleSarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
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Content ArticleIn her guest blog for the Professionals Standard Body (PSB), Sarah Seddon talks about the Duty of Candour and how it's affected her personal life.
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Content ArticleIn this latest report, the Healthcare Safety Investigation Branch (HSIB) has outlined their approach to working with patients and families with the aim of sharing that learning across the healthcare sector. They have set out their experiences so that other organisations can reflect on how it may be applicable to their work. The report not only covers HSIB's principles and process for effective family engagement, but also how they evaluated the approach using feedback from families involved in investigations. HSIB’s process for effective family engagement has been developed through close collaboration with families who have been involved in investigations. HSIB recognises that there is currently no national framework or process to assist those working with families during investigations. In the report foreword, HSIB’s Chief Investigator, Keith Conradi says: “in the past decade, the healthcare sector has recognised the need to ensure it works with patients and families…however it is also recognised that undertaking family engagement of a high quality can be challenging, particularly when the guidance on how to do it is limited.” The report also highlights some possible future developments, which includes a long-term aim of producing formal family engagement guidance which will be shared externally for organisations to access and use.
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Content ArticleSince January 2019, the Health Information and Quality Authority (HIQA) has been the competent authority for regulating medical exposure to ionising radiation in Ireland and receives incident notifications of significant events arising from accidental or unintended medical exposures. As part of its role, HIQA is responsible for sharing lessons learned from significant events. HIQA has published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. This report provides an overview of the findings from these notifications and aims to share learnings from the investigations of these incidents.
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Content ArticleThis survey, a collaboration between the International Society for Quality in Healthcare (ISQua) and the International Hospital Federation (IHF) was designed to frame the WHO Global Consultation on Patient Safety, which was held from 24-26 February 2020 to kick off the development of the Global Patient Safety Action Plan. Already then, the pandemic-to-be was affecting various regions, before striking health systems worldwide. The question of patient safety is a critical one in the discussion about COVID-19: hygiene and hospital-acquired infections, non-suitable hospital architecture, delayed surgeries and procedures, lack of personal protective equipment (PPE) and much more affected the safety of patients as well as of health workers, to whom the World Patient Safety Day 2020 is dedicated. In February 2020, the IHF disseminated a short survey on national safety plans to its Full Members, hospitals’ national/regional representatives. At the same time, ISQua disseminated their survey asking how well incident reporting is in place, and if the outcomes improve the 'no blame no shame' approach to their Individual and Institutional Members. The surveys were repeated in July 2020 to see if the onset of COVID-19 had made any positive or negative changes to the responses.
