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Showing results for tags 'Patient safety incident'.
Found 683 results
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Content Article
Medical error prevention (5 May 2020)
Sam posted an article in Good practice
Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved. Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers. -
Content ArticleA National Patient Safety Alert has been issued on the risk of foreign body aspiration during intubation, advanced airway management or ventilation. Foreign body aspiration can occur if loose items are unintentionally introduced into the airway during intubation, ventilation or advanced airway management. This can lead to partial or complete airway blockage or obstruction, and if the cause is not suspected, can be fatal. The most common types of foreign bodies identified in incident reports were transparent backing plastic from electrocardiogram (ECG) electrodes and plastic caps of unclear origin. The alert asks providers to reduce this risk by purchasing safer alternative equipment without loose and transparent parts. Providers are also asked to develop or amend local protocols to ensure pre-prepared intubation and advanced airway management devices are covered or protected until use; and that the ends of reusable breathing system hoses are closed between patient cases.
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Content Article
“I’m going to Datix you”
Jonathan posted an article in Investigations, risk management and legal issues
Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame? Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, looks at why this has come about and what needs to be done to improve incident reporting.- Posted
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Content ArticleIn advance of the second annual World Patient Safety Day on 17 September 2020, the theme of which is Health Worker Safety: A Priority for Patient Safety’, this blog from Patient Safety Learning looks at how staff safety relates to patient safety.
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Content ArticleThe COVID-19 pandemic has had an unprecedented impact on the delivery of healthcare services around the globe. This has resulted in important loss of life for our communities, including health professionals that have been exposed to the disease in their workplace. A human factors approach to the recent changes introduced due to the pandemic can help identify how we can minimise the impact of human error in these circumstances. Tejos et al., in Aesthetic Plastic Surgery, present a case study illustrating the application of human factors in the difficult times we are going through at present.
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Content ArticleThis study from Sanko et al., published in Simulation in Healthcare, found that improvements in systems thinking increase adverse event (AE) reporting patterns among undergraduate nursing students participating in a simulation exercise. The authors suggest that prelicensure training include reinforcement of systems thinking principles to achieve patient safety improvements.
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Content ArticleThis book explores patient safety themes in developed, developing and transitioning countries. A foundation premise is the concept of ‘reverse innovation’ as mutual learning from the chapters challenges traditional assumptions about the construction and location of knowledge. hub members can receive a 20% discount. Please email: feedback@pslhub.org to request the discount code.
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Content ArticleThis table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment.
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Content ArticleClinical decisions rarely occur in isolation. We must consider the social contexts in clinical environments and draw on theories of social emotion to help us better understand the influence of others’ emotion on our own thoughts, feelings and, ultimately, our ability to deliver safe care. In their Editorial in BMJ Quality & Safety, Jane Heyhoe and Rebecca Lawton explorie the role of social emotion in patient safety and looks at the recent research in this emerging area. They call on the patient safety community to embrace the idea that emotions and emotional contexts exert important impacts on healthcare delivery. Characterising these impacts will inform strategies for supporting staff and delivering safer and more effective care to patients.
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Content ArticleUser-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension, but no study has investigated whether this results in safer care. Jones et al. compared the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing.
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Content ArticleThis is a true story of ordinary people showing extraordinary determination and courage in the face of adversity. It is an unconventional, honest and deeply personal attempt to bring what has been hidden into the light for all to see. Alison was a vulnerable mentally ill patient taken advantage of by an older male nurse. She became pregnant and a crisis abortion was arranged by staff at the mental health hospital. Alison took her life on what would have been her child's third birthday. Though the names are known, no one has ever been held accountable for the crimes committed against her. Alison and her family have been lied to and failed by the NHS, the Police and Crown Prosecution Service. While this book pays tribute to the many leaderless heroes on the frontline of health services, it is scathing about the lack of honesty and integrity in their leaders and managers. This is a story of the abuse of power, the hiding of wrongdoing, and a quest for truth, accountability and justice that is not yet over.
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Content ArticleAdverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. The authors of this paper, published in BMJ Quality & Safety, performed a systematic review of the literature on in-hospital adverse events.
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Content ArticleThis report examines the key factors at work in organisational failure and learning, a range of practical experience from other sectors and the present state of learning mechanisms in the NHS before drawing conclusions and making recommendations. It's recommendations include the creation of a new national system for reporting and analysing adverse health care events, to make sure that key lessons are identified and learned, along with other measures to support work at local level to analyse events and learn the lessons when things go wrong.
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Content ArticleThe findings in this report followed a 14-year inquiry into hyponatraemia-related deaths in five children in Northern Ireland. The inquiry was set up in 2004 to investigate the deaths of Adam Strain, Claire Roberts, Raychel Ferguson, Lucy Crawford and Conor Mitchell. The chairman said that the deaths of Adam Strain, Claire Roberts and Raychel Ferguson were the result of "negligent care".
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Content ArticleAn ideal surveillance system for medical device safety would comprehensively collect data on adverse events across the life span of a device, discusses Salazar and Redberg in an Editorial in JAMA Internal Medicine. They suggest that the system should be integrated into electronic health records to allow seamless identification, tracking, and real-time reporting of device-associated adverse events. It would be able to take adverse events and detect substantial safety signals and underperforming devices. Such a system would also allow implementation of corrective actions quickly.
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Content ArticleHelen Marie Bousquet tragically passed away after what has been described by her son as 'a basic routine procedure' for knee surgery. He argues that her tragic and avoidable death highlights the need for better assessment of patients for sleep apnea and for better treatment and monitoring of these patients before, during and after surgery. The recent jury finding that a hospital nurse was negligent in the care of Helen Marie Bousquet raises the question whether negligence can result in safer patient care. In his blog, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), looks at this case and the lessons that can be learned.
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Content Article
NHS Complaints Advocacy
Patient Safety Learning posted an article in Complaints
NHS complaints advocacy service can help you if you, or someone you know, has not had the care or treatment you expect to receive from your NHS services and you want to complain. Advocacy is there to help you understand and go through the complaints process. Advocates will support you until you receive a satisfactory conclusion or until you no longer want advocacy support. -
Content ArticleThe Care Quality Commission (CQC)’s annual report on Ionising Radiation (Medical Exposure) Regulations in England has been published. The report gives a breakdown of the number and type of statutory notifications of errors received from healthcare providers in 2018/19 where patients were exposed to ionising radiation. These notifications are where there have been significant accidental or unintended exposures, for example where a patient received a higher dose than intended or where the wrong patient was exposed.
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Content ArticleThe results of the 2019 ‘Patient safety culture survey’ of 917 pharmacy professionals, carried out by the Community Pharmacy Patient Safety Group (PSG) in April and May 2019 came after the introduction of a legal defence for dispensing errors in 2018. The survey results found only 14% of pharmacy professionals are worried about criminal prosecution when reporting a patient safety incident, compared with 40% in 2016. The survey also showed that 22% of pharmacy professionals would not report a patient safety incident inside their organisation owing to fears of criminal prosecution. This is compared with 40% of 623 respondents saying in 2016 that they would not report a patient safety incident because of the possibility of criminal prosecution.
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Content ArticleJo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders. This blog is a continuation of that presentation.
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Content ArticleThe nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. I recommend that all those involved in 'engagement with harmed patients and families' read this and in particular, commit to making sure they are doing the '20 things organisations can do now' that is listed in table 3. This paper was published in the Joint Commission Journal on Quality and Patient Safety. Register for free to view the full article.
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Content ArticleMy previous blog talked about how the idea for SISOS (Safety Incident Supporting Our Staff) – an initiative to support staff involved in safety incidents – came about at Chase Farm Hospital. The SISOS team provide confidential, emotional support in a safe environment and make other support, including professional help more easily accessible. It is important to recognise that we are 'Listeners' and not professional counsellors. My second blog continues this journey.
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Content ArticleIn his article for KevinMD.com, Ashish Jha looks at the metrics associated with hospital acquired conditions (HACs) in the US. He discusses the imperfections of HAC scored and argues that we need better measures in order to make further progress in the field of patient safety.
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Content ArticlePublished by wbur, an American news station, this account from a doctor tells the story of his father's admission to hospital. Dr. Ashish Jha lists a catalogue of errors that took place over those few days, notes how common these mistakes are and argues we should be less tolerant of poor patient safety in healthcare.
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Content ArticleIn the past decade, hospitals and healthcare workers have become more familiar with medical errors and the harm they can cause. As a result, incident investigation has become a routine part of the hospital's response to an adverse event. Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment. There has also been increased attention paid to the appropriate handling of patients and families harmed by medical errors. There is developing recognition that disclosure of adverse events is necessary if hospitals are to learn from mistakes and improve patient safety outcomes. A growing number of accrediting and licensing bodies, as well as governmental entities and professional organisations, have stated the expectation that patients should be told about harmful medical errors. However, progress has been slower in translating policy into action at the level of the frontline clinician. Are these policies also beneficial to physicians and other healthcare workers, many of whom are already struggling just to get their work done? Wu and Steckelberg discuss this further in an Editorial published in BMJ Quality and Safety.
