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Showing results for tags 'Patient safety incident'.
Found 683 results
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Content ArticleThis alert describes the procedure which must be taken within Alberta Health Services (AHS) when a clinical adverse event (CAE) occurs.
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Content ArticleThe aim of this systematic review from Lawton et al., published in BMJ Quality & Safety, was to develop a ‘contributory factors framework’ from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings.
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Content ArticlePatient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring.
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Content ArticleTo ensure consistency and effectiveness of responses to health information under threat, Alberta Health has instituted the Provincial Reportable Incident Response Process (PRIRP) for all health stakeholders managing or accessing Alberta’s provincial Electronic Health Record (EHR), including its subsystems and repositories. This process covers incidents of data confidentiality, data integrity, and data availability and is divided into five phases. PRIRP is applicable to all health stakeholders managing, accessing, or regulating Alberta’s EHR, including its subsystems and repositories. • Health stakeholders use PRIRP to report a suspected or known security incident to Alberta Health. Alberta Health will assess the threat from the incident, and if valid will assemble an Incident Response Team (IRT). The IRT will be led by the Alberta Health Security team and include the reporting health stakeholder(s) and other applicable resources for any particular incident. The IRT will communicate as needed with other stakeholders impacted by the incident.
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Content ArticleEast Kent Hospitals University NHS Foundation Trust is delighted to have been the recipients of the Patient Safety Learning Award 2019 for ‘Professionalising Patient Safety’ for our FallStop programme.
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Content Article
Clinician Support: Five Years of Lessons Learned
Patient Safety Learning posted an article in Second victim
The University of Missouri Health Care (MUHC), an academic healthcare system located in Columbia, Missouri, USA, deployed an evidence-based emotional support structure for second victims based on research with recovering second victims. MUHC is a six-hospital healthcare system with 52 ambulatory clinics and approximately 6,500 employees. The second victim support structure, known as the forYOU Team, was designed to increase awareness of the second victim phenomenon, “normalise” the psychological and physical impacts, provide real-time surveillance for possible second victims within clinical settings, and render immediate peer-to-peer emotional support when a potential second victim is identified. This article published in Patient Safety & Quality analyses the success of the programme. -
Content ArticleThis systematic review from Willis et al., published in BMJ Leader, set out to understand what leaders and organisational cultures can learn about supporting doctors who experience second victim phenomenon; the types, levels and availability of support offered; and the psychological symptoms experienced.
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Content ArticleSuicide rates for doctors, nurses and allied healthcare workers are rising and being involved in a safety incident increases this risk. The need to support staff when things go wrong is evident. We come to work to do the very best we can for our patients, often ignoring and at the cost of our own health. Most adverse incidents happen, not because we are bad at what we do, but because of system failure. As professionals who care passionately about our work, we blame ourselves when things go wrong. Albert Wu (2000) recognised this phenomenon and coined the term second victim. In this series of blogs I will share my own experiences of setting up and developing Safety Incident Supporting Our Staff (SISOS). In this first blog I explain the catalyst that led to developing SISOS.
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Content ArticleIn our Blueprint for Action, we outline some of the concerns around the quality of investigations.
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Content ArticleA workbook published by Health and Safety Executive (HSE), for employers, unions, safety representatives and safety professionals.
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Content ArticleA report from the Public Administration Select Committee looking at the investigation process, how it impacts those involved and how risk can be reduced through learning.
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Content ArticleThe purpose of the International Classification for Patient Safety (ICPS) is to enable categorisation of patient safety information using standardized sets of concepts with agreed definitions, preferred terms and the relationships between them being based on an explicit domain ontology (e.g., patient safety). The ICPS is designed to be a genuine convergence of international perceptions of the main issues related to patient safety and to facilitate the description, comparison, measurement, monitoring, analysis and interpretation of information to improve patient care. Download visual representation of the framework
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Content ArticleDr Helen Higham, Co-Director of the Patient Safety Academy, presented at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference on how we can effectively learn from serious incidents.
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Content ArticleHelen Jones, National Investigator at Healthcare Safety Investigation Branch (HSIB), presented at the recent Patient Safety Strategy Discussion Forum. Helen's presentation focused on how the Patient Safety Incident Response Framework (PSIRF) will run alongside the investigation expertise at HSIB and the implications of the proposed changes set out in the Health Service Safety Investigations Bill. She shared the recommendations that HSIB have made and the delegates discussed the accountability framework for their implementation as this is outside of HSIB’s current remit.
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Content Article
What is a second victim?
PatientSafetyLearning Team posted an article in Second victim
Second Victim Support looks at the definition of a 'second victim', how they are impacted personally and professionally and what can be done to support them. Second victims are healthcare providers who are involved in an unanticipated adverse patient event, a medical error and/or a patient related injury and become victimised in the sense that the provider is traumatised by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base. (Scott et al, 2009) -
Content ArticlePublished in BMJ Quality and Safety The term ‘second victim’ refers to the healthcare professional who experiences emotional distress following an adverse event. This distress has been shown to be similar to that of the patient, the ‘first victim’. The aim of this study was to investigate how healthcare professionals are affected by their involvement in adverse events with emphasis on the organisational support they need and how well the organisation meets those needs.
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Content ArticleObjective: To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors. Originally published in Health Services Research.
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Content ArticleThis Care Quality Commission (CQC) briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review. The briefing provides a summary of the findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
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Content ArticlePractice staff should use the GP e-form to report all patient safety incidents and near misses whether they result in harm or not. These reports are used by to spot any emerging patterns of similar incidents or anything of particular concern. This will help protect patients by raising awareness of the risks through shared learning with general practices and other health providers across the country.
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Content ArticleAnalysis of the patient safety incidents reported in England to the National Reporting and Learning System (NRLS) up to June 2019.
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Content ArticlePublished in Systematic Reviews, this paper looks at how organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting.
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Content ArticleIn this interview with Nick Robinson from the BBC, Jeremy Hunt (then Foreign Secretary) speaks passionately about patient safety and the statistics surrounding avoidable patient deaths. Listen from 9:30 for this section. They veer away from the topic but return to it at 12:20 where he speaks about the importance of learning from mistakes in healthcare.
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PHSO: How we deal with complaints
Claire Cox posted an article in Complaints
The Parliamentary and Health Service Ombudsman (PHSO) make final decisions on complaints that have not been resolved by the NHS in England and UK government departments and other UK public organisations. Not all complaints that come to the PHSO go through their whole process. The PHSO have a three-step process for dealing with complaints. This webpage outlines what happens when they receive a complaint, how they decide if they can investigate it and what to expect if they do. -
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MHSC Patient Safety: Preventing serious incidents
Claire Cox posted an article in Patient safety in health and care
Manchester NHS asked Rogue Robot to create a film showing how, by getting the basics right, serious incidents can be prevented from occurring. The film uses the 'Swiss Cheese' risk analysis model. -
Content Article
What is NHS Resolution?
Claire Cox posted an article in NHS Resolution
Healthcare provision in the NHS is very safe but, on rare occasions when things go wrong, it is important that those involved are properly informed and supported, compensation is paid fairly, unnecessary costs are contained and that we learn in order to improve.
