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Showing results for tags 'Patient safety incident'.
Found 684 results
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Content Article
WHO: 10 facts on patient safety (September 2019)
Patient Safety Learning posted an article in WHO
Patient safety is a serious global public health concern. It is estimated that there is a 1 in 3 million risk of dying while travelling by aeroplane. In comparison, the risk of patient death occurring due to a preventable medical accident, while receiving health care, is estimated to be 1 in 300. Industries with a perceived higher risk, such as the aviation and nuclear industries, have a much better safety record than health care does. The World Health Organization (WHO) has produced a Patient Safety Fact File. -
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) became operational on 1 April 2017. Their purpose is to improve safety through effective and independent investigations that don't apportion blame or liability. Although funded by the Department of Health & Social Care and hosted by NHS England and NHS Improvement, HSIB operates independently. It is also independent from regulatory bodies like the Care Quality Commission (CQC). By offering a new perspective and developing meaningful and influential recommendations, they aim to drive positive change at a wider level.
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Patient Stories: Beth's story (27 December 2013)
Claire Cox posted an article in Patient stories
A moving and challenging short film about the Bowen family following the tragic death of five year old Bethany during ‘routine’ surgery and subsequent sudden death of father Richard aged 31, following the trauma of his daughter’s death and the ‘torture’ of the inquest. -
Content ArticleThere is a growing body of evidence to demonstrate that health professionals feel emotionally distressed after a patient safety incident and there is an emerging recognition of the potential negative impact on both the health professionals’ health and on patient safety. The Canadian Institute for Patient Safety partnered with the Mental Health Commission of Canada to develop a new toolkit for peer-to-peer support programmes in healthcare. It includes tools, resources and templates from organisations across the globe who have successfully implemented their own peer support programmes for healthcare providers, and is intended for policy makers and regulators, administrators, managers, healthcare teams and peer supporters.
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Content ArticleToolkit to improve safety in ambulatory surgery centres helps ambulatory surgery centres in the US make care safer for their patients. Ambulatory surgery centres can use the toolkit to help prevent surgical site infections and other complications and improve safety culture in their facilities.
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Content ArticleNational bodies can provide systems and policies for the NHS, but safety is improved at the point of care. Lauren Mosley, Head of Patient Safety Implementation, and Donna Forsyth, Head of Investigation, describe the new Patient Safety Incident Response Framework (PSIRF).
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Content ArticleThis action plan was produced by the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group following a treatment delay for a patient in intensive care.
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NHS Resolution: Annual report and accounts 2020/21
Patient Safety Learning posted an article in NHS Resolution
This performance summary provides an overview of the work of NHS Resolution, including their purpose, key risks to achieving their objectives and a summary of activities they have undertaken over the past year. It sets out the activity to meet the four strategic aims outlined in their business plan for 2020/21. -
Content ArticleThis Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.
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Content ArticleA ‘critical incident' is one that challenges your own assumptions or makes you think differently’. They provide the following helpful prompts to guide reflection on critical incidents. Here is a simple example of critical incident reflection produced by Birmingham City University.
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Content ArticleSerious Incidents in health care are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. This Framework, set out by NHS England, describes the circumstances in which such a response may be required and the process and procedures for achieving it, to ensure that Serious Incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.
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Content ArticleOn 20 March 2018 NHS Improvement launched an engagement programme to seek views from a wide range of stakeholders about how and when patient safety incidents should be investigated. Often those affected by incidents are not appropriately supported or involved in the investigation process; the quality of investigation reports is generally poor; and improvements to prevent the recurrence of harm are not effectively implemented. To obtain views on the problems with the current approach to the investigation of Serious Incidents, the issues driving these problems, and how such issues might be resolved, NHSI ran an online survey, national workshops and a live twitter chat, and held discussions with many individuals including patients, families, NHS staff, regulators and others. This document summarises the feedback received.
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Content ArticleNHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
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Content ArticleWritten by the safety team at Morecambe Bay Hospital NHS Trust. Introducing staff to the team, their governance hub, a new support system for staff involved in an investigation and what happens in an inquest by the legal team.
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Content ArticlePresentation from the BMJ/IHI 2012 conference in Paris.
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Content ArticleBoth national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
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Content ArticleRolling data updated monthly, to show the number of patient safety incidents reported to the National Reporting and Learning System (NRLS) in the last 12 months.
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Content ArticleSome of the serious findings of external reviews of NHS services from recent years, previously unpublished, have been released to HSJ. An HSJ investigation has found the NHS has kept secret dozens of external reviews into care failings in local services including: A hospital where surgery may have “shortened life expectancy”. An alleged “cartel” of private patients said to be put on NHS lists. “Very high risk” consultant on-call arrangements. Problems with fetal heart monitoring in a maternity service. Potentially unnecessary operations being carried out. Rows among doctors putting patients at risk. Read their full report below.
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Content ArticleNewly qualified nurses often fear making or identifying a clinical error so it is vital to know how best to prevent errors and manage them when they have occurred. This Nursing Times article looks at the most common clinical errors that are made, explains where to find the policies and procedures that should be followed, and highlights tips and tools that can be used to help rectify the issue or prevent it from happening in the first place.
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Content ArticleThe Chartered Institute of Ergonomics & Human Factors has issued today their White Paper on Adverse Events. This report states what good practice should be in incident investigation across all industries, including health and social care. The White Paper is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. How organisations learn, and fail to learn, from adverse events is discussed.
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Podcast: Incident reporting
PatientSafetyLearning Team posted an article in Good practice
Richard Smith is a trained paramedic who now works as Head of Quality and Safety at Addenbrooks Hospital. In this interview with East England Ambulance Service General Broadcast, Richard talks about his recent paper on incident reporting in the ambulance service. He asks if we have a blame and fear-free culture when concerns are raised, the value of feedback and highlights the importance of reporting the positive incidents too. -
Content ArticleNEBOSH and Great Britain’s Health and Safety Regulator, the Health and Safety Executive (HSE), have jointly developed a new one day qualification that shows how non-complex incidents can be investigated effectively. By learning lessons and making improvements, organisations can avoid similar incidents occurring in the future.
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Content ArticleOur NHS staff are doing fantastic work to tackle the COVID-19 pandemic and keep essential services going – their hard work and dedication during this difficult time is remarkable. As the NHS Chief Executive Sir Simon Stevens made clear in his letter of 29 April 2020 to NHS chief executives, it is important to remind everyone of the duty – and right – of those who work in the NHS to speak up about anything which gets in the way of patient care and worker wellbeing. Hear what Prerana Issar, the first NHS Chief People Officer, has to say in her blog. See also our hub resources on Whistleblowing and Speak Up Guardians.
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The Ombudsman’s Casework Report 2019 (3 March 2020)
Patient Safety Learning 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, UK government departments and other UK public organisations. The PHSO look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. The PHSO looks into complaints fairly, and the service is free for everyone. This first annual Ombudsman’s Casework Report highlights the breadth of cases received across PHSO's jurisdictions. It is only a small cross-section of the cases completed in 2019. The complaints presented here are typical of many of the complaints seen across PHSO's remit. They include complaints about government bodies and the NHS. -
Content ArticleJoanna is a Partner in the law firm Bevan Brittan LLP. In our interview, Joanna talks about her role supporting healthcare staff through the legal and investigatory processes that follow an adverse event, and why we must do all we can to maximise the opportunity to learn when things go wrong in healthcare.
