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Showing results for tags 'Patient safety incident'.
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Content ArticleThis is part 5 of a series of blogs about human factors and investigations in healthcare. The theme is ‘when’ and that covers ‘when’ to investigate and ‘when’ to try any remedies or interventions your investigation data suggests might prevent the incident occurring again. As this blog can be explained by a photo and a graph, we have some time to recap the story so far and, perhaps, predict a bit of the future.
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Content Article
Marking your own homework
Anonymous posted an article in Florence in the Machine
Having read the recent blog on the hub, ‘Silent witness’, this nurse too was compelled to share with us her frustrations on the current hospital reporting system.- Posted
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Content ArticlePatient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
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Content ArticleIncident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study, published in the International Journal of Health Care Quality Assurance, explores if intelligence from such datasets could be used to improve quality, efficiency, and safety. Results indicate that healthcare incident reporting data is underused and, with a small amount of analysis, can provide real insight and application to patient safety.
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Content ArticleThe objective of this study, published in Health Services Research, was to determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.
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Content ArticleIn this BMJ Opinion article, David Rowland from the Centre for Health and the Public Interest discusses why he thinks the Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model. David believes that although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. Yet these concerns about how the private hospital system works and the associated patient risks it produces had been established in a number of previous inquiries. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies.
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Content ArticleMedication errors may cause harm, including death, and increase use of health care services. This project aims to summarise the evidence on the burden of medication error, namely the number of errors occurring in the NHS in England, the costs of those errors to the NHS and the health losses due to medication error. This involves two systematic reviews, one on the incidence and prevalence of medication errors, and the other on the costs of health burden associated with errors. Additionally, economic modelling estimates the number of errors occurring in the NHS in England each year, their costs and health consequences.
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Silent witness – My experience when filing an incident report
Anonymous posted an article in Florence in the Machine
A newly qualified nurse describes what happened when she reported her first Datix for a serious incident.- Posted
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Content ArticleResponding to the Paterson Inquiry, Ian Kennedy, Emeritus Professor of Health Law and Policy at University College London, discusses the systemic weaknesses in the NHS.
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Content ArticlePresentation from Joanna Lloyd, Bevan Brittan, on incident investigations.
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Content ArticleThe Parliamentary Under-Secretary of State for Health and Social Care, Ms Nadine Dorries, responds to the Paterson Inquiry in the House of Commons. It is followed by questions from MPs in the chamber and Ms Dorries' responses.
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Content ArticleThe Committee of Inquiry was set up in 1967 by the Welsh Hospital Board at the request of the Minister of Health, to investigate allegations of ill-treatment of patients and of pilfering by staff which had been made by a nursing assistant employed at the hospital. The Committee was also asked to make their own examination of the situation in the hospital at the time of their inquiry.
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
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Content ArticleSir Liam Donaldson's presentation slide at the High Level Forum, Africa Patient Safety Initiative, Cape Town, South Africa 24- 25 October 2019.
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Content ArticleOn this General Broadcast episode, Patient safety Integration Lead Jordan talks with Andy Collen. Andy is a paramedic who has completed a huge range of roles, including being the medications and prescribing lead for the College of Paramedics, a national investigator for the Healthcare Safety Investigation Branch and has written a book about decision making in paramedic practice.
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Content ArticleCumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare providers. These factors contribute to inadvertent patient care errors, mental health issues and attrition which compromise patient safety. A peer support programme not only simply helps healthcare workers with their experiences with patient safety incidents but also improves the system and help make patient care safe. The Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers manuscript and the Canadian Peer Support Network are intended to assist healthcare organisations create peer-to-peer support programmes (PSPs) to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients.
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Content ArticleThe Patient Safety Database (PSD), previously called Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. They have begun by developing an open and anonymous incident reporting system focused on non-technical skills. Each quarter they summarise in their newsletter cases reported on the platform. Read the latest newsletter.
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Content ArticleSerious incidents not only have a considerable human impact, but they are also detrimental to NHS reputations and finances. The current Serious Incident Framework (SIF) is a reactive, bureaucratic process, where opportunities to reduce the recurrence of a harmful incidence is often missed. With a ‘Get It Right First Time’ mentality, the new PSIRF framework was road-tested by a number of nationally appointed ‘early adopter’ Trusts and commissioners working to implement it during the course of 2021. Now a wider implementation across the NHS is planned, starting spring 2022, with guidance informed by the early adopter pilots. This blog was written by Sian Williams, NHS Team Lead & Managing Consultant, and Paul Binyon, who in a recent assignment has worked with an NHS Trust contributing to an early adopter PSIRF pilot rollout.
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Content ArticleNHS England has published the new Patient Safety Incident Response Framework (PSIRF). Dr Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England, and Aidan Fowler, National Director of Patient Safety and Deputy Chief Medical Office at NHS England/DHSC, discuss the new framework, the preparation behind it, and how they see PSIRF fundamentally changing the NHS’s approach to patient safety incident response, supporting learning, improvement and compassion, to make care safer for our patients.
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Content ArticleOrganisations should uphold the patient safety incident response standards to ensure they meet the minimum expectations of the Patient Safety Incident Response Framework (PSIRF). The standards cover the following aspects of PSIRF: policy, planning and oversight competence and capacity engagement and involvement of those affected by patient safety incidents proportionate responses. This document provides the complete list of patient safety incident response standards, and where relevant refers to specific PSIRF documentation.
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Content ArticleThe NHS Patient Safety Incident Response Framework (PSIRF) promotes a range of system-based approaches for learning from patient safety incidents. These national tools and guides have been developed to incorporate the well-established SEIPS framework (Systems Engineering Initiative for Patient Safety) to help support organisations implementing PSIRF.
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Content ArticleThe NHS Patient Safety Strategy was published in 2019 and describes the Patient Safety Incident Response Framework (PSIRF), a replacement for the NHS Serious Incident Framework. This document is North Bristol NHS Trust's Patient Safety Incident Response Plan (PSIRP). It describes what North Bristol NHS Trust did to prepare for “go live” with PSIRF, as an early adopter organisation, and what comes next
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Content ArticleThis chapter from the 'Textbook of Patient Safety and Clinical Risk Management' reviews the most common adverse events that happen in a psychiatric unit and the safety measures that are needed to decrease the risk of errors and adverse events. It also highlights the role of staff members and patients in preventing or causing the error.
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Content ArticleAngie Middleton, Patient Safety Lead for Mental Health (London Region), presents on the Mental Health Suicide Report and discusses London's incident reporting. She highlights that we need to understand whether the extent to which the increase in reported incidents is as a result of more consistent reporting, or an actual increase in actual incidents or as a result of an increase in the number of patients accessing secondary mental health services. She asks whether there is a way of collectively getting timely, consistent and accurate data for multiagency use, and how we can collectively reduce suicides by 10% by 2020/21.
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Healthcare Safety Investigation Branch Annual Review 2019/20
Sam posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) has published their third annual review. During 2019/20: 109 patient safety referrals received. 515 maternity investigation reports completed. 15 national investigation reports published. 58 national safety recommendations made. 88% of families engaging with the maternity investigations and 87% with the national investigations. Family information available in over 20 languages to ensure greater inclusivity. Keith Conradi, Chief Investigator, said: “There has been a huge amount of hard work from everyone within the HSIB during this period and I want to thank them and acknowledge the support of our stakeholders in the wider healthcare sector, and in particular to all the organisations who responded promptly to our safety recommendations.”
