Search the hub
Showing results for tags 'Patient safety incident'.
Found 684 results
-
Content ArticleA key benefit of the new Learn from Patient Safety Events (LFPSE) service is its introduction of machine learning to hugely enhance the NHS’s capabilities for processing and analysing records of patient safety events. This podcast discusses how we plan to introduce machine learning in LFPSE, how this will support the NHS to improve patient safety, what changes staff will see as a result, our longer-term ambitions, and how providers can get involved in shaping this exciting new revolution in patient safety learning.
-
Content ArticleThis study aimed to operationalise and use the World Health Organization's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths.
-
Content ArticleThis study in PLOS ONE assessed the frequency of adverse event reporting in Ghanaian hospitals, the patient safety culture determinants of the adverse event reporting and the implications for Ghanaian healthcare facilities. The authors found that the majority of health professionals had at least reported adverse events in the past 12 months across all 13 healthcare facilities studied. The patient safety culture dimensions were statistically significant in distinguishing between participants who frequently reported adverse events and otherwise.
-
Content ArticleThe Royal United Hospital Bath NHS Trust project tested different ways to communicate with staff about patient safety, to encourage the reporting of incidents and to promote a learning culture.
-
Content ArticleLearn from Patient Safety Events (LFPSE) presentation from Southern Health NHS Foundation Trust.
-
Content ArticleIn the first in a series of blogs looking at the range of investigation methods used by HSIB, Nichola Crust reflects on how Appreciative Inquiry can be used to examine patient safety and identify opportunities for learning.
-
News Article
Error causes 800 patients to be wrongly removed from waiting list
Patient Safety Learning posted a news article in News
A trust is carrying out a review after hundreds of patients were wrongly removed from the waiting list and potentially missed out on treatment. York and Scarborough Teaching Hospitals Foundation Trust told HSJ that roughly 800 patients of its referral to treatment waiting list, were affected. A serious incident was declared after it emerged some patients “had their referral to treat clocks stopped erroneously, resulting in patients not receiving treatment”, according to a report to the trust board. The trust said reviews were under way but had not yet identified any cases of “moderate or significant clinical harm”, although it admitted some patients had been significantly delayed. Read full story (paywalled) Source: HSJ, 2 June 2023 -
News ArticleWomen are waiting too long for abortions, according to a major review into a leading UK provider. The Care Quality Commission (CQC) review of the leadership at the abortion provider the British Pregnancy Advisory Service found there were “delays” in “investigating incidents”. The remains of some pregnancies were sometimes not stored properly and there were issues were record keeping, patient monitoring and safe care, the review found. The watchdog also noted “women did not always receive care in a timely way to meet their needs”. The health watchdog said: “In August 2021 we found significant concerns in we found that safe care was not being provided; ineffective safeguarding processes; incomplete risk assessments were not fully completed; observations were not monitored or recorded; records were not fully completed, clear or up to date.” Read full story Source: The Independent, 2 June 2023
-
News Article
Metropolitan Police: Move to attend fewer mental health calls sparks alarm
Patient Safety Learning posted a news article in News
The Met Police's plan to stop attending emergency mental health incidents is "potentially alarming", a former inspector of constabulary has said. From September, officers will only attend mental health 999 calls where there is an "immediate threat to life". The Met argues the move will free up officers after a significant rise in the number of mental health incidents being dealt with by the force in the past five years. Metropolitan Police Commissioner Sir Mark Rowley wrote to health and social care services in Greater London to inform them of the plan last week. In the letter, which has been seen by the BBC, Sir Mark said it takes almost 23 hours on average from the point at which someone is detained under the Mental Health Act until they are handed into medical care. He writes that his officers are spending more than 10,000 hours a month on "what is principally a health matter", adding that police and other social services are "collectively failing patients" by not ensuring they receive appropriate help, as well as failing Londoners more generally because of the effect on police resources. However Zoe Billingham, who is now chair of the Norfolk and Suffolk NHS mental health trust after 12 years as Her Majesty's Inspector of Constabulary and Fire and Rescue, warned mental health services are "creaking" and "in some places are so subdued with demand they are not able to meet the requirements of people who need it most". Speaking to BBC Radio 4's Today programme, she warned there is "simply no other agency to call" other than the police for people in crisis, adding: "There isn't another agency to step in and fill the vacuum." Read full story Source: BBC News, 29 May 2023 -
Content ArticleThis study in the Journal of Patient Safety and Risk Management aimed to assess the patient safety situation in Ghana across the World Health Organization's (WHO’s) 12 action areas of patient safety. The authors used interviews and observation including a WHO adapted questionnaire across 16 selected hospitals, including two teaching hospitals selected from the northern and southern parts of the Ghana. The key strength identified in the patient safety situational analysis was knowledge and learning in patient safety, while patient safety surveillance was the weakest action area identified. There were also weaknesses in areas such as national patient policy, healthcare associated infections, surgical safety, patient safety partnerships and patient safety funding.
-
Content ArticleStandardised data and integration of systems are vital for full traceability, improving patient safety, and enabling swift action in healthcare incidents. The PIP breast implant scandal was not the first and transvaginal mesh will not be the last. In fact, the next national patient safety scandal is likely manifesting today. “There needs to be better processes to ‘track and trace’ patients who have received a device when a problem arises,” says Professor Sir Terence Stephenson, Nuffield professor of child health at UCL Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England, in the Scan4Safety 2020 report. “Clear strategies and channels are needed to inform patients, the public and clinical professionals to help improve safety.” One common denominator among such incidents is the lack of traceability – limited visibility of the devices used, when and where they are used and, most importantly, in or on which patients. This is where standardised data comes into play. There is no shortage of data in the NHS. However, the ability to standardise and share that data between systems and organisations is something the health service as a whole still lacks. Today, achieving full traceability remains a key challenge for the NHS, with repercussions that continue to have a detrimental effect on patient care.
-
Content Article
The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
Content ArticleEnsuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult.
-
Content ArticleThis mixed-methods study in the Journal of Multidisciplinary Healthcare examined how health staff in Indonesian hospitals perceived open disclosure of patient safety incidents (PSIs). The authors surveyed 262 health workers and interviewed 12 health workers. In the quantitative phase they found a good level of open disclosure practice, a positive attitude toward open disclosure and good disclosure according to the level of harm. However, in the qualitative phase they found that most participants were confused about the difference between incident reporting and incident disclosure. The authors concluded that a robust open disclosure system in hospitals could address several issues such as lack of knowledge, lack of policy support, lack of training and lack of policy. They also suggest that the government should develop supportive policies at the national level and organise initiatives at the hospital level in order to limit the negative implications of disclosing situations.
-
Content ArticleThe implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals.
-
Content Article
NHS Patient Safety Syllabus v. 2.1 (June 2022)
Patient Safety Learning posted an article in Training & education
The Academy of Medical Royal Colleges and the University of Warwick have developed this NHS Patient Safety syllabus to complement it as the basis for education and training for staff throughout the NHS. -
Content ArticleThe Patient Safety Authority (PSA) is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires acute care facilities to report all incidents of harm (serious events) or potential for harm (incidents). Long-term care facilities report infections into the Pennsylvania Patient Safety Reporting System (PA-PSRS). The PSA analyses those reports to prevent recurrence—either by identifying trends unapparent to a single facility or flagging a single event that has a high likelihood of recurrence— and disseminates that information through multiple channels. Here is the PSA's 2022 Annual Report.
-
Content ArticleJudy Walker summarises four tools that can be used for the Patient Safety Incident Response Framework (PSIRF), explaining what they are and the strengths and weaknesses of each: SWARM Huddle MDT Review After Action Review Patient Safety Incident Investigation (PSII).
-
News Article
Update on LFPSE implementation deadline
Patient Safety Learning posted a news article in News
In an email to staff today (9 May 2023) NHS England (NHSE) have confirmed that to meet the deadline for implementing the new Learn From Patient Safety Events (LFPSE) service, Trusts will only need to ensure this is underway by the 30 September 2023, rather than fully implemented. LFPSE is a new central national service for recording and analysing patient safety events that occur in healthcare. Some NHS organisations are now using this system, instead of the National Reporting and Learning System (NRLS), and all organisations will be expected to transition to this. The original date for Trusts to implement LFPSE was the 31 March 2023. However, in response to concerns about the achievability of this deadline, on the 18 October NHSE announced an optional six-month extension, meaning that Trusts needed to deploy the new system by the 30 September 2023. Today’s email to NHS staff noted that some Trusts “are still anticipating challenges with the time scales”. Responding to this, NHSE clarified that provided the LFPSE transition within organisations Local Risk Management Systems was underway by the end of September, and that application of the guidance to configure formals and fields was being actively worked on, this milestone should be considered as having been met. Commenting on this Helen Hughes, Chief Executive of charity Patient Safety Learning, said: “This is a welcome announcement by NHS England, reducing the immediate pressure on staff who had raised serious concerns on the ability to have LFPSE configured and ready to submit events by the 30 September deadline. This flexibility will ensure that the new LFPSE service has a stronger chance of successful transition and to enable patient safety improvement”. -
Content ArticleCare home residents are particularly vulnerable to patient safety incidents, due to higher likelihood of frailty, multimorbidity and cognitive decline. However, despite residents and their carers wanting to be involved in safety initiatives, there are few mechanisms for them to contribute and make meaningful safety improvements to practice. This study aimed to develop a measure of contributory factors to safety incidents in care homes to be completed by residents and/or their unpaid carers.
-
Content ArticleThe Primary Care Patient Measure of Safety (PC PMOS) is designed to capture patient feedback about the contributing factors to patient safety incidents in primary care. It required further reliability and validity testing to produce a robust tool intended to improve safety in practice. This study led to a reliable and valid 28-item PC PMOS that could enhance or complement current data collection methods used in primary care to identify and prevent error.
-
EventuntilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Transition webinars focus on the different phases of the PSIRF preparation guide and feature presentations from NHS organisations currently transitioning to PSIRF. Transition webinars are open to everyone to attend, including both NHS and arms length bodies Presenters: Nicky Ore – Deputy Director of Patient Safety, Mersey Care NHS Foundation Trust Jo Rowan – PSIRF Project Manager, Mersey Care NHS Foundation Trust Kim Bennett – PSIRF Clinical Project Manager, Mersey Care NHS Foundation Trust Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England Register
-
Content ArticleThe Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare, supporting the NHS to improve learning from the 2.5 million+ patient safety events recorded each year. All healthcare staff are encouraged to record patient safety events to support national and local improvement to make care safer for patients. This short video from NHS England introduces LFPSE.
-
News ArticleFresh concerns have been raised about the launch of the national incident reporting system, despite Steve Barclay taking a ‘personal interest’ in hitting the tight timetable, HSJ has learned. NHS England already delayed the launch of the “learning from patient safety events” database by six months, to September this year. It is due to replace the existing national reporting and learning system (NRLS) which is considered to be outdated and at risk of failing. But serious concerns are now being raised again by trust safety managers about whether the revised launch date can be met, HSJ has been told, with calls for it to be extended again until next year. HSJ has heard concerns from several managers that an upgrade due in July to the RLDatix risk management system – which is used by the majority of trusts – will cause knock-on problems implementing LFPSE in September. They said the timeframe was too short for testing and delivering the upgrade in time to make the transition and decommission the old NRLS. The creation of LFPSE is a key part of NHSE’s safety strategy, along with replacing the serious incident reporting system, with an aim of making it easier for staff to record safety events across all services, including primary care, which is excluded from NRLS. Read full story (paywalled) Source: HSJ, 3 May 2023
-
Content ArticleThe Dutch Hospital Patient Safety Program started in 2008. It initially ran for five years, and its aim was to decrease adverse events by 50% in all Dutch hospitals. A second National Safety Program launched in 2020. This focuses on reflection, interprofessional collaboration and explaining process variation in daily practice. It also looks to foster more patient involvement and shared decision making. The ultimate aim is to reach a significant reduction in preventable patient harm. This webinar provides an overview of patient safety in the Netherlands and discusses these two initiatives and their implementation, outcomes and ongoing impact.
