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Showing results for tags 'Patient safety incident'.
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Content ArticleThese tools and worksheets have been produced by NHS England to assist staff in conducting patient safety incident investigations. NHS England stresses that patient safety investigation is an important and complex task and should only be undertaken by those who have attended training and gained skills and experience from specialists in the field.
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Content ArticleThis guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.
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- Duty of Candour
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Content ArticleThis template has been published to guide local PSIRP early adopter organisations in prioritising investigation quality over quantity. NHS providers should follow this template when developing their local patient safety incident response plan.
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Content ArticleThe Serious Incident framework describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again. This framework explains the responsibilities involved when dealing with serious incidents and includes actions staff are required to take, and the tools available. It is designed to inform staff providing and commissioning NHS funded services in England who may be involved in identifying, investigating or managing a serious incident. It is relevant to all NHS-funded care in the primary, community, secondary and tertiary sectors, including private sector organisations providing NHS-funded services. At some point in 2022, the Serious Incident framework will be replaced by the Patient Safety Incident Response Framework
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- Patient safety incident
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Content ArticleThis article, published in the BMJ Quality & Safety, discusses the value of incident reporting systems. Reporting systems, both local and national, are overwhelmed by the volume of reports they receive and fall short in defining recommendations for improving healthcare safety. Focusing incident reporting systems on the local learning process of healthcare providers could mitigate many of the problems that have been attributed to reporting systems.
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- Patient safety incident
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Content ArticleThis new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
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Content ArticlePatient safety is fundamental to the delivery and outcomes of effective health care. But what happens when things go wrong? What can we learn from the data and how does nursing ensure effective incident reporting takes place to protect patients and staff? Chair of Patient Safety Learning and Datix expert Jonathan Hazan joins us to discuss how data is key to patient safety and the importance of a just culture in health care. Nursing Matters is presented by PNC Chair Rachel Hollis and PNC member Alison Leary.
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Content ArticleExternal clinical harm reviews aim to give assurance to patients, patient groups, commissioners and the public as to whether any patients have been harmed as a result of an incident, as well as to avoid future harm to patients. This handbook by Dr Henrietta Hughes, NHS Medical Director for London North, Central and East, outlines an approach to conducting clinical external harm reviews. It identifies the factors which make external clinical harm panels successful and provides example agendas and terms of reference for the process.
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- After action review
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Content ArticleIn this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture.
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- Organisational culture
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Content ArticleBev Curtis, Medical Device Safety Officer (MDSO) at Harrogate & District NHS Foundation Trust, describes the role of the MDSO in this presentation.
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Content ArticleThis paper from Samson et al. discusses the properties of complex systems and a systems approach to incident investigation, describes the differences between reactive and proactive safety approaches and describes some of the system-focused models applied to patient safety incident investigations.
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- Investigation
- System safety
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Content ArticleMedication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. The Pennsylvania Patient Safety Reporting System (PA-PSRS) was queried and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020.
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Content ArticleA trocar is a hollow device used during minimally invasive surgery that serves as an entry port for optical scopes and surgical equipment. Insertion of this device into the body is determined using anatomical landmarks taking into consideration the patient’s history and physical attributes, e.g., scars or abdominal size. Insertion of the first trocar is the time of highest risk of injury. Intestinal and vascular injuries are two potentially life-threatening injuries that can occur. This is a retrospective review of trocar-related events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between 1 January 2014 and 30 June 2020, which identified 268 events.
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Content ArticleIn his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe.
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- Accountability
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Screening incidents: thinking differently
PatientSafetyLearning Team posted an article in Improving patient safety
In this blog, Suzette Woodward, an international expert on patient safety, advises Public Health England on its review of the screening incident guidance, setting out her thoughts on how learning from safety incidents could be strengthened. -
Content ArticleThis first webinar of Global Patient Safety Webinar Series 2021 introducing the “WHO Patient Safety Incident Reporting and Learning Systems: Technical report and guidance” which was released on 17 September 2020 on World Patient Safety Day. The webinar presented an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems. A recording of the webinar is available below.
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- Patient safety incident
- Reporting
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Content ArticleIn this episode of VISION ZERO Podcast, Dr Abdulealah Alhawsawi interviews Susan Sheridan, a family member of two medical error victims and a global patient safety advocate. In this podcast they explore how we can prevent such medical errors and harm from happening again and the importance of patient / family empowerment.
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- Patient engagement
- Patient safety incident
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Content Article
Uppsala Monitoring Centre: VigiBase
Patient Safety Learning posted an article in Adverse interactions
VigiBase is the Uppsala Monitoring Centre (UMC)’s starting-point for the journey from data to wisdom about safer use of medicines and wise therapeutic decisions in clinical practice. It is the driving-force at the heart of the work of UMC and the WHO Programme. The purpose is to ensure that early signs of previously unknown medicines-related safety problems are identified as rapidly as possible. VigiBase is the unique WHO global database of individual case safety reports (ICSRs). It is the largest database of its kind in the world, with over 20 million reports of suspected adverse effects of medicines, submitted, since 1968, by member countries of the WHO Programme for International Drug Monitoring. It is continuously updated with incoming reports.- Posted
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Content ArticleThe MDU’s Michael Devlin argues in this BMJ Opinion article that the never events policy has had a limited effect on patient safety and welcomes a reassessment by the Healthcare Safety Investigation Branch.
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Content ArticlePennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.6 million acute care event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world. This report analyses the serious events and incidents from the database.
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Content ArticleTraditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these two methods might not overlap. This is a retrospective observational study from Anderson et al. of all hospitalisations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event identified by surgery faculty and residents for review by departmental M&M conference or administrative data. The authors analysed the degree to which these two processes captured PSI-defined events and reasons for exclusion by each process. The study found that surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.
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- Quality improvement
- Surgeon
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Content ArticleThis international review from the Health Information and Quality Authority highlights the considerable variation in place across countries in relation to patient safety reporting. It is clear however, that the coordination and triangulation of patient safety intelligence for risk profiling is extremely important. Incidents need to be combined with other quality and patient safety sources of information.
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Content ArticlePreventable adverse events are an ongoing challenge in healthcare. International studies demonstrate that 3%–17% of admissions are associated with an adverse event (defined as an injury caused by healthcare management resulting in prolonged hospitalisation, disability on discharge or death). Approximately half of the adverse events are preventable. Little is known about adverse events in the Irish healthcare system.Therefore, recommendations on improving patient safety at a national level are being made on limited information. The aim of the Irish National Adverse Events Study (INAES) from Rafter et al. was to quantify the frequency and nature of adverse events in acute hospitals in the Republic of Ireland for the first time using an internationally recognised retrospective patient chart review methodology.
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Content Article
What to do when complications occur (3 January 2018)
Patient Safety Learning posted an article in Processes
In this article, Cruikshanks and Bryden outline the process that should take place after an adverse event has occurred.- Posted
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want— mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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- Transparency
- Patient engagement
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