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Showing results for tags 'Patient safety incident'.
Found 682 results
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Content ArticleThis document describes Never Events, and the revised list of reportable patient safety incidents to be classed as Never Events from 1 April 2018.
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Content ArticleThis article describes how Never Events (NE) are serious clinical incidents that cause harm to patients. The authors analysed data from NHS England to categorise themes and identify common NE. Their results revealed 51 common NE themes in four main categories out of a total of 3247 between 2012 and 2020, identifying wrong-site surgery as the most common category. The authors conclude that with this research, awareness may help to reduce the amount of incidences in the future.
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Content ArticleNever Events are defined by the NHS as patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. This study considers how effective using of the absolute number of Never Events that take place at English hospital trusts, without accounting for hospital workload, is for judging their underlying safety performance and safety culture. In its conclusions the authors suggest that there are flaws in the current approach regulators take to using Never Events data to judge hospital performance.
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Content ArticleThis webinar is part of Global Patient Safety Webinar Series 2021 and focuses on the third WHO Global Patient Safety Challenge: Medication Without Harm. The webinar presents on overview of the Challenge, technical tools and resources to support its implementation and different approaches to implement the challenge at national, subnational, facility and community levels. A recording of the webinar is available below.
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Content ArticleThis blog looks at how positive reporting of good practice and success can help support health systems and organisations in their journey to become highly reliable and improve patient safety. This is part of a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix.
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Content ArticleAfter an investigation of an event, it’s important to touch base with the healthcare team and everyone involved so they can get some closure. This is an important part of the healing process that we have neglected too often. Alberta Health Services provide tips on how to support staff involved in adverse events.
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Content ArticleIn order to obtain compensation for harm arising out of medical treatment received within the NHS in Scotland, the elements needed to establish negligence under the law of delict must be satisfied. The Scottish government has expressed the view that a no-fault compensation scheme in relation to clinical negligence claims made against the NHS in Scotland could be simpler than the existing litigation system and could support the development of the concept of a mutual NHS, as well as a positive feedback and learning culture. With this in mind, the government considers that such a scheme is the favoured way forward for the NHS in Scotland. This report reviews and analyses existing no-fault schemes in a number of countries/jurisdictions: New Zealand (NZ); Nordic countries (Sweden, Finland, Denmark, Norway); and the schemes operating in Virginia and Florida (United States) for birth-related neurological injury.
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Content ArticleA new best practice guide helping trusts learn more from NHS negligence claims has been issued in the drive for better patient safety. With the cost of harm for clinical negligence claims from incidents in 2019/20 expected to cost the NHS £8.3 billion, the Getting It Right First Time (GIRFT) programme and NHS Resolution have worked together to produce 'Learning from Litigation Claims', offering trust clinicians, managers and legal teams a practical and structured approach to claims learning, and sharing examples of best practice from across England. The aim is to maximise what can be learned from litigation, for the benefit of patients and to curb escalating costs.
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Content ArticleMesh-related complications resulting from pelvic organ prolapse (POP) reconstruction operations may be a devastating experience leading to multiple and complex interventions. The aim of the study from Paulo Rodrigues and Shlomo Raz was to describe the experience and time frame of management of mesh-related complications in women treated for POP or stress urinary incontinence in a tertiary centre.
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Content ArticleA joint National Patient Safety Alert issued by the NHS England and NHS Improvement National Patient Safety Team and Royal College of Emergency Medicine, on the need for urgent assessment/treatment following ingestion of ‘super strong’ magnets.
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Content ArticleThe Once for Wales Concerns Management System Programme was developed from the recommendations made by Keith Evans in the Welsh Government report – “The Gift of Complaints” and is aimed at bringing consistency to the use of the electronic tools used by all NHS Wales health bodies. All organisations currently have varying versions and modules of the DatixWeb and DatixRichClient systems. Following a successful competitive tender, which really tested and explored the market, RLDatix Ltd have been awarded the contract for 5 years, with an opportunity to extend this period if it is successful. The solution is known as DatixCloudIQ and has many enhanced features compared to other systems. It is a new Datix.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) has analysed its first 22 HSIB national investigations to identify the recurring patient safety themes and to explore the impact so far of the 85 recommendations they have made to address them.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety It is intended to support one of the key aims of the NHS Patient Safety Strategy, to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This will replace the Serious Incident Framework with organisations expected to transition to PSIRF within 12 months of its publication, by Autumn 2023.
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Content ArticleThis study in the Journal of Patient Safety assessed the occurrence of incidents in inter-hospital transport for critically ill patients, their potential consequences, and whether they are actually reported. Two different services in Norway were asked to self-report incidents after every inter-hospital transport of critically ill patients. The study found that only 1% of incidents were actually reported in the hospital’s electronic incident reporting system. It also highlighted that experts who examined the incidents were inconsistent in which incidents should have been reported and to what degree different interventions could have prevented them. The study results show the existing quality and safety challenges relating to inter-hospital transport of critically ill patients.
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Content ArticleSerious Hazards Of Transfusion (SHOT) is the UK's independent, professionally-led haemovigilance scheme. This guidance replaces previous versions and provides information for healthcare professionals on reporting serious adverse reactions and serious adverse events to SHOT.
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A series of failures: a relative's story
Patient Safety Learning posted an article in Keeping patients safe
At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do. Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.- Posted
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Content ArticleIn this article for the Patient Safety Network, the authors highlight ways in which the Covid-19 pandemic initiated drastic modifications to the way in which health services are delivered across care settings, in particular in hospital emergency departments and inpatient units. They examine particular challenges highlighted by patient safety organisations (PSOs), including increases in safety incidents relating to pressure sores, sepsis, infections and communication issues. The article also highlights innovations to support safety that have been developed during the pandemic.
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Content ArticleThis article, published in the British Journal of Anaesthesia, explores how medication-related adverse events in anaesthesia care are frequent and require a deeper understanding if medication harm is to be prevented. The study looked at a Spanish incident report database over a ten-year period to conclude that harm could have been mitigated.
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Content ArticleThis article, published in Best Practice & Research Clinical Anaesthesiology, looks at the importance of Incident Reporting Systems in improving patient safety and how they can be better used to have an improved impact.
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Content Article
Bleed Out: HBO documentary (2018)
Patient Safety Learning posted an article in Investigations and complaints
Medical error is the third leading cause of death in the U.S. After a routine partial hip replacement operation leaves the mother of filmmaker and comedian Steve Burrows in a coma with permanent brain damage, what starts as a personal video diary becomes a citizen’s investigation into the state of American healthcare. -
Content ArticleIn this blog for the British Journal of Nursing, John Tingle, Lecturer in Law at Birmingham Law School, considers the two opposing viewpoints on the need for change in the clinical negligence litigation system. He concludes that reducing the costs of litigation with require more than refining how the system of compensation works. He states that the way care is delivered in the NHS needs to be examined at a more fundamental level.
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In this blog, Patient Safety Learning’s hub Editor, Samantha Warne, summarises a recent Patient Safety Management Network (PSMN) session she joined to hear from James Munro, Chief Executive of Care Opinion, about how patients are using Care Opinion to share their experiences and how Trusts are using the feedback. -
Content ArticlePatient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe. Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not, to the National Reporting and Learning System (NRLS). You can find out how to do this from the link below.
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Content ArticleThis report from the Department of Health and Social Care sets out the Government’s response to the Independent Inquiry into the Issues raised by Paterson.
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Content Article
Patient Safety Learning and the Safer Healthcare and Biosafety Network (SHBN) are undertaking a project, working with patient safety experts and frontline staff, to produce a manual to support staff after a serious safety incident. As part of this work, we are asking healthcare staff to complete a short survey relating to experiences of a serious safety incident.
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