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Showing results for tags 'Patient safety incident'.
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EventThis on-demand conference focuses on supporting staff who have been involved in patient safety incidents, or are the subject of complaints or claims. Involvement in an incident, complaint or claim can have severe consequences on staff who may experience a range of reactions including stress, depression, shame and guilt. This conference will enable you to: Network with colleagues who are working to support staff following incidents, complaints or claims. Understand national developments including the requirements in the 2020 Patient Safety Incident Response Framework. Reflect on how we can better support staff experiencing these issues through Covid-19. Deliver a just culture that supports consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents. Reflect on a healthcare’s professionals personal experience of being the subject of an incident investigation. Improve immediate support and debriefing when an incident occurs. Develop your skills in providing the staff member involved in a patient safety incident specific individual support or intervention to work safely. Understand how you can improve processes for ensuring candour and supporting staff. Identify key strategies for interviewing staff and taking statements and preparing staff for Coroner’s Inquests. Ensure you are up to date with the latest developments in psychological support for staff including building resilience. Self assess and reflect on your own practice. Gain CPD accreditation points contributing to professional development and revalidation evidence. For more information https://www.healthcareconferencesuk.co.uk/on-demand-training/patient-safety-incident-complaint-claim or email kerry@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #SupportingClinicians
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Community PostI was just listening to a podcast interview between Dr Rangan Chatterjee and Matthew McConaughey (In the series 'Feel better, live more'). Matthew M. mentioned that he came from a highly resilient family. If someone fell over, his mother would tell them to get right back up straight away and carry on. He added that he thought that while this resilience was generally a good thing, there should be (what he called) a 'loophole' in it so that there was time to learn why they have fallen over to begin with. Was there a crack in the pavement that needed to be avoided? That way, it wouldn't happen again in the future. This made me think about whether there really was a conflict between resilience in organisations and the need to learn from failure. What do you think??
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Community Post
Healthcare staff experience of a serious safety incident
Patient-Safety-Learning posted a topic in Patient safety in health and care
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Have you had first-hand experience of a serious safety incident? Were you aware of what support was available following this? What support do you think is needed for staff following a serious safety incident? Patient Safety Learning and SHBN are collaborating with patient safety experts and frontline staff to produce a manual to support staff, provide good practice and ‘how to’ tools to improve staff wellbeing following serious safety incidents. If you work in healthcare we would welcome views on this, by completing our short survey and/or sharing your thoughts below.- Posted
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Community PostI am currently working to develop a new process for the investigation of incidents related to digital healthcare, something which clearly sits outside of the usual framework or process of investigating traditional patient safety incidents. I would be grateful for opportunities to discuss and share experiences and ideas with others. If you have already investigated these sort of incidents what sort of approach did you utilise and have you reviewed it post event in respect of effectiveness. @Keith Bates Clive has suggested it would be beneficial for us to discuss?
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Community Post
What needs to be done to improve incident reporting?
Patient Safety Learning posted a topic in Investigations, risk management and legal issues
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Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame? Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, has written a blog for the hub looking at why this has come about and what needs to be done to improve incident reporting. Do you have any ideas on how we can improve incident reporting? We'd love to hear from you. Reply to this topic below.- Posted
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Content ArticleFrom September 2023 all organisations who previously reported to NRLS should make the switch to recording to the new Learn from Patient Safety Events (LFPSE) service, which will replace the NRLS. From Autumn 2023 organisations will also make the transition from the Serious Incident Framework (SIF) to the Patient safety incident response framework (PSIRF). This means there will be changes to the expectations and processes associated with recording information about the response to patient safety incidents This document provides detail into where incident responses are to be recorded during the transition to LFPSE and PSIRF.
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Content ArticleIn the early 21st century, the patient safety movement began to talk about system safety. Recognising that people are inherently fallible, advocates for patient safety proposed that it was wrong to blame individual clinicians for poorly designed systems that were full of error traps. However, in a 2013 BMJ editorial, Kaveh G Shojania and Mary Dixon-Woods argue that we must also take seriously the performance and behaviours of individual clinicians if we are to make healthcare safer for patients. They draw on research showing that ‘bad apples’—individuals who repeatedly display incompetent or grossly unprofessional behaviours—clearly exist. This is never more evident than today, when we read about the conviction of nurse Lucy Letby.
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Content ArticleAll health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were (1) to analyse the association between IHA and the development of subsequent AEs; and (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions. It found that patients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns.
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Content ArticleThis guidance for users of the new Learn from Patient Safety Events (LFPSE) service provides context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
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Content Article
NHS Resolution: Annual report and accounts 2022/23 (13 July 2023)
Mark Hughes posted an article in NHS Resolution
This annual report looks back at the work undertaken by NHS Resolution in 2022-23. NHS Resolution is an arm’s-length body of the Department of Health and Social Care, responsible for providing expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care. -
Content ArticleA useful glossary attached of PSIRF terms and acronyms created by the Tavistock and Portman NHS Foundation Trust. See also: HSIB: Safety investigation jargon buster
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Content ArticleWales' national policy on patient safety incident reporting and management.
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Community Post
Investigation methodologies - please help colleagues in Australia
HelenH posted a topic in Investigations, risk management and legal issues
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Dear hub members We've a request to help from New South Wales. They and their RLDatix colleagues request: The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions. Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out … Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads? We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including: UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020) Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations Patient engagement in investigations Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/ Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest. Thank you all, Helen- Posted
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Community Post
Making meaningful decisions from NRLS reports
Faizan posted a topic in Improving patient safety
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Dear All Please excuse my ignorance, especially if I am failing to see or understand something that is so glaringly obvious! However, I wondered if any of you, my esteemed colleagues, would be able to assist me with a conundrum that I currently face: Number of incidents occurring per 1,000 bed days My questions: What does this actually mean, and how is this useful exactly? How do you know if the sum of a bed days calculation is good or bad? How can this sum be used to quantify/understand incidents that occur within an outpatient setting (or a setting that does not involve bed days)? For example, if we say that an organisation has 5,910 incidents and a bed days figure of 171,971, we would then need to calculate 5,910 / 171,971 x 1000 = 34.36. As the NRLS uses the 'metric', incidents by 1000 bed days, to write a report which includes this sum for your organisation, and that of your "cluster" (other organisations that are 'supposedly' similar to yours), what does this sum actually signify and how can this be used to try and compare yourself to other service providers? Regards Faizan- Posted
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Community PostIncidents per 1000 bed days – what does this actually mean? How is this sum used to quantify incidents reported in an outpatient setting?
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Content ArticleThis letter in the BMJ in 2004 from Richard Thomson highlights the difficulty of accurately quantifying patient safety incidents. Thomson writes that data relevant to patient safety should not be presented alone and out of context. He highlights what was the National Patient Safety Agency and the development of a national reporting and learning system to enable healthcare staff to report incidents anonymously.
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Content ArticlePennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. 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, with over 4.5 million acute care event reports dating back to 2004. Herein, we examine patient safety event reports submitted to the PA-PSRS acute care database in 2022 and compare them to prior years. The authors extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Counts of reports were calculated based on report submission date, and rates were calculated based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). The study found there was a decrease in the number of incident reports submitted to PA-PSRS in 2022 and an increase in serious and high harm event reports.
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Content Article
Our heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it. -
Content ArticleThe extent to which postintensive care unit (ICU) clinics may improve patient safety for those discharged after receiving intensive care remains unclear. This observational cohort study from Karlick et al., conducted at an academic, tertiary care medical centre, used qualitative survey data analysed via conventional content analysis to describe patient safety threats encountered in the post-ICU clinic. For 83 included patients, safety threats were identified for 60 patients resulting in 96 separate safety threats. These were categorised into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviours (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). Of the 96 safety threats, 41% were preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable. Nearly 3 out of 4 patients within a post-ICU clinic had an identifiable safety threat. Medication errors and delayed medical follow-up were the most common safety threats identified; most were either preventable or ameliorable.
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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.
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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.
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Content Article
Adverse incidents arising from suboptimal healthcare are a major cause of worldwide morbidity and mortality. Arriving at an understanding of the conditions under which adverse incidents occur has the potential to improve the safety of healthcare provision. Staff working in the NHS have been contributing their experiences via a narrative data capture platform – SenseMaker – to help gain contextual insights on a wide range of topics under exploration by the NHS Horizons team. This blog by Rosanna Hunt (Senior Associate, NHS Horizons) in collaboration with Lizzy MacNamara (Junior Research Consultant, The Cynefin Co.) and Taj Nathan (Consultant Forensic Psychiatrist, Cheshire & the Wirral Partnership Foundation Trust) describes how the SenseMaker® platform could be used to extract staff experiences on the topic of patient safety incidents both reported and unreported by staff, and the facilitated conversations that would be needed to transform the data into actionable insights and commitment to change. -
Content ArticleA hot briefing template for the purpose of sharing lessons learned across Scotland particularly for rare or unusual events.
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Content ArticleThese templates were developed by Liverpool Heart and Chest Hospital for use in After Action Review, SWARM and Rapid Review toolkit responses.
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Content ArticleTim Fetherston provides background on the rates of critical incidences in hospitals and sets out the case for better reporting. He includes advice and examples for setting up reporting effective systems.
