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Found 675 results
  1. Content Article
    From April 2023 the new Health Services Safety Investigations Body will require doctors to be candid about errors that have led to patient harm. But can medics trust that material given in this “safe space” won’t be used against them?
  2. Content Article
    Patients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organisations where safe care is delivered consistently over time, which is in most cases. In this article, Ioana Popescu discusses patient safety in Canada. While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary. 
  3. Content Article
    Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period.  The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
  4. Content Article
    Serious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study from Mary Dixon-Woods and colleagues aimed to use the Human Factors Analysis Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports.
  5. Content Article
    Investigations of healthcare harm often overlook the valuable insights of patients and families. This review from Lauren et al. aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.
  6. Content Article
    Bob Hanscom, J.D., is retiring this week after a nearly 30-year career championing patient safety improvement. He has been Vice President of Risk Management and Analytics at Coverys since 2013 and earlier held similar positions at CRICO and CRICO Strategies. He was Vice President of Clinical Services at Lahey Clinic from 1993 to 1998 and prior to that practiced law.
  7. Content Article
    A systematic review and meta-analysis from Hodkinson et al. examines the association of physician burnout with the career engagement and the quality of patient care globally. A joint team of British and Greek researchers analysed 170 previous observational studies of the links between burnout among doctors, their career engagement and quality of patient care. Those papers were based on the views and experience of 239,246 doctors in countries including the US, UK and others in Africa, Asia and elsewhere globally. This meta-analysis provides compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organisations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care. Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency. Read accompanying BMJ editorial here.
  8. Content Article
    Improving health care quality and ensuring patient safety is impossible without addressing medical errors, so it is important to accurately estimate incidence rates and implement the most appropriate solutions to reduce medical errors. This systematic review in the journal Frontiers in Medicine aimed to identify interventions that have the potential to decrease medical errors. The authors concluded that although many interventions have been suggested and tried, patient safety has not significantly improved. They call on policymakers to focus more on implementing selected interventions effectively.
  9. Content Article
    This letter accompanies the publication of the Patient Safety Incident Response Framework (PSIRF) by NHS England. The PSIRF forms a major part of the NHS Patient Safety Strategy and replaces the Serious Incident Framework (SIF) that has been in place since 2015. It aims to improve safety management across the healthcare system in England and to support the NHS to embed the key principles of a patient safety culture. In his letter, Dr Aiden Fowler, National Director of Patient Safety in England outlines how PSIRF was developed, describes how the transition from the SIF to PSIRF will take place and highlights the tools available to support organisations to implement the changes. The letter is addressed to: NHS trust and foundation trust chief executives, medical directors and nursing directors Integrated Care Board medical directors and nursing directors NHS England Regional Team medical directors and nursing directors NHS England regional direct commissioning leads
  10. Content Article
    This literature review in The Operating Theatre Journal examines why the decision was made not to class surgical fires as a 'Never Event', even though research has identified them as a preventable hazard. The author also examines steps that could be taken to further reduce the risk of surgical fires in the NHS and other health systems. You will need to create a free online account to view this article.
  11. Content Article
    This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here
  12. Content Article
    A good safety culture in healthcare is one that includes value and respect for diversity, strong leadership and teamwork, openness to learning, and staff who feel psychologically safe. In this article the Nuffield Trust use data from the NHS Staff Survey to look at safety culture in the NHS.
  13. Content Article
    In 2019, the Korean National Patient Safety Incidents Inquiry was conducted in the Republic of Korea to identify the national-level incidence of adverse events. This study determined the incidence and detailed the characteristics of adverse events at 15 regional public hospitals in the Republic of Korea. The authors concluded that a review of medical records aids in identifying adverse events in medical institutions and helps prioritise actions to reduce their incidence.
  14. Content Article
    NHS England’s 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.  A Patient Safety Specialist in the North East of England has shared their 'plan on a page’ with the hub to help others prepare for the implementation of PSIRF. You can download the attachment below. Further reading: Applying the After Action Review for the PSIRF – some real life examples
  15. Content Article
    People increasingly provide feedback about healthcare services online. These practices have been lauded for enhancing patient power, choice and control, encouraging greater transparency and accountability, and contributing to healthcare service improvement. Online feedback has also been critiqued for being unrepresentative, spreading inaccurate information, undermining care relations, and jeopardising professional autonomy. Through a thematic analysis of 37 qualitative interviews, this paper explores the relationship between online feedback and care improvement as articulated by healthcare service users (patients and family members) who provided feedback across different online platforms and social media in the UK.
  16. Content Article
    Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organsation. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value.
  17. Content Article
    On the 21 July 2022 NHS Resolution’s Safety and Learning team, in partnership with the National Infusion and Vascular Access Society, hosted a virtual forum on extravasation injury claims. The intention of this event was to raise awareness of these injuries and help spread learning and process review across health providers.
  18. Content Article
    Reducing the risk of patient harm during the process of healthcare delivery is at the forefront of policy and practice. A considerable number of empirical studies and systematic reviews have examined the prevalence, causes and consequences of patient safety incidents and harms. However, a key limitation in the current patient safety literature is that existing reviews examine patient harm in general but there is less emphasis on understanding the burden of preventable patient harm, which in the interest of improvement is of particular importance. The primary aim of this study from Panagioti et al. was to identify the most common types of preventable patient harm and to examine the prevalence and severity of the identified harm. The authors also aimed to examine differences in the prevalence, types and severity of preventable harm across different healthcare settings and across studies published more recently, using more robust research designs and based in the UK. 
  19. Content Article
    The dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. This short paper from Susan Burnett and Charles Vincent, outlines the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalised health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
  20. Content Article
    This overview considers how the NHS has performed over the current parliament in relation to patient safety. It looks at data relating to reported incidents and harm, episodes of care free of certain types of harm, and patient and staff perceptions of safety.
  21. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to the use of a flush fluid and blood sampling from an arterial line in people who are critically ill in hospital. As its ‘reference case’, the investigation uses the experience of Keith, a 66 year old man who during a stay in a clinical care unit had blood samples taken from an arterial line which were contaminated with the flush fluid containing glucose. As a result he received incorrect treatment which led to his blood glucose levels being reduced to below the recommended limit.
  22. Content Article
    Adverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study from St Clair et al. used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs.
  23. Content Article
    The purpose of the Learn from patient safety events (LFPSE) service (previously known during development as the Patient Safety Incident Management System - PSIMS) is to enable learning from patient safety events – incidents, risks, outcomes of concern and also things that went well. Our ability to protect future patients from harm depends on promoting a culture that welcomes and encourages the recording of events. It is essential to abide by these principles to ensure that we continue to successfully learn from patient safety events and reduce harm. This document sets out the circumstances in which LFPSE data are the appropriate data source to be used and describes their appropriate use. These principles emphasise the purpose and characteristics of LFPSE data, and promote consistency across data users. It is essential that users of LFPSE data understand and represent it appropriately, as inappropriate presentations of LFPSE data could discourage recording.
  24. Content Article
    As organisations continue to adapt to a faster pace of change and seek to achieve their organisational purpose, it’s essential that the resources and time needed to change are minimised. Improving performance by learning effectively from mistakes is a vital part of the change process but the method of learning employed is critical. In this LinkedIn post, Judy Walker discusses the application of After Action Reviews (AARs).
  25. Content Article
    Cognition is the mental process of knowing, including awareness, perception, reasoning and judgement, and is distinct from emotion and volition. Cognitive processes include mental shortcuts, which speed up decision making. However, cognitive bias occurs when the shortcut causes inferences about other people and/or situations to be drawn in an illogical fashion. There is a tendency to display bias in judgements that are made in everyday life, indeed this is a natural element of the human psyche. Jumping to a conclusion, tunnel vision, only seeing what is expected/wanted, being influenced by the views of others, all are recognisable behaviours. However, whilst such biases may be commonplace and part of human nature, it is essential to guard against these in forensic science, where many processes require subjective evaluations and interpretations. The consequences of cognitive bias may be far-reaching; investigators may be influenced to follow a particular line of enquiry or interpretation of a finding that may be incomplete, or even wrong. Simply because there is a risk of a cognitive bias does not imply that it occurs. The problem is that as it is a subconscious bias it is unlikely that an individual will know either way and therefore it is wise that all practitioners understand the issue and take proportionate steps to mitigate against it.
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