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Showing results for tags 'Patient safety incident'.
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Content Article
Healthcare Safety Investigation Branch Annual Review 2019/20
Sam posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) has published their third annual review. During 2019/20: 109 patient safety referrals received. 515 maternity investigation reports completed. 15 national investigation reports published. 58 national safety recommendations made. 88% of families engaging with the maternity investigations and 87% with the national investigations. Family information available in over 20 languages to ensure greater inclusivity. Keith Conradi, Chief Investigator, said: “There has been a huge amount of hard work from everyone within the HSIB during this period and I want to thank them and acknowledge the support of our stakeholders in the wider healthcare sector, and in particular to all the organisations who responded promptly to our safety recommendations.” -
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) carried out a themed review of their maternal death investigations during the coronavirus (COVID-19) pandemic. The national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety. Explore wider patient safety processes.
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Content ArticleMaking Families Count (MFC) aims to improve outcomes for families affected by serious harm and traumatic bereavements in health and social care services. In this webinar, which was part of The Patients Association's Patient Partnership Week programme, members of MFC talk through their guide for patients and families on working with the system after a serious incident.
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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.
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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.
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
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Content ArticleThis report describes an adverse incident at Queen's Medical Centre in Nottingham in 2001, when a male patient being treated for leukaemia died after being mistakenly given the chemotherapy drug Vincristine intrathecally (into the spine). Vincristine should be administered intravenously, and accidental intrathecal administration of Vincristine is almost always fatal.
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Content ArticleIn this blog the Safer Healthcare and Biosafety Network and Patient Safety Learning reflect on the results of the NHS Staff Survey 2020, considering how staff safety relates to patient safety in the context of this.
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Content ArticleMeasuring a patient’s height is a routine part of a healthcare encounter. But once completed, how often is this information used? For most of us who fall within 95% of the mean population height, this metric is rarely discussed, but what happens when it is overlooked? And what about those on the outer tails of the bell curve of population distribution? Almost 1 million (909,222) adults in the United States are at least 6'4", more than the entire population of South Dakota (884,659). Conversely, an estimated 30,000 Americans have a form of dwarfism, typically defined as an adult height no taller than 4'10". However, despite this prevalence, the healthcare system struggles to provide consistent, adequate care for patients with extreme heights.
