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Found 675 results
  1. Content Article
    Sarah Kay and Jaydee Swarbrick are involved in the Patient Safety in Primary Care Project in Dorset. In this blog, they summarise a recent event they held to share learning from medicines incidents.
  2. Content Article
    Radar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
  3. News Article
    Eighteen people died at two Teesside hospital trusts following patient safety lapses over a 12-month period. Sixteen such deaths were recorded at the South Tees Hospitals NHS Foundation Trust, with two at the North Tees and Hartlepool NHS Foundation Trust. Examples of patient safety lapses include a failure to provide or monitor care, a breakdown in communication, an out-of-control infection in a hospital, insufficient staffing or a missed diagnosis. NHS England figures show that, between April 2021 and March this year, there were 16,557 incidents at the South Tees Trust, which operates James Cook University Hospital in Middlesbrough, and Northallerton's Friarage Hospital. Thirty-four resulted in "severe" harm. Middlesbrough MP Andy McDonald told the Local Democracy Reporting Service the figures were a concern and that he planned to take them up with the South Tees Trust's chief executive. He said NHS staff worked under "the most demanding of conditions" but added: "Every person going into hospital rightly expects to receive the best treatment. Patient safety is paramount and no family wants to see a loved one suffer." Dr Mike Stewart, the trust's chief medical officer, said: "We encourage an open and transparent culture and promote the reporting of all patient safety incidents, even when there is uncertainty over a direct link between any problems in care and incidents of severe harm or death. "In the last year there were no deaths graded as definitely preventable due to a problem in the care delivered by the trust. "While our reporting has increased consistently over the last three years, the number of serious incidents has not risen, which is strong evidence of a positive safety culture." Read full story Source: BBC News, 30 October 2022
  4. News Article
    The deadline for the NHS to move to a new system for safety incident reporting has been delayed after widespread concerns the rollout could be a ‘disaster’. A memo from NHS England to local teams yesterday, seen by HSJ, says the deadline to transition to the new “learning from patient safety events” database has been pushed back by six months to September 2023. The creation of LFPSE is a key strand of NHSE’s safety strategy, along with the overhaul of how serious incidents are investigated. It aims to make it easier for staff across all healthcare settings to record safety events, as the service will be expanded to include primary care. It will replace the current national reporting and learning system, a central database created in 2003 to help identify trends and maximise learning from mistakes. The new system is part of a national strategy that pledges to save 1,000 extra lives and £100m in care costs each year from 2023-24. Multiple patient safety managers at local trusts had raised concerns to HSJ about the previous March deadline, with one patient safety lead saying it would have been a “disaster” if enforced. Helen Hughes, chief executive of charity Patient Safety Learning, said NHSE also needs to change its way of working, as well as the deadline extension. She said: “We believe that NHS England needs to seriously reconsider their approach to engaging with trust leaders and staff on this issue, so that improvements can be made to the new LFPSE service to ensure it has the best possible chance of success, and to enable patient safety improvement.” Read full story (paywalled) Source: HSJ, 20 October 2022
  5. Content Article
    The NHS Resolution Just and learning culture charter has been developed as a resource to support the creation of a person-centred workplace that is compassionate, safe and fair when care in the NHS goes wrong. Most of the time, care received by patients in the NHS is safe. Sometimes, even with our best intentions, things can go wrong. When things go wrong, support, care and understanding for everyone involved must be a priority. At no time is there an excuse for incivility, bullying and harassment within the NHS. We accept the evidence that the NHS will provide safer care and be a healthier place to work if we address all of the components of a learning organisation and this underpins our charter. The hope is that this charter will act as a tool to help organisations take a consistent approach towards staff in relation to incidents and errors.
  6. Content Article
    To thrive and deliver the best healthcare, healthcare professionals depend on their ability to self-reflect and adapt their working behaviours. This skill is developed through self-awareness, an openness to alternative perspectives, proactively seeking feedback and a willingness to change behaviours as a result of reflecting. Transformative reflection is a type of reflective practice that can transform a person's sense of work-based identity, sense of purpose and how they work, ultimately influencing the collective wellbeing. This guide explains what transformative reflection is, how to create an environment in which it can take place and suggests formats and resources to aid organisations in encouraging transformative reflection.
  7. Content Article
    Commentary from quality and safety leaders on the persistence of adverse events in care delivery — and where health care organisations should go from here. Further reading: The safety of inpatient health care Constancy of purpose for improving patient safety.
  8. Content Article
    Clinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
  9. Content Article
    Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. Two articles in this month's issue we want to highlight are the Surgical safety update (p.10) on cases from the Confidential Reporting System for Surgery (CORESS) and Safe passage (p.18) discussing the National Patient Safety Syllabus.
  10. Content Article
    Improving medication safety during transitions of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. This study in the journal Therapeutic Advances in Drug Safety aimed to characterise the nature and contributory factors of medication-related incidents during transitions of care from secondary to primary care. The authors found several themes for future research that could support the development of interventions, including: commonly observed medication classes older adults increase patient engagements improve shared care agreements for medication monitoring post hospital discharge.
  11. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line. The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream). This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.
  12. Content Article
    This document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
  13. Content Article
    In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.
  14. Content Article
    Second victims are healthcare workers who experience emotional distress following patient adverse events. This mixed method study in BMJ Open looks at how the RISE (Resilience In Stressful Events) programme was developed at the Johns Hopkins Hospital to provide this support. It examined: developing the RISE programme recruiting and training peer responders pilot launch in the Department of Paediatrics hospital-wide implementation.
  15. Content Article
    Within the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey’s pragmatism, in this study Kirstine Z. Pedersen and Jessica Mesman propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey’s understanding of transaction as the inseparability between human and environment, they develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. They further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.
  16. Content Article
    Some medical mistakes have been stubbornly hard to eliminate. Now, hospitals hope technology can make a difference. This Washington Post article highlights are some of the biggest problems that caregivers are trying to address with technology.
  17. Content Article
    Monthly publications from the Joint Commission that outlines an incident, topic or trend in healthcare that could compromise patient safety.
  18. Content Article
    Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.
  19. Content Article
    Medical errors, especially those resulting in patient harm, have a negative psychological impact on patients and healthcare workers. Healing may be promoted if both parties are able to work together and explore the effect and outcome of the event from each of their perspectives. There is little existing research in this area, even though this has the potential to improve patient safety and wellness for both healthcare workers and patients. Using a patient-oriented research approach, this study in BMJ Open Quality examined the potential for patients and healthcare workers to heal together after harm from a medical error. The study's findings suggest that, after a medical error causing harm, both patients and healthcare workers have feelings of empathy and respect towards each other that often goes unrecognised. Barriers to communication for patients were related to their perception that healthcare workers did not care about them, showed no remorse or did not admit to the error. For healthcare workers, communication barriers were related to feelings of blame or shame, and fear of professional and legal consequences. Patients reported needing open and transparent communications to help them heal, and healthcare workers required leadership and peer support, including training and space to talk about the event.
  20. Content Article
    The NHS Patient Safety Incident Response Framework (PSIRF) was launched in 2022 and is intended for full implementation by Autumn 2023. PSIRF requires Integrated Care Board (ICB)’s to work collaboratively with providers to develop a Patient Safety Incident Response Plan (PSIRP) and Patient Safety Incident Response Policy. Within the PSIRP, each organisation must work with their ICB and other stakeholders to identify how it will respond proportionately to all incidents requiring investigation.  Suffolk and North East Essex NHS Foundation Trust share their Standard Operating Procedure on PSIRF ICB sign off process.
  21. Content Article
    Tension pneumothorax can occur following chest trauma, respiratory disease and infection, or during resuscitation requiring invasive or non-invasive ventilation. It is a life-threatening condition resulting from a collapsed lung when air trapped in the pleural cavity compromises cardiopulmonary function. Immediate temporary decompression is required to prevent cardiac arrest. This is commonly done by inserting a needle and cannula, usually used for intravenous access, through the chest wall into the pleural cavity (needle thoracostomy). The needle is withdrawn, and the cannula left in place to allow the trapped air to flow out. New blood control (closed system) intravenous cannulas are increasingly used in the NHS; at least 130 trusts bought a total of three million of them in the last year. They look very similar to both traditional and standard safety cannula (with needle guard or shield) but have an extra integral septum which closes when the needle is withdrawn and stops free flow in or out of the cannula. Flow is only possible once an intravenous line or Luer-lock syringe is attached to the hub, which opens the septum. Blood control (closed system) cannulas help prevent blood spillage, exposure and contamination, when used for their intended intravenous purpose, but they cannot be used to decompress a pneumothorax without additional equipment. The main patient safety risks are: staff may select a blood control (closed system) cannula not realising its limitations for this procedure a blood control (closed system) cannula may wrongly be assumed to be functioning in a patient who is deteriorating rapidly a second needle might be introduced risking very significant damage to the lung as it reinflates.
  22. Content Article
    Pleural effusions are the accumulation of fluid between the lung and chest wall, which may cause breathlessness, low oxygen saturation and can lead to collapsed lung(s). They are a common medical problem and have over 50 recognised causes and various treatments. Large effusions, such as those caused by pleural malignancy, may require insertion of a chest drain and controlled drainage of fluid to allow the lung to inflate. If large volumes of pleural fluid are drained too quickly, patients can rapidly deteriorate. Their blood pressure drops, and they can become increasingly breathless from the potentially life-threatening complication of re-expansion pulmonary oedema. T A review of the National Reporting and Learning System (NRLS) over a recent three-year period identified 16 incidents where patients experienced acute and significant deterioration after uncontrolled or unmonitored drainage of a pleural effusion; two of these patients died and a cardiac arrest call was made for one patient although the outcome was not reported.
  23. Content Article
    Slides from the recent Patient Safety Incident Response Framework (PSIRF) governance workshop giving an update and overview from the national team. Presentations were given from the early adopters: Jacquetta Hardacre, Assistant Director Safety and Risk, East Lancashire Hospitals NHS Trust and Kerry Crowther, Patient Safety Specialist, Cornwall Partnership NHS Foundation Trust. The workshop concluded with a Q&A panel with the presenters and Gillian Lewis Head of Patient Safety Strategy Delivery, NHS England.
  24. Content Article
    Adverse incidents are well studied within acute care settings, less so within aged care homes. The aim of this scoping review, published in Gerontology and Geriatric Medicine, was to define the types of adverse incidents studied in aged care homes and highlight strengths, gaps, and challenges of this research.  Authors conclude that: Aged care policy and adverse incident research needs to expand through the inclusion of a broader definition of what is “adverse” to an older person’s health and well-being. A greater level of specific contextual information within aged care adverse incident research could assist in international comparisons and transferability of research. Importantly, greater inclusion of voices of older people themselves through qualitative and multi-method research would provide a key missing perspective on the concept of “adverse” incidents in aged care homes.
  25. Content Article
    The Patient Safety Authority has developed a series of decision trees to determine whether a patient safety event is a serious event or incident in a range of different situations.
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