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Found 290 results
  1. Content Article
    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, looks at why this has come about and what needs to be done to improve incident reporting.
  2. Content Article
    The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body composed of 27 national organisations. In 1995, the United States Pharmacopeial Convention (USP) spearheaded the formation of the National Coordinating Council for Medication Error Reporting and Prevention: Leading national health care organizations are meeting, collaborating, and cooperating to address the interdisciplinary causes of errors and to promote the safe use of medications.
  3. Community Post
    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.
  4. Content Article
    As a healthcare worker, you could be asked to write a statement for an investigation at work, in response to a complaint, or about an unexpected incident. These are the main points to consider, developed by the Royal College of Nursing (RCN).
  5. Content Article
    Near miss events are much more common than events where harm actually reaches a patient, as much as 7-100 times more frequent. However, reporting systems for such events are much less common. At Faulkner Hospital, over 75% of the safety event reports the hospital captures in RL6 are near misses.
  6. Content Article
    The Workforce Race Equality Standard (WRES) is a set of metrics that would requires NHS organisations to demonstrate progress against a number of indicators of race equality, including a specific indicator to address the low representation of black and minority ethnic (BME) staff on Boards. NHS providers are expected to show progress against a number of indicators of workforce equality, including a specific indicator to address the low numbers of BME board members across the organisation. Follow the link below to find out more about WRES and to access the annual reports.
  7. Content Article
    In this edition of the Royal College of Anaesthetists bulletin, articles include: psychological consequences of COVID-19 a shift in incident reporting sleep and exhaustion.
  8. Content Article
    This study from Sanko et al., published in Simulation in Healthcare, found that improvements in systems thinking increase adverse event (AE) reporting patterns among undergraduate nursing students participating in a simulation exercise. The authors suggest that prelicensure training include reinforcement of systems thinking principles to achieve patient safety improvements.
  9. Content Article
    SHOT (Serious Hazards of Transfusion) is the UK's independent professionally led haemovigilance scheme.  This year’s Annual SHOT Report looks back at trends and data for the last calendar year, but also highlights several very important messages for us in the present extraordinary times. The data in the report come from across the UK and include material from all areas of healthcare where transfusion is practised.
  10. Content Article
    Richard Smith is a trained paramedic who now works as Head of Quality and Safety at Addenbrooks Hospital. In this interview with East England Ambulance Service General Broadcast, Richard talks about his recent paper on incident reporting in the ambulance service. He asks if we have a blame and fear-free culture when concerns are raised, the value of feedback and highlights the importance of reporting the positive incidents too.
  11. Content Article
    Due to COVID-19 and the safety issues the pandemic is highlighting, I have decided to write a sequel to my previous blog 'Dropped instrument, washed and immediately reused'. I am writing this because it recently came to my notice from colleagues that safety is once again being compromised in the same private hospital where my shifts were blocked after I reported a patient safety incident.
  12. Content Article
    Effective speaking up arrangements protect patients and improve the experience of NHS workers. The guidance set out by Sir Robert Francis in his Freedom to Speak Up review, was to develop a more open and supportive culture that encourages staff to speak up about any issues of patient care, quality or safety.  In this blog I want to explore why this hasn’t been happening in Trusts up and down the country, despite everyone wanting a safe culture to speak up, no more so than myself, a clinician who has a keen interest in patient and staff safety. Sir Robert Francis laid out six principles for Trusts to follow in his review of speaking up in NHS Trusts in 2015. I would like to reflect on the times when I have spoken up about patient safety issues and the responses I have had when I have raised them.  I will use Francis’ six principles to frame the blog. 
  13. Content Article
    This second comprehensive edition of these Principles is to help public authorities, industry and communities worldwide anticipate accidents involving hazardous substances resulting from technological and natural disasters, as well as sabotage. It addresses the following issues: preventing the occurrence of chemical accidents and near-misses; preparing for accidents through emergency planning, public communication, etc.; responding to accidents and minimising their adverse effects; and following-up to accidents, regarding clean-up, reporting and investigation.
  14. Content Article
    This is the letter from Monitor (now part of NHS Improvement) to all foundation trust chief executives about Sir Robert Francis’ Freedom to Speak Up review.
  15. Content Article
    CORESS Programme Director Frank Smith's talk at the Royal College of Surgeons of Edinburgh.
  16. Content Article
    This website allows patients and professionals to report suspected side effects to medicines or medical device and diagnostic adverse incidents used in coronavirus treatment to the Medicines and Healthcare products Regulatory Agency (MRHA) to ensure safe and effective use. When reporting patients and healthcare professionals are encouraged to provide as much information as possible.
  17. Content Article
    The Learning Disabilities Mortality Review (LeDeR) Programme is a world-first. It is the first national programme of its kind aimed at making improvements to the lives of people with learning disabilities. The University of Bristol is one of the partners in the programme, which is funded and run by NHS England. Reviews of deaths are being carried out with a view to improve the standard and quality of care for people with learning disabilities. People with learning disabilities, their families and carers have been central to developing and delivering the programme. Further information and useful resources can be found on the University of Bristol's website.
  18. Content Article
    Presentation slides for topic 5 of the WHO Multi-professional Patient Safety Curriculum Guide. The learning objective from this topic is to understand the nature of error and how healthcare providers can learn from errors to improve patient safety.
  19. Content Article
    This international review from the Health Information and Quality Authority highlights the considerable variation in place across countries in relation to patient safety reporting. It is clear however, that the coordination and triangulation of patient safety intelligence for risk profiling is extremely important. Incidents need to be combined with other quality and patient safety sources of information.
  20. News Article
    The Care Quality Commission (CQC) has suspended its routine inspections due to the coronavirus outbreak following pressure from system leaders and NHS bosses. The decision to suspend inspections where there are no immediate safety concerns is understood to have been taken by the CQC’s executive team this morning, senior sources told HSJ. Both the NHS Confederation and The Royal College of GPs said the decision had been made. NHS Confederation called the move a “sigh of relief” for front-line staff, while the RCGPs said it would enable GPs to dedicate their time to providing care. NHS Confederation chief executive Niall Dickson said: “Front-line staff will breathe a sigh of relief that CQC has responded to our concerns and will now postpone its inspections where there is no immediate safety concern so that they can gear themselves up to prepare for the huge task ahead in dealing with the coronavirus pandemic.” Read full story Source: HSJ, 16 March 2020
  21. Content Article

    Marking your own homework

    Anonymous

    Anonymous posted an article in Florence in the Machine

    Having read the recent blog on the hub, ‘Silent witness’, this nurse too was compelled to share with us her frustrations on the current hospital reporting system. 
  22. Content Article
    A research paper published by researchers from the Johannes Kepler Universität and the University of Applied Sciences, both in Austria, examined the process of developing what is termed as a ‘constructive error culture’ in organisations. This Research Brief from Oxford Review summarises the findings.
  23. Content Article
    The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. Alerts available on the CAS website include National Patient Safety Alerts (from MHRA, NHS England and NHS Improvement and the UK Health Security Agency (UKHSA)), NHS England and NHS Improvement Estates Alerts, Chief Medical Officer (CMO) Alerts, and Department of Health & Social Care Supply Disruption alerts.
  24. Content Article
    There is widely shared agreement that the Canadian healthcare system needs a sharper patient safety focus. The rate of preventable harm in all care settings is alarming, yet poorly understood, leading to complacency and acceptance of patient safety risks. 2018-2019 brought about a change in the strategic direction of the Canadian Patient Safety Institute. Their aim is to inspire and advance a culture committed to sustained improvement for safer healthcare. In this first year of their new five-year business plan, they've laid the groundwork to demonstrate what works and strengthen commitment for end-to-end patient safety improvements and are using those strategic elements to make care safer. Read this annual report to learn more about their priorities and progress.
  25. Content Article
    In the past 15 years, healthcare has focused primarily on building the technical infrastructure for incident reporting systems: online reporting systems, data collection forms, categorisation schemes and analytical tools. These are all important foundations. But this focus on incident data is also the source of many of our current problems with incident reporting: we collect too much and do too little. Learning depends critically on the less visible social processes of inquiry, investigation and improvement that unfold around incidents. Over the next 15 years we must refocus our efforts and develop more sophisticated infrastructures for investigation, learning and sharing, to ensure that safety incidents are routinely transformed into system wide improvements.
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