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Found 289 results
  1. Content Article
    This article, published by the Journal of Clinical Nursing, argues there can be no healthy patient safety culture where Datix or other electronic incident reporting systems (EIRS) are trivialised and weaponised. Nurses at every level can support and enable the blame free culture where nurses use Datix to genuinely promote patient safety.  Follow the link below to download the full article. Other blogs you may also be interested in: “I’m going to Datix you” – a blog from Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan Silent witness: My experience when filing an incident report – newly qualified nurse describes what happened when she reported her first Datix for a serious incident. Marking your own homework – an anonymous blog
  2. Content Article
    Vaccination is the single most effective way to reduce deaths and severe illness from COVID-19. A national immunisation campaign has been underway since early December 2020. All vaccines and medicines have some side effects. These side effects need to be continuously balanced against the expected benefits in preventing illness. The Medicines and Healthcare products Regulatory Agency (MHRA)'s role is to continually monitor safety during widespread use of a vaccine. They have in place a proactive strategy to do this. They also work closely with our public health partners in reviewing the effectiveness and impact of the vaccines to ensure the benefits continue to outweigh any possible side effects. Part of their monitoring role includes reviewing reports of suspected side effects. Any member of the public or health professional can submit suspected side effects through the Yellow Card scheme. The nature of Yellow Card reporting means that reported events are not always proven side effects. Some events may have happened anyway, regardless of vaccination. This is particularly the case when millions of people are vaccinated, and especially when most vaccines are being given to the most elderly people and people who have underlying illness.
  3. Content Article
    In Spring 2021, a new national Patient Safety Incident Management System (PSIMS) will enter its public beta stage. The new system will be phased in to replace the current National Reporting and Learning System (NRLS). Its aim is to maximise the NHS’s ability to learn from when things go wrong. In this, the first in a series of blogs from Lucie Mussett, PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer., PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer.
  4. Content Article
    The aim of this project from Hollis et al. was to improve engagement with the incident reporting process and to encourage staff to raise issues and create a proactive culture of quality improvement. This project demonstrates that a relatively simple intervention can have effect significant positive cultural change in an organisation over a small period of time. By giving frontline staff a mechanism to record issues it is possible to develop a positive culture of grass roots change. Incident reporting can act as a vehicle not only to improve patient safety but more broadly to generate ongoing ideas for quality improvement within an organisation.
  5. Content Article
    RIDDOR puts duties on employers, the self-employed and people in control of work premises (the Responsible Person) to report certain serious workplace accidents, occupational diseases and specified dangerous occurrences (near misses). There is no requirement under RIDDOR (The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) to report incidents of disease or deaths of members of the public, patients, care home residents or service users from COVID-19. The reporting requirements relating to cases of, or deaths from, COVID-19 under RIDDOR apply only to occupational exposure, that is, as a result of a person’s work.
  6. Content Article
    The Early Notifcation scheme is a national programme for the early reporting of infants born with a potential severe brain injury following term labour to NHS Resolution.  This leaflet has been produced as an overview to highlight the: key findings of the report six recommendations information on our collaborative partners and other resources available on our website including information on supporting staff and families.
  7. Content Article
    This case study is featured on the National Institute for Health and Care Excellence (NICE) shared learning database. The associated project aims to optimise the safe use of medicines and reduce avoidable harm to patients. Objectives: To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018) To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter). To ensure practices responded to patient safety alerts from the MHRA in a timely manner.
  8. Content Article
    Six monthly summaries of how the NHS reviewed and responded to the patient safety issues you reported.
  9. 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.
  10. 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).
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. Content Article
    Dr Catherine Oakley speaks to ecancer at the 2019 UKONS meeting in Telford about the recognition of patient symptoms during treatment. She explains some of the issues that patients face during treatment and why they may be hesitant in reporting their symptoms. Dr Oakley states that the Cancer Research UK patient treatment guide, which has been based on the UKONS triage tool can be used to help patients manage their treatments.
  17. Content Article
    Much policy focus has been afforded to the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), the authors of this paper, published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice. 
  18. Content Article
    This article is from the US-based organisation - The Joint Commission, published by Sentinel Alert Event. The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.
  19. Content Article
    The objective of this research paper, published in the Journal of the Royal Society of Medicine, was to investigate doctors’ intentions to raise a patient safety concern by applying the socio-psychological model ‘Theory of Planned Behaviour’.
  20. Content Article
    The Public Interest Disclosure Act 1998 (PIDA) protects workers by providing a remedy if they suffer a workplace reprisal for raising a concern which they believe to be genuine. 
  21. Content Article
    If you're concerned about the quality of care, you can contact the Care Quality Commission (CQC). If someone is in danger you should contact the police immediately. You can call them on 03000 616161.
  22. Content Article
    Protect, formerly Public Concern at Work, aim to stop harm by encouraging safe whistleblowing. They advise people through their free, confidential advice line, train managers, senior managers and board members and support organisations to strengthen their internal whistleblowing or ‘speak up’ arrangements. They were closely involved in setting the scope and detail of the Public Interest Disclosure Act 20 years ago.
  23. Content Article
    Speaking up is the act of reporting concerns about malpractice, wrongdoing or fraud. Within the NHS and social care sector, these issues have the potential to undermine public confidence in these vital services and threaten patient safety. If you are working in this sector but don’t know what to do, or who to turn to about your concerns, Speak Up are the leading source of signposting, advice and guidance. Whether you are an employee, worker, employer or professional body/organisation, you can call their free speaking up helpline, send them an email or complete the online form safe in the knowledge everything you tell them is strictly confidential and anonymous. Speak Up offer legally compliant, unbiased support and guidance to ensure you can act in accordance with your values. This ensures you fully understand your options and legal rights specific to your employment situation. You can call the helpline on 08000 724 725.
  24. Content Article
    This guidance is for all providers of health and adult social care who are registered with the Care Quality Commission (CQC) under the Health and Social Care Act 2008.
  25. Content Article
    The purpose of the International Classification for Patient Safety (ICPS) is to enable categorisation of patient safety information using standardized sets of concepts with agreed definitions, preferred terms and the relationships between them being based on an explicit domain ontology (e.g., patient safety). The ICPS is designed to be a genuine convergence of international perceptions of the main issues related to patient safety and to facilitate the description, comparison, measurement, monitoring, analysis and interpretation of information to improve patient care. Download visual representation of the framework
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