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Found 289 results
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Content ArticleNHS England has recorded two podcasts sharing insight and advice from organisations that have completed the transition from the National Reporting and Learning System (NRLS) to the new Learn from Patient Safety Events (LFPSE).
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Content ArticleIncident reporting is a crucial tool for improving patient safety, alongside an open culture that supports this. In the NHS the new Learn from Patient Safety Events (LFPSE) service is now being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). This article details correspondence between Patient Safety Learning and NHS England in relation to concerns raised by staff about the development and implementation of the LFPSE service
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Content ArticleThis article by the Betsy Lehman Center in Massachusetts draws attention to research by ECRI, a US non-profit research and risk management firm, which shows that efforts to address racial inequalities in medical care need to include an examination of the way in which patient safety events are reported. Research by ECRI shows that existing patient safety reporting systems may be undercounting events experienced by patients who are Black , Latino or from other ethnic groups. It also highlights that racial, ethnic and other demographic data about patients is missing in adverse event reports from most US healthcare organisations.
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Content ArticleIn this podcast, the Learn from Patient Safety Events (LFPSE) team talks to the National Director for Patient Safety about the new LFPSE service, why it’s important, and the benefits he thinks it will bring for patient safety.
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Content ArticleThe Patient Safety Database (PSD), previously called the Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. This year, PSD has also been involved in the development of the SafeTeam Academy, an e-learning training platform associated with the Patient Safety Database, which offers video immersive courses using the power of cinema to train healthcare professionals. This is the latest newsletter from PSD, featuring a wide range of content by safety experts across Europe.
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Content ArticleRadar 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.
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Content ArticleWest Suffolk is first of a small number of trusts in England that are part of a pilot programme recently launched by NHS Improvement and NHS England called the Patient Safety Incident Response Framework (PSIRF). A national initiative, it is designed to further improve the quality and safety of the care we provide through learning from patient safety incidents. PSIRF outlines how providers should respond to patient safety incidents, and how and when an investigation should be carried out. It includes the requirement for the publication of a local Patient Safety Incident Response Plan (PSIRP), which sets out how trusts will continually improve the quality and safety of the care they provide, as well as the experience which patients, families and carers have when using our services. Find out more about what West Suffolk NHS Foundation Trust are doing.
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Content ArticleOn the 18 October it was announced that NHS Trusts have been given an optional six-month extension to implement Learn From Patient Safety Events (LFPSE). There are a lot of messages being talked about and there has been some confusion over what this means. So, what do organisations need to have in place by 31 March 2023 and what has changed? In this blog*, Radar Healthcare cover some of the key information.
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EventRegister
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Content ArticleThis survey by In-FACT (Independent Fetal Anti Convulsant Trust) is intended to provide patients, no matter what anti-epileptic drug (AED) they are prescribed or what condition the AED is prescribed for, the opportunity to report problems and worries about taking their medication during pregnancy. The results will be used to inform In-FACT's ongoing work to improve medication safety and their engagement with the Medicines and Healthcare products Regulatory Agency (MHRA).
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EventFrontline staff often perceive event reporting as a black hole where no information exits once it enters. Join Andy Moyer, BSN, RN-BC, patient safety informatics specialist at Penn State Health Milton S. Hershey Medical Center, where he will help you tackle this perception by providing reporters better feedback. Moyer will also demonstrate ways to increase the quantity and quality of reported events. Register
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Content ArticleSafety communication refers to the sharing of safety information within organisations in order to mitigate hazards and improve risk management. External stakeholders, such as patients and carers, also communicate safety information to healthcare organisations. This article in the Journal of Risk Research examines the nature of safety communication behaviours seen in patients and their families by identifying and examining 410 narrative accounts. The author found that the success of patient and family safety communication in reducing risk was variable. Problems in hospital safety culture such as high workloads and downplaying safety problems, meant that information provided was often not acted upon.
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News ArticleThe 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
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Content ArticleIn this blog, Dr Amy Proffitt, Royal College of Physicians (RCP) patient involvement officer, explores how the patient voice is represented in patient safety. She highlights the importance of engaging patients from a diverse range of backgrounds and responding to research that highlights particular populations who are experiencing worse outcomes. Eddie Kinsella, chair of the RCP’s Patient and Carer Network, then goes on to share his thoughts on patient safety, highlighting the role of patient partners in bringing about culture change in the NHS, and as advocates for the wider community, especially those who are most disadvantaged.
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Content Article
Nine specialist mesh centres have been set up by NHS England to offer removal surgery and other treatment to women suffering from complications and pain as a result of vaginal mesh surgery, but women are reporting that they are not operating effectively. In this opinion piece, Kath Sansom highlights ten problems with these specialist mesh centres, evidenced by the real experiences of women who are part of the Sling the Mesh campaign Facebook group. -
Content ArticleThis dashboard presents the results of a patient safety survey conducted by the European Alliance for Access to Safe Medicines (EAASM) and European Collaborative Action on Medication Errors and Traceability (ECAMET). The dashboard shows variations in different hospital-reported measures of patient safety across thirteen European countries. The questions in the survey focus on accreditation, training, electronic health records and recording, tracking and publishing of medication error data.
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Content ArticleThe US President’s Council of Advisors on Science and Technology (PCAST) consists of individuals from sectors outside of the US Federal Government who advise the President on policy matters where the understanding of science, technology and innovation is key. This is the recording of a live-streamed meeting of PCAST, where invited speakers presented opportunities to advance scientific innovation, including improving patient safety.
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Content ArticleLaura Pickup and Suzy Broadbent present on the impact staff fatigue has on patient safety.
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Content ArticleThe purposes of the Canadian Medication Incident Reporting and Prevention System (CMIRPS) programme are to:Coordinate the capture, analysis and dissemination of information on medication incidents;Enhance the safety of the medication use system for Canadians.Support the effective use of resources through the reduction of potential or actual harm caused by preventable medication incidents.The goals of the CMIRPS information system are to:Collect data on medication incidents.Facilitate the implementation of reporting of medication incidents.Facilitate the development and dissemination of timely, targeted information designed to reduce the risk of medication incidents (e.g. ISMP Canada Safety Bulletins).Facilitate the development and dissemination of information on best practices in safe medication use systems.
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Content ArticleThe Care Quality Commission provides answers to the following common myths.
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Content ArticlePatients, 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.
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Content Article
What is safety management system? (31 August 2022)
Patient Safety Learning posted an article in Organisational
Safety Management System (SMS) is a collection of structured, company-wide processes that provide effective risk-based decision-making for daily business functions. A SMS helps organisations offer products or services at the highest level of safety and maintain safe operations. This article explains more. -
Content ArticleThis cross-sectional study in BMJ Quality & Safety aimed to assess patient comfort in speaking up about problems during hospitalisation, and to identify patients at increased risk of having a problem and not feeling comfortable speaking up. The authors assessed the responses of 10,212 patients at eight hospitals in Maryland and Washington to the question, "How often did you feel comfortable speaking up if you had any problems in your care?" The study found that 48.6% of respondents indicated that they had experienced a problem during hospitalisation. Of these, 1,514 (30.5%) did not always feel comfortable speaking up. The authors concluded that creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience.
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Content ArticleThe UK is considered one of the safest health systems in the world, with dedicated teams of healthcare professionals delivering high standards of care. But with healthcare rates of avoidable harm stubbornly not reducing at the rate we all want, for the benefit of patients we need to strive to achieve more. This extends to how we source, supply and monitor the use of healthcare equipment and products. Procurement and supply chains can be complex and may involve many organisations, with patient safety concerns manifesting themselves in a range of diverse ways. Using value-based procurement (VBP) is one way we can achieve safer care.
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Content ArticleThis study in the Journal of the American Medical Informatics Association aimed to evaluate the feasibility of using Unified Medical Language System (UMLS) semantic features for automated identification of reports about patient safety incidents by type and severity. UMLS was compared with results produced by bag-of-words (BOW) classifiers on three testing datasets. The authors found that UMLS-based semantic classifiers were more effective in identifying incidents by type and extreme-risk events than classifiers using bag-of-words (BOW) features.
