Search the hub
Showing results for tags 'Reporting'.
Found 289 results
-
Content Article
Nuffield Trust: Safety culture in the NHS (25 August 2022)
Mark Hughes posted an article in Culture
A good safety culture in healthcare is one that includes value and respect for diversity, strong leadership and teamwork, openness to learning, and staff who feel psychologically safe. In this article the Nuffield Trust use data from the NHS Staff Survey to look at safety culture in the NHS. -
Content ArticleIn 2019, the Korean National Patient Safety Incidents Inquiry was conducted in the Republic of Korea to identify the national-level incidence of adverse events. This study determined the incidence and detailed the characteristics of adverse events at 15 regional public hospitals in the Republic of Korea. The authors concluded that a review of medical records aids in identifying adverse events in medical institutions and helps prioritise actions to reduce their incidence.
-
Content ArticleThis US study in the journal Medical Care aimed to assess the accuracy of Nursing Home Compare's (NHC) pressure ulcer measures, which are chief indicators of nursing home patient safety. The authors identified hospital admissions for pressure ulcers and linked these to nursing home-reported data at the patient level. They then calculated the percentages of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay status, and race. Next, they estimated the correlation between an alternative claims-based measure of pressure ulcer events and NHC-reported ratings. The study found that pressure ulcers were substantially underreported in data used by NHC to measure patient safety. The authors call for alternative approaches to improve surveillance of health care quality in nursing homes.
-
Content ArticleThis study in JAMA Network Open aimed to investigate how often patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes they report. The results of the study showed that: 1 in 5 patients who read a note reported finding a mistake 40% perceived the mistake as serious the most common mistakes reported were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient and sidedness. The authors suggest that patients may perceive important errors in their visit notes, and inviting them to report mistakes may be associated with improved record accuracy and patient engagement in safety.
-
Content ArticleSafety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organsation. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value.
-
Content ArticleEarlier this year in March, a nurse from Vanderbilt University, RaDonda Vaught, was found guilty of criminally negligent homicide and gross neglect of a patient. In 2017, Vaught gave 75-year-old Charlene Murphey the incorrect medication. Murphey died as a result. Charlene Murphey’s tragic death highlights the failures of healthcare organisations and their leadership to be trustworthy as well as a fractured and weakened accountability system for patient safety in the United States.
-
Content Article
Can being open and transparent make us more opaque?
Anonymous posted an article in Florence in the Machine
‘Neo’ is an Allied Health Professional working on the frontline and asks what being open and transparent actually means and whether publishing a report or an investigation is just another tick box exercise if lessons aren't learned. -
Content ArticleRAND Corporation and MedStar researchers examined the intersection of patient safety and racism, focusing on patient safety and health equity from clinician leaders' perspectives. An overarching emphasis of the work concerned the impact of racism and other related factors (i.e., bias) on patient safety events and potential interventions or changes (such as creating a culture of speaking up about racism in care) that can help prevent such events.
-
Content ArticleAdverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study from St Clair et al. used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs.
-
Content ArticleSuccessful adoption of novel noncontact physiological measurement and physical monitoring requires analysis of how they support patient care. Lloyd-Jukes et al. review available technologies and present their vision-based patient monitoring and management system, supported by a framework enabling its integration within clinical workflows. The framework links tasks such as assessing patients to elements of the patient journey (eg, risk factors and early warning signs). The system enabled insights from patient activity reports and noncontact vital sign measurements. It supports staff in ensuring patients' health follows desired trajectories, avoiding adverse events, making observations without disrupting patients' rest, intervening proactively, and learning from incidents.
-
EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the new Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Summer 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
-
News Article
Multiple reporting systems undermine patient safety, says watchdog
Patient Safety Learning posted a news article in News
A single system to report patient safety concerns would “keep people safer”, a newly appointed NHS watchdog has told HSJ. Henrietta Hughes – who will take up the post of patient safety commissioner in September – said both clinicians and patients faced a bewildering choice when looking to raise a safety concern, and that there was a need for a “report once” system. She said that when ”exhausted” clinicians “come to the end of a 12-hour shift, they don’t want to have to do a Datix report and a yellow card report, and if they’ve got a safeguarding concern or a concern about an individual condition, [to have to] send that somewhere else”. Dr Hughes added: ”Wouldn’t it be better if we had one report that you do, and all the information that comes from that report just gets sent to the appropriate authority? That’s the type of change that I think we’d like to see. I know, as a GP myself, that’s what I would rather do as a professional. But also, I think, for all the organisations, we could get so much more richness of information, we would get more reporting, and we’d keep people safer as a result of it.” She added that if a patient “wanted to report an individual clinician” they often ended getting bounced around the system, like a pinball. They get sent from pillar to post.” Read full story (paywalled) Source: HSJ, 8 August 2022 -
Content ArticleClinical governance can be defined as ‘the framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high quality of care’. This article aims to provide an introduction to clinical governance based on UK practice. The article defines and examines how UK health systems priorities safe care, effective care, person-centred care and assured care.
-
Content ArticlePatient safety culture is the foundation of patient safety and refers to a healthcare organisation’s shared values, norms and beliefs that influence staff’s behaviour and actions. This study in BMJ Open Quality aimed to assess nurses’ reporting on the predictors and outcomes of patient safety culture and the differences between patient safety grades and the number of events reported. It aimed to fill a gap in research by looking at patient safety culture in terms of both predictors and outcomes. The author developed a cross-sectional comparative research design and recruited 300 registered nurses to take part in a survey on patient safety culture. The author found that nurses generally perceived patient safety culture as 'moderate', and identified areas that should be prioritised to improve patient safety culture. They concluded that assessing patient safety culture is the first step in improving hospitals’ overall performance and quality of services, and that improving patient safety practices is essential to improving culture and clinical outcomes.
-
Content ArticleIn two videos, Mark Fewster, Head of Product and Innovation at Radar Healthcare, talks to Marcos Manhaes, NHS Improvement, and Paul Ewers, Milton Keynes University Hospitals NHS Trust, about the journey from the National Reporting and Learning System (NRLS) to Learn from Patient Safety Events (LFPSE) and the future benefits the NHS could see.
-
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.
-
Content ArticleThis study, published in the Journal of Patient Safety, looks at how preventable adverse events and near misses are identified, based on data from an acute care hospital in western Sweden. It examines how many events are identified through structured record review, web-based incident reporting and daily safety briefings, and the different types of events identified by each method. Reflecting on its findings, the authors suggest that health care organisations should adopt multiple methods to get a comprehensive review of the number and type of events occurring in their setting.
-
Content ArticleLucie Musset, Senior Product Manager, and Hugh Archibald, Product Manager, at NHS England and NHS Improvement present on the new Learn from patient safety events (LFPSE) service (formerly known as PSIMS).
-
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the decontamination of surgical instruments. It focuses on the work of sterile services departments (SSDs) in hospitals, where reusable medical equipment is cleaned, disinfected and sterilised to make it safe before it is used again. The investigation looked at the regulatory framework which SSDs work within, and their use of assurance models, which provide evidence that a service is running according to the relevant policies and procedures. These mechanisms are designed to keep patients safe and enable NHS trusts to manage risk within their organisations. For its reference case, the investigation used the case of a 56 year-old woman who underwent surgery to remove a kidney stone in her right kidney. During the procedure, 'black stuff' came out of one of the instruments being used, which was later analysed and found to be dried blood. The surgeon stopped the surgery immediately and proceeded with an alternative procedure to remove the kidney stone, for which the patient had already consented. The patient was tested for blood-borne viruses as she had been exposed to another person's dried blood, but tests did not show any evidence that she had contracted any.
-
EventThe Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient
-
News Article
Families dismay at interim report plans despite review ‘chaos’
Patient Safety Learning posted a news article in News
Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022 -
Content Article
Patient Safety Authority Annual Report 2021
Sam posted an article in International patient safety
The Patient Safety Authority (PSA) share its 2021 annual report, highlighting the agency’s expansion of education and reporting efforts to improve patient safety throughout the commonwealth. PSA is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires acute care facilities to report all incidents of harm (serious events) or potential for harm (incidents). -
Content ArticleA Quality Account is a annual report about the quality of services offered by an NHS healthcare provider. Quality Accounts allow providers to demonstrate how they have improved their services to the communities they serve. This webpage provides information on how to put together Quality Accounts, which providers need to submit them and how to publish them.
-
Content ArticleThe Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.
-
Content ArticleHuge numbers of patients suffer avoidable harm in US hospitals each year as a result of unsafe care. In this blog, published in the Harvard Business Review, the authors argue that these numbers could be greatly reduced by taking four actions: Make patient safety a top priority in hospitals’ practices and cultures, establish a National Patient Safety Board, create a national patient and staff reporting mechanism, and turn on EHRs machine learning systems that can alert staff to risky conditions.
