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News ArticleAn NHS trust has been urged to publish the full findings of an independent review of its services after it released a heavily redacted report. University Hospitals Sussex has refused to reveal the recommendations made after a review by the Royal College of Surgeons in 2019. A patients' group said the findings should be "in the public domain". The trust said the review of its neurosurgery department "did not highlight any safety concerns". The review was discovered as part of a BBC Panorama investigation into unpublished patient safety reports. A heavily edited report was released under freedom of information laws. It showed the trust asked the Royal College of Surgeons to look at "concerns raised in respect of clinical outcomes, allocation of sub-specialties and governance arrangements". All issues and recommendations were obscured, with only positive feedback disclosed. Read full story Source: BBC News, 20 May 2021
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News Article
Unpublished hospital patient safety reports exposed
Patient Safety Learning posted a news article in News
Serious patient safety issues are being buried in confidential hospital reports, BBC Panorama has found. Freedom of Information requests revealed 111 reports, written by medical royal colleges, which NHS trusts have a duty to share. Eighty reports were given to the BBC but only 26 had been shared in full with regulators, and 16 published. The Department of Health would not comment on whether it might change the law to ensure publication. Since the 2015 Morecambe Bay maternity scandal in which 11 babies and a mother died, NHS Trusts are supposed to publish summaries of external reviews, and share them with the regulator. An earlier review into the hospital had previously identified concerns but had not been made public. Dr Bill Kirkup, who led a 2015 investigation into the Morecambe Bay scandal, said Panorama's findings were a "great disappointment". "People should know that there is something that is important enough to be looked at and they should know what the results of that scrutiny are. I can't understand what the rationale would be for withholding the existence of a report or the findings of the report. These are important matters of accountability in the public service." Read full story Source: BBC News, 19 May 2021 -
Content ArticleThis webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust
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Content Article
In this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture. -
Content ArticlePsychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that highlight both resilience (“we avoided failure”) and vulnerability (“we nearly failed”). Near misses offer learning opportunities for addressing underlying causes of potential incidents, and it is crucial to understand what facilitates near-miss reporting. This study by Jung et al. found near misses are not processed and reported equally. The effect of psychological safety on reporting near misses becomes stronger with their increasing proximity to a negative outcome. Educating healthcare workers to properly identify near misses and fostering psychological safety may increase near-miss reporting and improve patient safety.
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Content ArticleBev Curtis, Medical Device Safety Officer (MDSO) at Harrogate & District NHS Foundation Trust, describes the role of the MDSO in this presentation.
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Content ArticleThis manual by the Healthcare Quality Improvement Partnership provides an overview of the basic clinical audit process for non-clinician members of a clinical audit team. Topics include: What is Clinical Audit? How to Set Objectives How to Select an Audit Sample Clinical Audit Confidentiality and Ethics Comparing Performance Against Criteria and Standards Writing an Audit Report Implementing Change and Action Plans
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Content ArticleThe Once for Wales Concerns Management System Programme was developed from the recommendations made by Keith Evans in the Welsh Government report – “The Gift of Complaints” and is aimed at bringing consistency to the use of the electronic tools used by all NHS Wales health bodies. All organisations currently have varying versions and modules of the DatixWeb and DatixRichClient systems. Following a successful competitive tender, which really tested and explored the market, RLDatix Ltd have been awarded the contract for 5 years, with an opportunity to extend this period if it is successful. The solution is known as DatixCloudIQ and has many enhanced features compared to other systems. It is a new Datix.
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Content ArticleThis first webinar of Global Patient Safety Webinar Series 2021 introducing the “WHO Patient Safety Incident Reporting and Learning Systems: Technical report and guidance” which was released on 17 September 2020 on World Patient Safety Day. The webinar presented an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems. A recording of the webinar is available below.
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Content ArticleVisual representation from Steven Shorrock on a quick way to evaluate where you can improve the flows of reporting within your organisation. The red highlights stronger influences.
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Content ArticleThe ISMP Targeted Medication Safety Best Practices for Hospitals (TMSBP) were developed to identify, inspire, and mobilise widespread, national adoption in the US of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications. The best practice recommendations presented in this guidance document are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. This initiative was first launched in 2014 and is updated with additional best practices, as needed, every two years. While targeted for the hospital-based setting, some best practices are applicable to other healthcare settings. Facilities can focus their medication safety efforts on these Best Practices, which are realistic and have been successfully adopted by numerous organisations.
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Content Article
Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Content ArticleThis 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
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Content ArticleVaccination 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.
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Content ArticleIn 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.
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Content ArticleThe Patient Safety Database (PSD), previously called 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. They have begun by developing an open and anonymous incident reporting system focused on non-technical skills. Each quarter they summarise in their newsletter cases reported on the platform. Read the latest newsletter.
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Content ArticlePatient safety remains one of the most pressing health issues for public awareness and further policy action. Since 2006, OECD’s Health Care Quality and Outcomes (HCQO) Working Party (WP) has developed patient safety indicators (PSIs) based on administrative data sources. These data have been regularly collected and reported with an aim of assessing and comparing cross-country differences in patient safety. However, the international comparability of existing PSIs is challenging due to a number of methodological variations in measure implementation, for example, how countries record diagnoses and procedures, define hospital admissions, processes for reporting safety events. Consequently, in some cases, higher adverse event rates may signal more developed patient safety monitoring systems and a stronger patient safety culture rather than worse care. Current PSIs have limitations in that they fail to adequately capture important aspects of patient safety, such as the extent to which health care practices to prevent and address safety incidents are implemented. This report summarises activities undertaken to date as part of the international indicator development on patient-reported experiences of safety and also a set of questions to be used for the pilot data collection of patient-reported experience of safety, guidelines for the pilot data collection and ongoing pilot data collection
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Content ArticleThis editorial in BMJ Quality & Safety suggests that individual doctors' conduct, performance and responsibility are important factors in improving patient safety. The authors argue that although a 'systems approach' is important, it is necessary to examine the role of individuals within those systems. They highlight recent research that points to small numbers of individual doctors who contribute repeatedly to patient dissatisfaction and harm, and to difficult working environments for other staff. They suggest that identifying and intervening with these individuals plays a role in the wider systems approach to patient safety. They also highlight an urgent need for further research into identifying and responding to problematic clinicians.
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Content ArticleThis 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.
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Content Article
Pain as the neglected adverse event (April 2010)
PatientSafetyLearning Team posted an article in Pain management
Authors of this commentary published in the Canadian Medical Association journal argue that many patients suffer from a specific adverse event on a daily basis: pain. It is never reported as an adverse event and corrective action is often not taken. -
Content ArticleThis blog, published in the BMJ, sets the context for an Evidence Based Nursing (EBN) Twitter Chat that took place on 18 March 2015. The chat focused on whether mismanaged (undertreated) pain should be considered an adverse event. The Twitter Chat was hosted by Dr Alison Twycross who is editor of EBN and has also done lots of work in the area of paediatric pain management. This blog provides some context for the chat. The examples given relate to paediatric pain but the principles apply to pain in patients of all ages.
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Content ArticleFindings from the Healthcare Inspectorate Wales Chief Executive's Annual Report. This report provides an overview of the work undertaken during the past year and what has been found. Healthcare Inspectorate Wales is the independent inspectorate and regulator of healthcare in Wales.
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Content ArticleRIDDOR 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.
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Content ArticleHealthcare worldwide is faced with a crisis of patient safety: every day, everywhere, patients are injured during the course of their care. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. Mary Dixon-Woods and Peter J Pronovost propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors – organisations, individuals, groups – each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. Efforts by individual actors, including local quality improvement projects, may have the paradoxical effect of undermining system safety. Many challenges cannot be resolved by individual organisations, since they require whole-sector coordination and action. The authors call for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.
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Content ArticleThis summary, published by the Health and Safety Executive, outlines the legal necessity of reporting and recording incidents in the workplace. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) require employers to report to the relevant enforcing authority and keep records of work-related deaths, accidents and injuries.
