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Content ArticleOnline patient feedback is becoming increasingly prevalent on an international scale. However, limited research has explored how healthcare organisations implement such feedback. This research from Baines et al. sought to explore how an acute hospital, recently placed into ‘special measures’ by a regulatory body implemented online feedback to support its improvement journey.
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Content ArticlePeople increasingly provide feedback about healthcare services online. These practices have been lauded for enhancing patient power, choice and control, encouraging greater transparency and accountability, and contributing to healthcare service improvement. Online feedback has also been critiqued for being unrepresentative, spreading inaccurate information, undermining care relations, and jeopardising professional autonomy. Through a thematic analysis of 37 qualitative interviews, this paper explores the relationship between online feedback and care improvement as articulated by healthcare service users (patients and family members) who provided feedback across different online platforms and social media in the UK.
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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.
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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.
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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.
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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.
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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.
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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.
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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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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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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 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.
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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 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 Article
An encounter with an error trap by Steve Highley (6 August 2015)
Sam posted an article in Error traps
Steve Highley looks at responding positively to error using a personal experience involving his car and highlights how to find and deal with error traps. -
Content ArticlePresentation 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.
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Content ArticleCIRAS (Confidential Reporting for Safety) is a safety charity for the transport industry. They look at a range of concerns affecting the health, wellbeing and safety of staff, passengers or the public. The concerns raised through their hotline often have common themes – non-compliance, equipment issues, fatigue, security and working conditions – and they share this learning and good practice across the CIRAS community. Some of this learning and good practice can be applied to other industries and organisations, including healthcare. Each month, CIRAS publish a newsletter: Frontline Matters, with articles on health and safety.
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Content ArticleThis document from the World Health Organization (WHO) is to urge the readers to understand the purpose, strengths and limitations of patient safety incident reporting. Data derived from incident reports can be very valuable in understanding the scale and nature of harm arising from health care, provided that the properties of the data are reviewed carefully and conclusions are drawn with caution. The use of incident reporting systems for true learning in order to achieve sustainable reductions in risk and improvements in patient safety is still work in progress. It can be and has been done, but not yet on the scale and with the speed that compares with some other high-risk industries. That is what we must all strive for. This technical guidance will help the journey to a position where we can show patients and their families how we used this learning to give them care that is safe and dependable, every time they need it.
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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 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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