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Showing results for tags 'Reporting'.
Found 287 results
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Content ArticleCORESS Programme Director Frank Smith's talk at the Royal College of Surgeons of Edinburgh.
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Content ArticleThis study in the Journal of Patient Safety assessed the occurrence of incidents in inter-hospital transport for critically ill patients, their potential consequences, and whether they are actually reported. Two different services in Norway were asked to self-report incidents after every inter-hospital transport of critically ill patients. The study found that only 1% of incidents were actually reported in the hospital’s electronic incident reporting system. It also highlighted that experts who examined the incidents were inconsistent in which incidents should have been reported and to what degree different interventions could have prevented them. The study results show the existing quality and safety challenges relating to inter-hospital transport of critically ill patients.
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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 ArticleSerious Hazards Of Transfusion (SHOT) is the UK's independent, professionally-led haemovigilance scheme. This guidance replaces previous versions and provides information for healthcare professionals on reporting serious adverse reactions and serious adverse events to SHOT.
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Content ArticlePatient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe. Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not, to the National Reporting and Learning System (NRLS). You can find out how to do this from the link below.
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Content ArticleThe Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. Alerts available on the CAS website include National Patient Safety Alerts (from MHRA, NHS England and NHS Improvement and the UK Health Security Agency (UKHSA)), NHS England and NHS Improvement Estates Alerts, Chief Medical Officer (CMO) Alerts, and Department of Health & Social Care Supply Disruption alerts.
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Content ArticleThis study in Risk Management and Healthcare Policy aimed to explore healthcare workers’ perceptions of patient safety culture at primary healthcare centres in the Eastern Province of Saudi Arabia, and the factors that influence them. It also aimed to identify the challenges of adopting patient safety culture in these centres. The study findings highlight a number of areas for improvement, particularly in relation to event reporting, non-punitive responses, and openness in communication. The authors highlight that error reporting should not just be considered a means of learning from mistakes, but should also be considered the first step towards preventing injury and improving patient safety. They highlight the need to eliminate three crucial elements associated with errors - blame, fear, and silence - in order to build a safety culture.
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Content ArticleThis blog by the Institute for Safe Medication Practices identifies ten medication safety concerns in the US from 2021 that still need to be addressed. These concerns are: Mix-ups between the paediatric and adult formulations of the Pfizer-BioNTech COVID-19 vaccines Mix-ups between the COVID-19 vaccines or boosters and the 2021-2022 influenza (flu) vaccines EPINEPHrine administered instead of the COVID-19 vaccine Preparation errors with the Pfizer-BioNTech purple cap or grey cap COVID-19 vaccines Errors and delays with hypertonic sodium chloride Errors with discontinued or paused infusions Infection transmission with shared glucometers, fingerstick devices, and insulin pens Adverse glycaemic event errors Every organisation needs a medication safety officer Increasing error reporting
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Content Article
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This is the first in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Josie tells us about the nursing error that first sparked her interest in patient safety, how a just culture helps healthcare workers and systems learn from their mistakes, and how her love of skiing has inspired her to think differently about risk in healthcare. -
Content ArticleMedical expertise is fundamental to the practice of medicine. But other skills and knowledge are important too. Doctor Informed gives the inside story on the evidence about giving the best care and having positive relationships with patients and colleagues.
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EventRegister
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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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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
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Community Post
What needs to be done to improve incident reporting?
Patient Safety Learning posted a topic in Investigations, risk management and legal issues
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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, has written a blog for the hub looking at why this has come about and what needs to be done to improve incident reporting. Do you have any ideas on how we can improve incident reporting? We'd love to hear from you. Reply to this topic below.- Posted
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Content ArticleThis guide published by NHS England & Improvement describes the validation rules relating to the LFPSE project, specifically around submitting an Adverse Event via the Adverse Event Application Programming Interface (API). It covers several types of validation rules, which have been split into three sections. Bespoke business validation rules which have been implemented based on the dependencies between responses and extensions that cannot be captured by the FHIR resource validation. FHIR validation responses which may be returned from the API when native FHIR validation checks the submission body against the LFPSE FHIR profiles defined for an adverse event. Invalid operations and similar responses which are external to validation of the submission, including responses pertaining to permissions, personal information and any other responses that do not fit into the two categories above.
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Content ArticleThis NHS dentistry and oral health update has a special focus on patient safety. It includes an introduction by newly appointed Interim Chief Dental Officer (CDO) for England, Jason Wong and covers the following topics: Quality and safety in dental care Contributing to patient safety learning Using the Learning from Patient Safety Events (LFPSE) service Patient safety incidents and harm Patient Safety Incident Response Framework (PSIRF) Spotlight on Project Sphere Regulatory support Clinical leadership in patient safety
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Content ArticleThis guidance for users of the new Learn from Patient Safety Events (LFPSE) service provides context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
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Content ArticleJust like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns a company’s safety philosophy into a clear reality. This article, published by Safety Management Group (SMG), looks at the importance of reporting 'good catches' and the positive impact this can have on safety culture and behaviour.
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Content ArticleA good catch in healthcare is recognised as an employee interception of a potential safety event before a patient is harmed. Both near misses and good catches present healthcare organisations with opportunities for learning to reduce harmful events, which is why reporting near misses in healthcare should be a priority for all organisations, regardless of type or size. It is important that all employees can recognise common examples of good catches in healthcare that prevent patient harm before it reaches the patient. This article, published by Performance Health Partners, includes five situations in which harm can likely occur when no action is taken. It also looks at how to establish a good catch program and how to recognise staff for reporting.
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Content Article
Near-miss and good-catch reporting
Patient_Safety_Learning posted an article in Quality and safety reports
In this article, published by Incident Prevention, authors define what a 'near miss' or 'good catch' is and look at why it is so important to report them. -
Content ArticleWales' national policy on patient safety incident reporting and management.
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Content Article
This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. -
Community Post
Near misses
Claire Cox posted a topic in Investigations, risk management and legal issues
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Do any areas of healthcare capture ALL near misses and act on them? What systems do you use? -
Community Post
How nurses can spot and report error traps and near misses
HelenH posted a topic in Stories from the front line
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How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?- Posted
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Content ArticleThe Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the US. In addition to over 4.5 million acute care reports, the PA-PSRS database contains more than 396,000 long-term care healthcare-associated infection (HAI) reports. This study in Patient Safety aimed to look at trends in HAIs in long term care using data from the PA-PSRS database. The study found that there was an increase in the total number and rate of infections reported to PA-PSRS in 2022.
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