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Showing results for tags 'Reporting'.
Found 288 results
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EventThis webinar from The European Hospital and Healthcare Federation (HOPE) on 29 March at 14:00 BST (15.00 CEST) will look at the Flemish Institute for Quality of Care (VIKZ). VIKZ is a network organisation financed by the Flemish government that has as primary goal to measure, follow up and publicly report quality and safety of care in the Flemish healthcare sector for the purpose of quality improvement. The objectives of the webinar are to: present the methodology used. give an overview of preliminary results. discuss challenges and future objectives of the VIKZ. Speaker Svin Deneckere, director Flemish Institute for Quality of Care (VIKZ) Register
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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.
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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.
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Content ArticleHertfordshire Partnership University NHS Foundation Trust's Quality Account has been designed to report on the quality of their services in line with regulations. The aim in this report is to describe in a balanced and accessible way of how the Trust provides high-quality clinical care to service users, the local population and commissioners.
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Content ArticleThese professional standards describe good practice and good systems of care for reporting, learning, sharing, taking action and review as part of a patient safety culture. The accompanying guidance and information support the implementation of the standards. These professional standards are for pharmacists, pharmacy technicians and the wider pharmacy team across the United Kingdom. This may also be of interest to the public, to people who use pharmacy and healthcare services, healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
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Content ArticleThis second comprehensive edition of these Principles is to help public authorities, industry and communities worldwide anticipate accidents involving hazardous substances resulting from technological and natural disasters, as well as sabotage. It addresses the following issues: preventing the occurrence of chemical accidents and near-misses; preparing for accidents through emergency planning, public communication, etc.; responding to accidents and minimising their adverse effects; and following-up to accidents, regarding clean-up, reporting and investigation.
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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).
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Content ArticleReporting to the National Reporting and Learning System (NRLS) is largely voluntary, to encourage openness and continual increases in reporting to facilitate learning from error. Increases in the number of incidents reported reflects an improved reporting culture and should not be interpreted as a decrease in the safety of the NHS. Equally, a decrease cannot be interpreted as an increase in the safety of the NHS. This report covers the early stages of the COVID-19 pandemic in England, from April 2020 through to the end of March 2021, when cases had declined rapidly. The number of incidents reported from April 2020 to March 2021 was 2,109,057, and represent a small decrease of 6.1% compared to April 2019 to March 2020 (2,246,622).
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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.
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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.
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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 ArticleAdverse drug reactions (known as ADRs) can occur both in the home, and within the healthcare setting, when combinations of medications produce unexpected side effects. Unfortunately this means that in the most serious cases fatalities can occur. However ADRe has helped all service users by addressing life-threatening problems, reducing pain or improving quality of life. With preventable ADRs responsible for 5-8% unplanned hospital admissions in the UK, and costing the NHS up to £2.5bn pa, it is crucial that healthcare organisations take advantage of tools which can help improve how medicines are managed. ADRe has been developed with the aid of nursing professionals to help nursing staff take a structured approach to the monitoring of medicines, identifying any ADRs service users may be experiencing, and then making changes to improve a patients' health and wellbeing.
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Content ArticleThis study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England’s national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used. AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen.
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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 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 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.
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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 ArticleThe Care Quality Commission provides answers to the following common myths.
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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.
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Content ArticleThe National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body composed of 27 national organisations. In 1995, the United States Pharmacopeial Convention (USP) spearheaded the formation of the National Coordinating Council for Medication Error Reporting and Prevention: Leading national health care organizations are meeting, collaborating, and cooperating to address the interdisciplinary causes of errors and to promote the safe use of medications.
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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 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 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.
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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.
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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.
