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Showing results for tags 'Safety assessment'.
Found 81 results
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Content ArticleThis perspective from the US discusses problems with the use of root cause analysis (RCA) in healthcare. The authors summarise research examining the process and share recommendations to enhance the use of RCAs from the National Patient Safety Foundation document RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
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Community Post
Practical tips to help keep patients safe
PatientSafetyLearning Team posted a topic in Improving patient safety
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Stephen Moss, Patient Safety Learning Trustee, suggests four practical tips to help staff keep patients safe: With your colleagues ask a random selection of patients if they have felt unsafe in the last 24 hours (you might want to select a different form of words). If the answer is yes, get under the skin of why they have felt unsafe, pool the knowledge and agree what action you are going to take, or what might need escalating to your line manager. Have a discussion with your colleagues about how you can support each other to uphold your values and professionalism when the going gets tough. Be clear about what help you might need from outside of the team, and follow it up. When looking at your Ward Assurance results, satisfy yourself that where it is possible, they are outcome orientated rather than just focusing on compliance with a process. Look for ways of 'humanising' the data i.e. use a language that identifies the impact on patients and, importantly, use language throughout that will be understood by patients and the public. Too many times I see Ward Assurance results on ward corridors, for the attention of patients and families, written in 'NHS speak' ! When measuring your compliance with the Duty of Candour, don't just look at the numbers! Find a way that also establishes how families feel about the 'quality' of the response, i.e. was it open, honest and transparent and did it give what they needed. How do you think these tips could benefit your patients or service users? Have you tried anything similar that you've found has really helped? Let us know your thoughts and please feedback if you try any of them.- Posted
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Content ArticleDrawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring.
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Content Article
The harms of promoting ‘Zero Harm’
Claire Cox posted an article in Research papers
In their paper 'Managing risk in hazardous conditions: improvisation is not enough', Almaberti and Vincent ask "what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to". This is clearly a critical and much overdue question, as many healthcare organisations are in an almost constant state of stress from high workload, personnel shortages, high-complexity patients, new technologies, fragmented and conflicting payment systems, over-regulation, and many other issues. These stressors put mid-level managers and front-line staff in situations where they may compromise their standards and be unable to provide the highest quality care. Such circumstances can contribute to low morale and burn-out. Eric Thomas discusses this further in his Editorial published in BMJ Safety & Quality.- Posted
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Content ArticleIn 2019, the US-based National Quality Forum (NQF), is convening a new multi-stakeholder expert committee to revisit and build on the work of the Diagnostic Quality and Safety Committee. This report updates a scan done when the National Quality Framework (NQF) diagnostic measures framework first came out in 2017. The assessment of the current state of diagnostic errors measurement, themes that have emerged since the earlier document and new measures that have been published may be of interest to researchers in the UK doing work in this important segment of patient safety work.
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Content ArticlePromoting patient and occupational safety are two key challenges for hospitals. Recent studies have shown there are key topics that are interrelated and form a critical foundation for promoting patient and occupational safety in hospitals. So far, these topics have mainly been studied independently from each other. This study did a combined assessment of hospital staffs’ perceptions of four different topics: psychosocial working conditions leadership patient safety climate occupational safety climate.
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Content ArticleInpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
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Content ArticleObjectives: To explore patients' and carers' experiences of rural general practice to identify their perceptions of safety of care. Design, participants and setting: Four focus group interviews were conducted with 26 rural patients and carers in south-west Victoria between September and December 2012. Frequent users of general practice were recruited from local allied health self-management programs and a mothers' group. Focus groups were audio recorded, transcripts were independently analysed and interpreted using narrative methodologies.
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Community Post
Staff safety in the mental healthcare setting
Patient Safety Learning posted a topic in Mental health
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Interesting blog posted from @Sarahjane Jones on her research findings on staff safety: Do you work in mental health? We'd be interested to hear your own experiences? What challenges do you face? -
Content ArticleIn 2004, the Agency for Healthcare Research and Quality (AHRQ) released the Hospital Survey on Patient Safety Culture (SOPS™ Hospital Survey) for providers and other staff to assess patient safety culture in their hospitals. Since then, hospitals across the United States and internationally have implemented the survey. In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The original survey is still available; however, the use of version 2.0 is encouraged.
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Content ArticleThis paper, published in BMJ Quality and Safety, investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm.
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Content ArticleIn his article for KevinMD.com, Ashish Jha looks at the metrics associated with hospital acquired conditions (HACs) in the US. He discusses the imperfections of HAC scored and argues that we need better measures in order to make further progress in the field of patient safety.
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Content Article
Swab safe management to prevent retained swabs
Kathy Nabbie posted an article in Improving systems of care
Implementation of the Swabsafe™ management system at the The Princess Grace Hospital following a never event. -
Content ArticleA great initiative by East Sussex Healthcare NHS Trust to reinforce the importance of basic checks to keep patients from harm when administering medicines.
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Content ArticleSafety in aviation has often been compared with safety in healthcare. This article, published in JRSM Open, presents a comprehensive review of similarities and differences between aviation and healthcare and the application to healthcare of lessons learned in aviation.
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Content ArticleFallStop is a quality improvement programme from the Falls Prevention Team at the East Kent Hospitals University NHS Foundation Trust. It was developed in 2016 when they found there was a high rate of falls at one of their hospitals and a failure to learn from incidents. A FallStop Practitioner co-ordinates the programme and delivers training.
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Community Post
Patient deterioration out of hours
Emma Richardson posted a topic in Improving patient safety
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Hello I would be interested in hearing from anyone who has done any work on how we monitor patient deterioration overnight? I am currently working on am improvement project looking at patient surveillance of deterioration during night shifts. I have chosen this project as part of a Clinical Improvement Scholarship Program I am on. The program is combined with my day job as a Critical Care Outreach Sister as well as enabling me to develop my research and leadership skills alongside implementing improvements in clinical care. I am in the early stages of my work, however I have some literature and local research around deficiencies in how we monitor patients for deterioration overnight (as well as personal experiences as a CCOT nurse) which is why this topic is so important to me. I would be interested in hearing from anyone who has worked on anything similar, or can point me in the direction of anyone who maybe able to help. Thank you ?- Posted
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Content Article
NHS Quality Accounts FAQs
PatientSafetyLearning Team posted an article in Patient safety standards
A Quality Account is a report about the quality of services offered by an NHS healthcare provider.The reports are published annually by each provider, including the independent sector, and are available to the public. Quality Accounts are an important way for local NHS services to report on quality and show improvements in the services they deliver to local communities and stakeholders. The quality of the services is measured by looking at patient safety, the effectiveness of treatments patients receive, and patient feedback about the care provided. -
Content Article
Rethinking Patient Safety by Suzette Woodward
Claire Cox posted an article in Recommended books and literature
The vast majority of healthcare is provided safely and effectively. However, just like any high-risk industry, things can and do go wrong. There is a world of advice about how to keep people safe but this delivers little in terms of changed practice. Written by Suzette Woodward, a leading expert in the field with over two decades of experience, Rethinking Patient Safety provides readers with a critical reflection upon what it might take to narrow the implementation gap between the evidence base about patient safety and actual practice. This book provides important examples for the many professionals who work in patient safety but are struggling to narrow the gap and make a difference in their current situation. It provides insights on practical actions that can be immediately implemented to improve the safety of patient care in healthcare and provides readers with a different way of thinking in terms of changing behaviour and practices as well as processes and systems. Suzette Woodward shares lessons from the science of implementation, campaigning and social movement methods and offers the reader the story of a discovery. Her team has explored an approach which could profoundly affect the safety culture in healthcare; a methodology to help people talk to each other and their patients and to listen through facilitated safety conversations. This is their story. -
Content ArticleThere are an estimated 200,000 severe adverse drug errors (ADRs) in Canada each year, though it is estimated that 95% of ADRs are not reported. They cost the Canadian healthcare system between $13.7 and $17.7 billion each year and kill up to 22,000 Canadians each year. Over 5,000 of these are Canadian children. ADR Canada is working to prevent this. This article explains the role of genomics in the solution to adverse drug reactions.
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Content ArticleThe Patient Safety Climate in Healthcare Organizations (PSCHO) is a tool, outlined by Singer et al. in their 2007 paper Workforce Perceptions of Hospital Safety Culture: Development and Validation of the Patient Safety Climate in Healthcare Organizations Survey (available on the Health Services Research website). Designed in the US, it is used to assess healthcare employees' perception of the safety culture in their organisation. PSCHO is available to download via the Measurement Instrument Database for the Social Sciences (MIDSS).
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Content Article
AHRQ: SOPS surveys
PatientSafetyLearning Team posted an article in Incentives and techniques
The Agency for Healthcare Research and Quality (AHRQ) has produced a series of Surveys on Patient Safety Culture (SOPS™). The SOPS ask healthcare providers and other staff in hospitals, medical offices, nursing homes, community pharmacies and ambulatory surgery centres about their organisational culture’s support for patient safety. Each SOPS survey kit contains survey instruments, instructions on administering the survey and any supplemental items for those surveys. -
Content ArticleIdentification of hospitalised patients with suddenly unfavorable clinical course remains challenging. Models using objective data elements from the electronic health record may miss important sources of information available to nurses.
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Content ArticleThere has been growing interest in the concept of safety cases for medical devices and health information technology, but questions remain about how safety cases can be developed and used meaningfully in the safety management of healthcare services and processes. This paper in Reliability Engineering & System Safety presents two examples of the development and use of safety cases at a service level in healthcare. These first practical experiences at the service level suggest that safety cases might be a useful tool to support service improvement and communication of safety in healthcare. Sujan et al. argue that safety cases might be helpful in supporting healthcare organisations with the adoption of proactive and rigorous safety management practices. However, it is also important to consider the different level of maturity of safety management and regulatory oversight in healthcare. Adaptations to the purpose and use of safety cases might be required, complemented by the provision of education to both practitioners and regulators.
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Content ArticleCharles Vincent and René Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.
