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Found 143 results
  1. Content Article
    This report contains the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel formed under Section 103 of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA). Reporting to the US Federal Aviation Administration (FAA) and Congressional committees of jurisdiction, the Expert Panel reviewed the safety management processes and their effectiveness for each holder of an ODA for the design and production of transport aeroplanes.
  2. Content Article
    Ambulances lined up outside hospital Emergency Departments (EDs) are a vivid, and politically embarrassing, indication of inadequate capacity in the NHS. Media reports of diktats demanding that hospital CEOs meet performance targets suggest a desire for action, but are the local solutions being implemented to ease the pressure in the best interest of patient safety? The use of ‘safety cases’ in healthcare has received some interest in recent years but the conclusion drawn by, for example, Leberati and her colleagues,[1] was that while they have some potential value they are "fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors". A survey of the literature suggests that there is a danger of conflating ‘safety cases’ with ‘safety management’ or ‘quality’ systems. Part of the problem might be that safety cases are more a concept rather than a methodology: there is no script to follow. In this blog, Norman MacLeod discusses whether the the current crisis in hospital capacity can be explored through the safety case lens.
  3. Content Article
    This report examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. 
  4. Event
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    Join this free webinar to learn how collaboration and support for HSSIB (Health Services Safety Investigations Body) will make a difference and will promote a culture of safety in your organisation. During the course the webinar will explore what meaningful recommendations look like and how these recommendations will directly impact individual patient care, policy and strategy. Additionally, we will take a look at how the views of patients and healthcare professionals feed into building a Safety Management System. The primary aim of this webinar is to strengthen the relationship of HSSIB with those who work in the medical profession to aid understanding and future collaboration. By attending the webinar, you will: Gain and build your understanding of HSSIB. Be able to consider how we can contribute and support investigations. Be able to consider how we can contribute and support the implementation of recommendations. Register
  5. Content Article
    A new MIT study identifies six systemic factors contributing to patient hazards in laboratory diagnostics tests. By viewing the diagnostic laboratory data ecosystem as an integrated system, MIT researchers have identified specific changes that can lead to safer behaviours for healthcare workers and healthier outcomes for patients.
  6. Content Article
    Great Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
  7. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.
  8. Content Article
    It was recently reported that NHS Finance Directors were ‘incensed’ that the Health Services Safety Investigations Body (HSSIB) should think that they could be working more closely with patient safety chiefs. Whereas medical staff and clinicians represent the sharp end of healthcare delivery, the administrative functions, including finance, are the blunt end. Removed in space and time from the action, it can be hard to see how their behaviour can directly influence workplace outcomes. To understand the issue, Norman MacLeod reflects on how systems behave and the decision-making hierarchy within healthcare organisations.
  9. Content Article
    This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network.
  10. Content Article
    Those who work in health and care are keenly aware of the need to identify and manage risks to protect patients from harm. But we are not the only industry that must take safety seriously. This video from the Healthcare Services Safety Investigation Branch (HSSIB) we compare notes with other safety-conscious industries – oil and gas, shipping, aviation, rail, road, nuclear and NASA – to understand their approach to safety management. In these fields, systems for organising and coordinating safety are often called Safety Management Systems (SMSs). See also HSSIB's report: Safety management systems: an introduction for healthcare.
  11. Content Article
    Safety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
  12. Content Article
    Healthcare often uses the experience of aviation to set its patient safety agenda, and the benefits of a ‘safety management system’ (SMS) are currently being espoused, possibly because the former chief investigator for HSIB, Keith Conradi, had an aviation background. So, what does an SMS look like and would it be beneficial in healthcare? In this blog, Norman MacLeod discusses aviation's SMS, its many component parts, the four pillars of an SMS, just culture and its role in healthcare.
  13. Community Post
    Strategy - NHS Culture Change.pdf
  14. Community Post

    Better use of data for medication safety in hospitals

    Kenny Fraser

    Kenny Fraser posted a topic in Medicine management

    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  15. Content Article
    In this report, Patient Safety Learning considers the roles and responsibilities of Integrated Care Systems (ICSs) in relation to patient safety, and how this fits in with the wider patient safety landscape in England. This article contains a summary of the report, which can be read in full here or from downloading the attachment below.
  16. Content Article
    This is an overview of the role and responsibilities of the National Patient Safety Committee. This was established in 2021 to bring key national healthcare organisations together to address complex patient safety issues that require cross-organisation effort and input to make care safer within the NHS.
  17. Content Article
    In this blog Aiden Fowler, the National Director of Patient Safety in England and a Deputy Chief Medical Officer at the Department of Health and Social Care, reflects on progress made in implementing the NHS Patient Safety Strategy, four years on from its publication. He outlines some of the main programmes of work associated with this and considers their impact on avoidable harm in the NHS.
  18. Event
    The annual Healthcare Safety Investigation Branch (HSIB) conference agenda will cover: A focus on patient and family engagement. Sharing learning from HSIB national investigations – what has been learnt and how it can help support and improve local investigation practice. HSIB's maternity investigation programme work with families and trusts. This includes how HSIB implements learning from investigations and where the opportunities are to influence change. HSIB's work on Safety Management Systems. How HSIB's education programme is sharing learning to develop and improve local safety investigations. • An overview of HSIB's international work. Breakout sessions to share knowledge. You will also hear how the HSIB will form into the Health Services Safety Investigations Body and the Maternity and Newborn Safety Investigations (MNSI) function and how this may impact you. Register
  19. Content Article
    NHS Impact ‘improving patient care together’ is the term NHS England is using for the new single, shared NHS improvement approach. This includes the five components which form the ‘DNA’ of all evidence-based improvement methods, which underpin a systematic approach to continuous improvement: Building a shared purpose and vision. Investing in people and culture. Developing leadership behaviours. Building improvement capability and capacity. Embedding improvement into management systems and processes. When these 5 components are consistently used, systems and organisations create the right conditions for continuous improvement and high performance, responding to today’s challenges, and delivering better care for patients and better outcomes for communities.
  20. Content Article
    This report by Press Ganey outlines the key trends shaping safety culture in 2023 and makes recommendations for senior healthcare leaders to create and sustain safety culture across their organisations. Based on survey data from 814,000 US healthcare professionals, it highlights that in 2022 there was an upward trend in the perception of safety culture among clinical and nonclinical staff, but perception continues to trend downwards among senior leadership and doctors.
  21. Event
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    The provision of safe and quality care is the most fundamental principle to consider for patients in perioperative practice. Alongside this commitment, is the safety and welfare of all staff and visitors within the setting. Risk assessment, staffing ratios, competency and skill are crucial to ensuring that the intended outcome for patients is achieved as far as is reasonably practicable. The discussion will outline how this can be achieved utilising the recommendations by the Association for Perioperative Practice (AfPP). Learning outcomes: Understanding risk and the process of risk assessment in perioperative practice. The components of a safe perioperative environment. How to calculate a safe staffing model for your environment based on the AfPP standard. Register
  22. Event
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    Start time: 6pm GMT or 1pm ET. A panel discussion with: Karen Wolk Feinstein, PhD, President and CEO of the Pittsburgh Regional Health Initiative Ken Segel, CEO of Value Capture Moderated by Mark Graban, Value Capture Register here
  23. Content Article
    Radar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
  24. Content Article
    On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare. Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. Here, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject. The full transcript of the interview is available to download in the attachment at the end.
  25. Content Article
    In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.
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