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Showing results for tags 'Safety process'.
Found 208 results
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Content ArticleThis article in Patient Safety looks at a new approach to identifying and monitoring patients with sepsis developed by a team of nurses at WellSpan Health in the USA. The Central Alert Team (CAT) works remotely, looking for indicators of sepsis in patient charts and vital signs. They relay information and treatment advice to nurses working at the bedside and take an adaptive approach to find the best ways of working. This focused approach means the CAT nurses are able to quickly identify patients who are deteriorating and ensure treatment is administered at the right time.
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Content ArticleSerious Hazards of Transfusion (SHOT) introduced a new Human Factors Investigation Tool (HFIT) in 2021. The tool can be used to investigate and capture systemic as well as individual factors where there has been an error. This case study uses the updated Human Factors Investigation Tool and Systems Engineering Initiative for Patient Safety (SEIPS) framework to work through an ABO incompatible red cell transfusion case reported to SHOT.
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Content ArticleThis new book by Professor Harold Thimbleby of Swansea University tells stories of widespread problems with digital healthcare and explores how they can be overcome. "The stories and their resolutions will empower patients, clinical staff and digital developers to help transform digital healthcare to make it safer and more effective."
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Content ArticleDouble-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors. The authors found that: most nurses complied with mandated double-checking, but the process was rarely independent when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious. They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.
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Content ArticleThis paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
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Content ArticleDr Helen Simpson, Lisa Shepherd and Dr Steve Kell summarise the guidance and implementation of the steroid emergency card in primary care.
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Content ArticleThe Essentials of Safe Care is a practical package of evidence-based guidance and support that enables Scotland’s health and social care system to deliver safe care.
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Content ArticleAs part of the NHS family, NHS Supply Chain is prioritising patient and user safety as a core part of their approach to supplying clinical products to the NHS by raising standards and effective partnership working. Jonathan Devereux, Head of Safety and Innovation, heads up a small team focused on driving proactive action on safety complaints, building an innovation pathway and ensuring they drive safety into the agenda for future procurement. In this article for the National Health Executive he explains the work the clinical and product assurance team are doing.
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Content ArticleIn my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed.
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Content ArticleThis report produced by the American Medical Association details action steps that can be taken by an organisation before, during and after a crisis to reduce psychosocial trauma among healthcare workers.
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Content ArticleIn this reflection, published in the BMJ's Post Graduate Medical Journal, Dr John Launer talks about an exercise to help people to become better supervisors, to use peer supervision as a safe space for people to develop better interactional skills generally – and particularly to cultivate their curiosity.
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Content Article
Double checking: a second look (16 November 2015)
Patient Safety Learning posted an article in Process improvement
Double checking is a standard practice intended to improve patient safety. It is used in different areas of health care, such as medication administration, radiotherapy and blood transfusion. Some studies have found double checking to be a useful practice, which has been endorsed by agencies and individuals. The confidence in double checking exists in spite of the lack of evidence substantiating its effectiveness. In this study, Hewitt et al. asks: ‘How do front line practitioners conceptualise double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?’ The authors conclude that double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged. -
Content ArticleMedication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. This paper, published in the Cochrane Database of Systematic Reviews, considers the effectiveness of interventions to reduce medication errors in adults in hospital settings. The review covered 65 studies involving 110,875 participants.
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Content ArticleIn this podcast episode, host Aaron Harmon speaks to Dr Neil Vargesson, chair in developmental biology at the University of Aberdeen, about the importance of Good Laboratory Practice (GLP) and why pre-clinical studies are key to keeping people safe. They discuss the history of Primodos, a hormone-based pregnancy test that was given to women between 1959 and 1978. It was developed before GLP and before standardised testing for teratogenesis (causing birth defects). There are data that suggests Primodos caused birth defects, but more questions remain.
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Content ArticleThis article, published in BMJ Quality and Safety, examines the relationships between non-routine events, teamwork and patient outcomes in paediatric cardiac surgery. Structured observation of effective teamwork in the operating room can identify deficiencies in the system and conduct of procedures, even in otherwise successful operations. High performing teams are more resilient, displaying effective teamwork when operations become more difficult.
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Content Article'The Theatre: Surgical Learning & Innovation Podcast' is a podcast by the Royal College of Surgeons of England. This episode features a panel discussion on the nature of “human factors” in surgery, presented by Peter Brennan, consultant oral and maxillofacial surgeon, Louise Cousins, trainee general surgeon, Neil Tayler, British Airways pilot and trainer, and Graham Shaw, also a British Airways pilot and Director of Critical Factors, a consulting and training service for professionals operating in safety-critical environments.
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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. -
Community Post
Resetting priorities for Safer Healthcare
Dr Akhil Sangal posted a topic in Leadership for patient safety
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Content ArticleIn this article Steven Shorrock argues that understanding the complexities and nuances of human work is critical if we are to improve how work really works. In healthcare, as clinicians and other healthcare professionals navigate their roles, they encounter a diverse array of situations that create goal conflicts, dilemmas and other challenges. One way to explore these is via micro-narratives. These are short stories based on personal observations and experiences. One method to capture these is via simple written postcards. Postcards from Work (Healthcare Edition) delves into these experiences. A sample of the cards is shown within the article.
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Community Post
National Patient Safety Syllabus
Jon Holt posted a topic in Professionalising patient safety
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The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey- Posted
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Content ArticleExtravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue which can damage the tissue and cause serious harm to the patient. This is a survey for healthcare professionals on approaches to extravasation management outside of cancer care. It is part of a campaign led by the National Infusion and Vascular Access Society (NIVAS) to improve awareness of infiltration and extravasation to reduce avoidable harm.
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Content ArticleThe publication of a new single, shared improvement approach, ‘NHS Impact’, is an exciting milestone. It reflects recognition, at the highest level in the English NHS, that improvement principles need to be part of the mainstream approach to the challenges facing the sector. Penny Pereira, Q’s Managing Director, considers the new approach, its potential impact and what it means for members and others working to improve health and care in England and beyond.
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Content Article
NHS Impact resources
Patient Safety Learning posted an article in NHS England
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. -
Content ArticleThis blog on the Sling the Mesh website provides an overview of research by Professor Carl Heneghan, Director of the Centre for Evidence-Based Medicine at Oxford University, into regulatory issues relating to pelvic mesh. It outlines issues uncovered by Professor Heneghan and his colleagues, including the fact that clinical trial data was not required in the regulation of mesh and that early evidence of complications was ignored in the approval of subsequent devices.
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News Article
NHS staff fear speaking out over crisis in English hospitals
Patient Safety Learning posted a news article in News
Nine months ago, Boris Johnson praised staff at St Thomas’ for saving his life. Now, a senior intensive care nurse at the London hospital has warned that patient care is being compromised because of staff shortages and a failure to plan for the second Covid wave. Dave Carr, an intensive care charge nurse, is one of many NHS workers desperate for the public to know what is going on inside their hospitals at a time when misinformation and scepticism about the virus are rife. “The public needs to be aware of what’s happening. This is worse than the first wave; we have more patients than we had in the first wave and these patients are as sick as they were in the first wave. Obviously, we’ve got additional treatments that we can use now, but patients are still dying, and they will die,” said Carr. As a representative for the union Unite, Carr feels emboldened to speak out. But across the NHS, many more staff claim they have been threatened with disciplinary action or even dismissal if they put their head above the parapet. In Devon, one nurse working on a Covid ward said safety standards had slipped at her hospital, but she feared for her job if she was identified by name. “The infection control restrictions are more relaxed. Before, we had to use a separate entrance but now we don’t, and some doctors feel they don’t have to obey the infection control protocols and are still unsure of how to properly remove the PPE,” she said. Read full story Source: The Guardian, 1 January 2021
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