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Showing results for tags 'Safety report'.
Found 45 results
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Content ArticleThis table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment.
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Content ArticleFollowing the first confirmed case of COVID-19 in Pennsylvania, facilities began submitting patient safety reports to the Pennsylvania Patient Safety Reporting System related to management of this emerging infection. Events in the analysis most often took place in the Emergency Department, on a Medical/Surgical Unit, or in the Intensive Care Unit. This is a study of 343 Event Reports From 71 Hospitals in Pennsylvania. The table within this document outlines the factors associated with patient safety concerns within COVID-19.
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Content ArticleThis joint report by the Prison Reform Trust (PRT), INQUEST and Pact (the Prison Advice and Care Trust) reveals that most prisons in England and Wales are failing in their duty to ensure that emergency phone lines are in place for families to share urgent concerns about self-harm and suicide risks of relatives in prison. This is in serious breach of government policy that families should be able to share concerns ‘without delay’.
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Content ArticleMark Chassin, M.D., president and CEO of The Joint Commission, sat on the Institute of Medicine committee that authored the landmark 1999 report, To Err is Human. In this podcast, he speaks to Nancy Foster, AHA vice president for quality and patient safety, about its impact on health care safety. He speaks about the need to reflect more on the type of culture that exists within zero harm organisations. He also argues that we need to ensure people feel free to speak up and ensure that everyone is accountable for consistently upholding safety processes and standards.
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Content ArticleThe Patients Association welcomed our publication of ‘A Patient-Safe Future’, which provides a well-founded critique of the shortcomings in safety in our NHS. This is their full response.
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Content ArticleThis review has examined the commissioning and use of clinical advice by the Parliamentary Health Service Ombudsman’s (PHSO) service during the assessment and investigation of complaints made by (or on behalf of) recipients of NHS care. In establishing findings, conclusions, and recommendations, the author, Liam Donaldson, has asked a series of important questions, including: Does the current process for engaging clinical advice work effectively? What, if any, are the main problems, risks, and areas of dysfunction? Does the process need to be improved and if so why and how?
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Content ArticleThis comprehensive systematic review, produced by the General Medical Council) examined the prevalence, severity and key types of preventable patient harm.
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Content ArticleSafety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture). Safety-I and Safety-II is written for all professionals responsible for their organisation's safety, from strategic planning on the executive level to day-to-day operations in the field. It presents the detailed and tested arguments for a transformation from protective to productive safety management.
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Content ArticleAt a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing root cause analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
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Content ArticleA National Patient Safety Alert has been issued around the risk of depleted batteries in intraosseous injectors. The intraosseous (IO) route (that is, through the bone marrow) is used to access the venous system when intravenous access is not possible to administer medicines or fluids, often in emergency situations, including cardiopulmonary resuscitation. IO access is most commonly achieved using a battery-powered injector. As the battery is sealed within the device and cannot be recharged or replaced, the first sign a battery may be depleted is in some circumstances when it does not work. The alert asks providers to replace any battery-powered IO devices that do not have a battery power indicator light with ones with a display that shows how much power is remaining. Where IO devices with a battery power indicator are used, providers are asked to take steps to regularly check these devices to ensure sufficient battery power remains so the devices are always ready and available.
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Content Article
Dirty Dozen and COVID-19 (webinar, May 2020)
Claire Cox posted an article in Coronavirus (COVID-19)
There are fears around maintaining personal safety whilst ensuring patient safety. Staff need to protect both themselves and their families at home. Equally, it is essential that staff feel supported in identifying risks and the potential for errors with a robust mechanism in place to reduce, eliminate or mitigate such risks. The Human Factors 'Dirty Dozen' is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This webinar, from the Clinical Excellence Commission, looks at ways you can identify risks or 'hot spots' in your area of work and then discuss with your team at handover and huddles and plan strategies to reduce, eliminate or mitigate the risks -
Content ArticlePrimary care services provide an entry point into the health system which directly impact's people well-being and their use of other health care resources. Patient safety has been recognised as an issue of global importance for the past 10 years. Unsafe primary and ambulatory care results in greater morbidity, higher healthcare usage and economic costs. According to data from World Health Organisation (WHO), the risk of a patient dying from preventable medical accident while receiving health care is 1 in 300, which is much higher than risk of dying while travelling in an airplane. Unsafe medication practices and inaccurate and delayed diagnosis are the most common causes of patient harm which affects millions of patients globally. However, majority of the work has been focussed on hospital care and there is very less understanding of what can be done to improve patient safety in primary care. Provision of safe primary care is priority as every day millions of people use primary care services across the world. This paper, published in The Journal of Family Medicine and Primary Care, focuses on various aspects of patient safety, especially in the primary care settings and also provides some potential solutions in order to reduce patient harm as much as possible. Some important challenges regarding patient safety in India are also highlighted.
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Content ArticleMedication errors may cause harm, including death, and increase use of health care services. This project aims to summarise the evidence on the burden of medication error, namely the number of errors occurring in the NHS in England, the costs of those errors to the NHS and the health losses due to medication error. This involves two systematic reviews, one on the incidence and prevalence of medication errors, and the other on the costs of health burden associated with errors. Additionally, economic modelling estimates the number of errors occurring in the NHS in England each year, their costs and health consequences.
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Content Article
Team of Teams: Fixing healthcare safety (June 2017)
PatientSafetyLearning Team posted an article in Systems
This article, from the Australian-based Patient Safe Network, argues that healthcare environments have become increasingly complex, existing error reporting systems based on traditional command structures are ineffective and we need to work as a ‘Team of Teams’. -
Content ArticleThere is widely shared agreement that the Canadian healthcare system needs a sharper patient safety focus. The rate of preventable harm in all care settings is alarming, yet poorly understood, leading to complacency and acceptance of patient safety risks. 2018-2019 brought about a change in the strategic direction of the Canadian Patient Safety Institute. Their aim is to inspire and advance a culture committed to sustained improvement for safer healthcare. In this first year of their new five-year business plan, they've laid the groundwork to demonstrate what works and strengthen commitment for end-to-end patient safety improvements and are using those strategic elements to make care safer. Read this annual report to learn more about their priorities and progress.
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Content ArticleThe Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high quality care and we encourage care services to improve. Their role: They register health and adult social care providers. They monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led, and we publish what we find, including quality ratings. They use our legal powers to take action where we identify poor care. They speak independently, publishing regional and national views of the major quality issues in health and social care, and encouraging improvement by highlighting good practice.
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Content ArticleThis report, from the Care Quality Commission, looks at the use of restraint, seclusion and segregation in care services for people with a mental health condition, a learning disability or autistic people.
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Content ArticleThis progress report outlines the contribution of Academic Health Science Networks (AHSNs) during the first year of the NHS Patient Safety Strategy. It looks at the impact it has had in improving safety in hospitals, maternity and neonatal units, care homes and the community. It also describes how AHSNs and the Patient Safety Collaboratives they host have responded to the COVID-19 pandemic, supporting programmes on tracheostomy safety and the use of pulse oximeters to safely monitor patients at home. Examples featured in the report include tools to spot and manage patients at risk of serious illness in hospitals and care homes, discharge safety bundles, and award-winning projects to support premature babies and their families.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the prescribing of medicines for children based on their weight. This HSIB investigation reviewed the case of a four-year-old child who was diagnosed with a blood clot in her leg following a surgical procedure in hospital. She was prescribed an anticoagulant medicine using an electronic prescribing and medicines administration (ePMA) system. Errors in the prescription, dispensing and administration processes meant that the child received ten times the intended dose on five separate occasions over three days. A scan of the child’s brain showed evidence of a bleed and she was admitted to the paediatric intensive care unit. Following three months in hospital, the child was discharged home with an ongoing care plan.
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Content ArticleSince April 2018, the Healthcare Safety Investigation Branch (HSIB) has been responsible for initiating over 1000 independent safety investigations in NHS maternity services in England. This report summarises eight prominent themes that have emerged through analysis of completed maternity investigations, and how HSIB will explore these themes in more detail during the coming year.
