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Showing results for tags 'System safety'.
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Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
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Content Article"Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
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Content ArticleEZDrugID is a campaign to improve the distinctiveness of medication packaging set up by a group of healthcare workers. Inadequate standards around medication packaging mean that medications with very different actions are sometimes packaged in a very similar way causing "look-alike drugs”. This can lead to errors and serious harm to patients if the wrong drug is mistakenly used. The EZDrugID website contains information about their campaigns to maximise distinctiveness of different medications as well as a "lookalikes" gallery. See also: the hub's error traps gallery The medication safety area of the hub
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- Medication
- Adminstering medication
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Content ArticleDr Robert D. Glatter, medical advisor for Medscape Emergency Medicine, Dr Megan Ranney, professor of emergency medicine and the academic dean at Brown University School of Public Health and Dr Jane Barnsteiner, emeritus professor at the University of Pennsylvania School of Nursing, discuss the tragic case involving RaDonda Vaught, who was an ICU nurse who was recently convicted in Tennessee of criminally negligent homicide and gross neglect following a medical error due to administration of the wrong medication that led to a patient's death.
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- Human error
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Content ArticleAcciMap graphically maps the multiple contributing factors to an accident and their inter-relationships onto the following six levels: Government policy and budgeting. Regulatory bodies and associations. Local health economy planning and budgeting (including hospital management). Technical and operational management. Events, processes and conditions. Outcomes.
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Content ArticlePresentation on the of theme of prevention of medication error from Philip A Routledge and James Coulson (All Wales Therapeutics and Toxicology Centre). Presentation available as slides a written transcript.
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- Medication
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Content ArticleThe delivery of safe and effective healthcare to paediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events. This review from Elkeshawi et al. will explore the medication-use system for hospitalised children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the paediatric medication-use system.
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Content ArticleRebuild General Practice is a campaign that represents GPs from across England, Scotland and Wales, to call for support to address the severe pressures currently faced by primary care. Rebuild GP is calling for Government action on: Recruitment: The UK Government delivering on its commitment of an additional 6,000 GPs in England by 2024 Retention: Tackling the factors driving GPs out of the profession such as burn out Safety: A plan to reduce GP workload and in turn improve patient safety This video shows highlights of a press conference held to launch the campaign. It features accounts from GPs about the pressures they face and how this is affecting staff and patients, as well as a statement from Jeremy Hunt MP, former Health Secretary. Dr Kieran Sharrock, deputy chair of the BMA GP Committee, calls on the Government to work with GPs to find a solution to the issues faced by primary care.
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- General Practice
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News ArticleOn 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
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- Patient death
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Content ArticlePublic satisfaction with the NHS is currently at a 25-year low, and lack of effective communication and engagement with patients has contributed to this dissatisfaction. In this blog, Lucy Watson, Chair, and Rachel Power, Chief Executive of The Patients Association, reflect on the findings of the Ockenden Report and the implications for patient trust in the NHS. They highlight the immense damage to trust caused by the combination of the hospital's substandard clinical care, lack of compassion, tendency to blame mothers and unwillingness to respond to concerns. The authors argue that listening to and better engaging with patients is essential to create the culture change the NHS needs to rebuild public trust and improve safety. They call for honest and transparency about how the NHS is coping, and for more action to tackle low staff morale.
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- Patient engagement
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News Article
Nurse's conviction should be wake-up call for health system leaders, IHI says
Patient Safety Learning posted a news article in News
RaDonda Vaught's conviction for a fatal medical error has already damaged patient safety and should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improvement has said. Ms. Vaught was convicted 25 March of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. "We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors." The organization said criminal prosecution of errors over-focuses on the individual and diverts attention from necessary system-level issues and improvements. "Were this practice to be repeated in future cases of a serious or fatal error, there will be more damage, less transparency, less accountability and more lives lost," IHI said. "Instead, this case should be a wake-up call to health system leaders who need to proactively identify system faults and risks and prevent harm to patients and those who care for them."- Posted
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- Nurse
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Content ArticleIn this video, Dr Zubin Damania discusses the recent criminal conviction of US nurse RaDonda Vaught for a medical error and why this is terrible for patient safety, moral and the future of nursing and medicine.
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Content ArticleRaDonda Leanne Vaught faced criminal charges over a fatal medication error she made in 2017. Her trial has raised important questions over medical errors, reporting and process improvement, as well as who bears responsibility for widespread use of tech overrides in hospitals. There is debate over whether automated dispensing cabinet overrides are a reckless act or institutionalised as ordinary given the widespread use of IT workarounds among healthcare professionals. The Nashville District Attorney's Office described this override as a reckless act and a foundation for Ms. Vaught's reckless homicide charge, while some experts have said cabinet overrides are used daily at many hospitals.
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Content Article1 in 5 women are affected by maternal mental health problems, which are the leading cause of maternal death in the first postnatal year. This report by the Maternal Mental Health Alliance (MMHA) estimates the costs and benefits of a model of care which could give women’s mental health the same priority as their physical health during the perinatal period. The model focuses on the essential role of midwives and health visitors and would allow for women’s mental wellbeing to be accurately assessed at every routine contact and suitable treatments to be offered. It is based on research commissioned by MMHA and conducted by the London School of Economics and Political Science (LSE), which estimates that making changes to standard practice could mean £52 million in NHS savings and quality of life improvements worth £437 million.
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- Maternity
- Mental health
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Content ArticlePatient safety is typically assessed by the frequency of adverse events or incidents, which means we seek to determine safety by its absence rather than its presence. The Safety-II perspective aspires to overcome this paradox by bringing into focus situations where safety is actually present, that is, in everyday work that usually goes well. Central to Safety-II is the notion that, in complex systems such as healthcare, safety is a consequence of collective efforts to adapt to dynamic conditions and uncertainty, rather than the natural state of a system where nothing untoward happens. This type of thinking has been met with significant interest and enthusiasm in healthcare, because it feeds increased appreciation for the fact that healthcare workers continuously ensure that most patients receive safe and high-quality care in challenging circumstances. However, despite its appeal and potential, significant challenges remain for the fruitful interpretation and application of the Safety-II perspective in healthcare, which could give rise to misinterpretations, misuse and a missed opportunity for the potential enrichment of quality and safety practices in healthcare.
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- Safety II
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Content ArticleThis analysis by the Organisation for Economic Co-operation and Development provides the latest comparable data and trends on the performance of health systems in OECD countries and key emerging economies. It examines performance indicators that suggest the following trends: Overall health status in the United Kingdom is close to the OECD average Overweight/obesity and alcohol consumption are higher than the OECD average Population coverage is high, with high satisfaction and strong financial protection The United Kingdom performs well on many key indicators of care quality, though avoidable hospital admissions could be further reduced Health and long-term care spending are above average, though hospital beds and the number of doctors and nurses are slightly below the OECD average The analysis also looks at the impact of the Covid-19 pandemic on deaths, health spending, life expectancy, healthcare activity and mental health.
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News Article
Gloucestershire CQC inspection highlights urgent care delays
Patient Safety Learning posted a news article in News
An inspection of a county's urgent and emergency services found delays were caused by a lack of empty beds and prolonged waiting times. The Care Quality Commission (CQC) inspected Gloucestershire emergency care services in November and December. The report found staff worked well in challenging circumstances but the CQC said pressures on workers across the system needed addressing. Dr Jeremy Welch said: "The system is being stretched and we need to adapt." CQC deputy chief inspector for hospitals, Nigel Acheson, said: "We found the system to be complicated. As a result, staff and patients weren't always able to understand which urgent and emergency care service was best suited to their needs. "This meant people sometimes attended the emergency department when they could have been treated more appropriately elsewhere." In addition the report touched on adult social care and the possibility of using empty care home beds when hospitals were struggling to cope. Dr Welch recognised "it's been a blinking tough time in care homes" over the pandemic and credited the relaxing of rules to allow visits but said there are other factors that would need to be considered. However he added: "We've got enough beds when we map across, it's just getting patients through the hospital and home because home is where they want to be." Read full story Source: BBC News, 17 March 2022- Posted
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- Staff factors
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Content ArticleWithin the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey’s pragmatism, in this study Kirstine Z. Pedersen and Jessica Mesman propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey’s understanding of transaction as the inseparability between human and environment, they develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. They further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.
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- System safety
- Collaboration
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Content ArticleEurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
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- Human factors
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Content ArticleUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. The World Health Organization (WHO) has launched the Third WHO Global Patient Safety Challenge: Medication Without Harm to improve medication safety. Considering the huge burden of medication-related harm, Medication Safety has also been selected as theme for World Patient Safety Day 2022. WHO has launched a series of webinars to introduce the strategic framework for implementation of the Challenge, technical strategies, tools and provide technical support to countries for reducing medication-related harm. The webinars share country and patient experiences in implementing the Challenge. This webinar focuses on the role of patients and their families in improving medication safety, recognising that they are the only constants in increasingly complex healthcare systems, and that they can provide essential information and feedback.
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Content ArticleIn this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the difficulties people experience in disposing of needles and injection devices safely at home. Variation in services across the UK can lead individuals to dispose of sharps incorrectly, posing a risk to refuse workers and the wider public.
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- Patient engagement
- Diabetes
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Content ArticleMedication errors harm patients and cost the NHS money – but with the right approach they can be significantly reduced. An HSJ article with Patrick Wilkinson and Nick Rodger from BD.
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Content ArticleThe impermanent nature of a waiver flexibility and intensified staffing shortages leave health systems that have not yet moved forward with "hospital-at-home" programs in a policy-driven, wait-and-see limbo. The centricity of the home during pandemic life brought renewed attention to the "hospital-at- home" model, but the model dates to the mid-1990s, when it was developed by Bruce Leff, MD, a geriatrician and health services researcher at Johns Hopkins University in Baltimore. His expertise has been even more widely sought since March 2020, as hospitals looked to move care outside of their walls to meet the demands of COVID-19's earliest surges.
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Content ArticleThe Covid-19 pandemic has had a significant impact on people’s mental health, and the knock-on effect is putting services and organisations under considerable pressure. In this briefing for the NHS Confederation, Paula Lavis outlines the case for change in mental health services and makes recommendations on how to address the increasing post-pandemic demand. The briefing covers the following areas: Increased severity of mental health problems linked to the pandemic The wider social context The case for change: Prevention and easy access to mental health support, Funding, Workforce Viewpoint and recommendations
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- Pandemic
- Secondary impact
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Content ArticleThe UK has fewer acute hospital beds relative to its population than many comparable health systems, and the Covid-19 pandemic has had a significant impact on their availability and use. This article by The King's Fund illustrates long-term trends in hospital beds, using 2019-20 data from before the pandemic as the most recent comparator. However, where data is available for 2020/21, the authors have included this for information and to show the impact of the pandemic.
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- Equipment shortages
- Pandemic
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