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Showing results for tags 'System safety'.
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Content Article
Seven features of safety in maternity units 1. Commitment to safety and improvement at all levels, with everyone involved 2. Technical competence, supported by formal training and informal learning 3. Teamwork, cooperation, and positive working relationships 4. Constant reinforcing of safe, ethical, and respectful behaviours 5. Multiple problem-sensing systems, used as basis of action 6. Systems and processes designed for safety, and regularly reviewed and optimised 7. Effective coordination and ability to mobilise quickly- Posted
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- Maternity
- System safety
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Community Post
See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.- Posted
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- Patient death
- Patient harmed
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Content Article
"The book describes how a process oriented management system, already well established in other safety critical industries, can be used in the healthcare industry to ensure patient safety. The principles of the management system are rooted in Safety 2 and the book gives practical. detailed instructions on how to create such a system, with processes that map out 'work as done'. The book also explains how healthcare differs from other industries and describes how to implement a safety management system within a healthcare organisation. Leadership, culture and learning also have central roles to play in patient-safe care and the author explains how the management system must work with these three elements. Aside from this, I particularly like the practical nature of the book and the way you give detailed instructions so it can serve as a manual for creating and implementing a management system, based on learning from other industries and the principles of Safety 2. I've seen other people advocate for the use of a safety management system in healthcare, but you have taken it much further than that. I've certainly not seen anyone giving such detail on the practical steps to take to create one." Jonathan Hazan Chairman at Patient Safety Learning. Chief Executive at Perfect Ward- Posted
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- Organisational culture
- System safety
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Content Article
Nigeria: World Patient Safety Day 2020
Patient Safety Learning posted an article in Staff safety
Ehi Iden, Chief Executive Officer of the Occupational Health and Safety Managers, shares with the hub his blog 'Safety of the patients and correlation with the safety of the healthcare workers' (see attachment below). He also share the interview he did for TVC News Nigeria on World Patient Safety Day. Images from the day- Posted
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- Staff safety
- Leadership
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News Article
The Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement.John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required." John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.” Read full story Source: HIQA, 9 September 2020- Posted
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- Radiology
- Health and safety
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News Article
Following four deaths and more than 300 incidents with steroid replacement therapy involving patients with adrenal insufficiency in the past two years, patients at risk of adrenal crisis will be issued with a steroid emergency card. All adults with primary adrenal insufficiency (AI) will be issued an NHS steroid emergency card to support early recognition and treatment of adrenal crisis, a National Patient Safety Alert has said. The cards will be issued by prescribers — including community pharmacists — from 18 August 2020. AI is an endocrine disorder, such as Addison’s disease, which can lead to adrenal crisis and death if not identified and treated. Omission of steroids in patients with AI, particularly during physiological stress such as an additional illness or surgery, can also lead to an adrenal crisis. The alert has requested that “all organisations that initiate steroid prescriptions should review their processes/policies and their digital systems/software and prompts to ensure that prescribers issue a steroid emergency card to all eligible patients” by 13 May 2021. Read full story Source: The Pharmaceutical Journal, 17 August 2020 -
Content Article
This was an explorative study, with qualitative in-depth interviews of 23 family carers of older people with suspected or diagnosed dementia. Family carers participated after receiving information primarily through health professionals working in dementia care. A semi-structured topic guide was used in a flexible way to capture participants’ experiences. A four-step inductive analysis of the transcripts was informed by hermeneutic-phenomenological analysis. -
Content Article
Acute Data Alignment Programme (ADAPt)
Claire Cox posted an article in Data and insight
The aims of ADAPt: To make it easier to monitor the quality and safety of services by including private healthcare data within healthcare reporting systems. To help staff keep accurate and complete records when a patient journey spans both private and public providers. To ensure transparency for patients by publishing comparable performance measures relating to quality of care and patient safety for both privately funded and NHS funded healthcare. To identify where the burden of data collection and reporting by NHS and private care providers can be reduced. Find out via the link below.- Posted
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- Database
- Private sector
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Content Article
Presentation slides Video of presentation (29:21)- Posted
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- Safety culture
- User centred design
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Content Article
PDSA is a very structured four-step cycle which requires effort and discipline. It incorporates careful and detailed consideration of the following: Plan: A plan of what is to be tested including questions to be answered, predictions and answers to the questions and a plan for collection of data to answer the questions. Do: Carry out the test of change according to the plan, recording observations including unexpected outcomes/observations. Study: A comparison of the data against the predictions made in the plan and study the results. Act: Make a decision about the next course of action. Whilst the PDSA cycle originates from industry, it has been incorporated into the Model for Improvement It can be used to test ideas in the real or simulated context.- Posted
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- Quality improvement
- System safety
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