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Found 511 results
  1. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Ashley talks to us about the need to professionalise patient safety roles while also upskilling frontline healthcare staff to improve patient safety, describing the role that professional coaching can play. He also discusses the challenges we face in understanding how AI affects decision making in healthcare and how it could contribute to patient safety incidents.
  2. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture. Register hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  3. 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.
  4. Content Article
    This is the recording of a presentation given by Niall Downey at a recent Patient Safety Management Network (PSMN) meeting. Niall considered why error is inevitable, how it affects many different industries and areas of society and, most importantly, what we can do about it.
  5. Content Article
    In this blog to mark World Patient Safety Day 2023, Patient Safety Learning sets out the scale of avoidable harm in health and social care, highlights the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, ‘Engaging patients for patient safety’.
  6. Content Article
    In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
  7. Content Article
    In 2008, five ‘serious untoward incidents’ occurred on a small maternity unit in a hospital in the UK. The prevailing view, held by clinical staff, hospital managers, and executives, was that these events were unconnected and did not signal systemic failures in care. This view was maintained by the testimony of staff and governance procedures which prevented the incidents from being considered together. Drawing on the inquiry report of the Morecambe Bay Investigation (2015), Dawn Goodwin examines how the prevailing view was built and dismantled, eventually being replaced with a very different description of events. Overturning this view required affected parents to engage with governing bodies and legal processes, challenge clinical staff, lobby for inquests, and mobilise social media and the national press. Tracing how different descriptions of events weaken or gather force as they travel through different forums, processes, and are presented to different audiences, she explores the sociology of knowledge around establishing failures of care.
  8. Content Article
    The Aviation Safety Reporting System (ASRS) is an important part of the continuing effort by the US government, industry and individuals to maintain and improve aviation safety. The ASRS collects voluntarily submitted aviation safety incident/situation reports from pilots, controllers and others. it analyses and responds to these incident reports to reduce the likelihood of aviation accidents. ASRS data are used to: identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities. support policy formulation, planning for and improvements to the NAS. strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally recognised that over two-thirds of all aviation accidents and incidents have their roots in human performance errors. The ASRS website outlines the purpose and aims of the system, provides details on how to submit reports and lists related research studies and resources.
  9. Content Article
    The SAFER Guides are designed to help healthcare organisations conduct self-assessments to optimise the safety and safe use of electronic health records (EHRs). Each of the nine SAFER Guides begins with a Checklist of “recommended practices.” This Patient Identification SAFER Guide identifies recommended safety practices associated with the reliable identification of patients in the EHRs. Accurate patient  identification ensures that the information presented by and entered into the EHR is associated with the correct person. Processes related to patient identification are complex and require careful planning and attention to avoid errors. The SAFER Guides are produced by The Office of The National Coordinator for Health Information Technology.
  10. Content Article
    The horrifying case of neonatal nurse Lucy Letby, convicted of murdering seven babies and attempting to murder six others at the Countess of Chester Hospital, has raised hard questions for NHS leaders about how organisations respond to concerns about staff, but could digital systems help detect NHS staff who harm patients at an earlier point? If the pattern connecting Letby to the babies’ deaths had been detected by a digital system, would the response from the trust have been different? Would a machine have been believed?    Alison Leary, chair of healthcare and workforce modelling at London South Bank University and a leading expert on nursing and data, suggests there is potentially a much bigger role for digital in patient safety.
  11. Content Article
    This debate was requested by Barbara Keeley MP of Worsley and Eccles South, following the death of Emily Chesterton, the daughter of her constituents Marion and Brendan Chesterton. Emily died in November 2022 after suffering a pulmonary embolism. She was just 30 years old when she died. The conclusion of the coroner was: “Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”
  12. Content Article
    In this blog, Patient Safety Learning looks ahead to World Patient Safety Day 2023 and the theme of this year’s event, ‘Engaging patients for patient safety’.
  13. Content Article
    The majority of safety failures in the NHS are caused by bad systems not by malicious or incompetent staff, writes Steve Black in this HSJ opinion piece. The Letby case has provoked plenty of discussion of the way the NHS handles safety critical issues. But there were some hints that the way the case was handled was too typical of how the NHS thinks about safety issues both culturally and procedurally. One part of the issue is how the system resists ideas that work elsewhere, the other is how the standard approach to problems makes learning hard and vastly increases the expense of handling safety errors.
  14. Content Article
    In this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
  15. Content Article
    In the early 21st century, the patient safety movement began to talk about system safety. Recognising that people are inherently fallible, advocates for patient safety proposed that it was wrong to blame individual clinicians for poorly designed systems that were full of error traps. However, in a 2013 BMJ editorial, Kaveh G Shojania and Mary Dixon-Woods argue that we must also take seriously the performance and behaviours of individual clinicians if we are to make healthcare safer for patients. They draw on research showing that ‘bad apples’—individuals who repeatedly display incompetent or grossly unprofessional behaviours—clearly exist. This is never more evident than today, when we read about the conviction of nurse Lucy Letby.
  16. Content Article
    Although well-established principles exist for improving the timeliness and efficiency of care, many organisations struggle to achieve more than small-scale, localised gains. Where care processes are complex and include segments under different groups' control, the elegant solutions promised by improvement methodologies remain elusive. This study, published in BMJ Quality and Safety, sought to identify common design flaws that limit the impact of flow initiatives.
  17. Content Article
    While there is much potential and promise for the use of artificial intelligence in improving the safety and efficiency of health systems, this can at times be weakened by a narrow technology focus and by a lack of independent real-world evaluation. It should be expected that when AI is integrated into health systems, challenges to safety will emerge, some old, and some novel. In this chapter of the book Safety in the Digital Age: Sociotechnical Perspectives on Algorithms and Machine Learning, Mark Sujan argues that to address these issues, a systems approach is needed for the design of AI from the outset. He draws on two examples to help illustrate these issues: Design of an autonomous infusion pump and Implementation of AI in an ambulance service call centre to detect out-of-hospital cardiac arrest.
  18. News Article
    Racism is a significant issue affecting recruitment, retention, and patient care. With this in mind, the Royal College of Psychiatrists launched the Act Against Racism campaign, offering guidance and actions to combat racism in the workplace for better staff well-being and patient care, writes Adrian James In June, HSJ revealed that mental health trusts in England are among the biggest users of locum doctors in the NHS. With one in seven medical posts in mental health trusts vacant, many providers now rely on locum doctors to deliver essential services to patients. Read full story Source: HSJ, 9 August 2023
  19. Content Article
    The Covid-19 public inquiry has been in the news recently, with former Chancellor George Osborne and ex Prime Minister David Cameron denying that austerity policies in the UK before the pandemic weakened how prepared the NHS was for such a crisis. In this blog, published by the Nuffield Trust, Leonora Merry and Sally Gainsbury take a closer look at how true this is.
  20. Content Article
    This book, edited by Chartered Health Psychologist Holly Blake, demonstrates the breadth of research on work, health and wellbeing, during and beyond the COVID-19 pandemic, covering workforce impacts and workforce interventions in various countries and settings. Learning from this research will help to build global preparedness for future pandemics and foster resilience for responding in times of crisis and uncertainty.
  21. Content Article
    This investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic.
  22. Content Article
    Clive Flashman, Patient Safety Learning's Chief Digital Officer, shares his presentation slides from the Health Plus Care 2022 conference. The presentation slides include basic principles, how to involve the patient and public in design, key issues and Clive's ten top tips for digital health innovators.
  23. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  24. Content Article
    At a recent Patient Safety Management Network meeting, Hester Wain, Head of Patient Safety Policy at NHS England, and Dr Matt Hill, Consultant Anaesthetist, University Hospitals Plymouth NHS Trust & National Clinical Advisor on Safety Culture at NHS England, presented slides on patient safety culture. Download the presentation slides from the attachment below.
  25. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-based-solutions-patient-safety-masterclass or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org
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