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Found 189 results
  1. Content Article
    Part I illustrates why improving safety is so difficult and complex, and why current approaches need to change. Part II looks at some of the work being done to improve safety and offers examples and insights to support practical improvements in patient safety. Part III explains why the system needs to think differently about safety, giving policymakers an insight into how their actions can create an environment where continuous safety improvement will flourish, as well as how they can help to tackle system-wide problems that hinder local improvement.
  2. Content Article
    From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
  3. Content Article
    Patient Safety Learning works with experts on guidance around ventilator safety As part of the Government’s fast track approach to the development of ventilators, the Medicines & Healthcare products Regulatory Agency (MHRA) issued guidance for clinical requirements based on ‘minimally acceptable’ performance. [2] Patient Safety Learning approached a range of human factors/ergonomics experts, asking for their input on the procurement of these new ventilators due to the involvement of new manufacturers, flexing of established guidelines and ‘safety in use’ issues. We asked them what
  4. News Article
    In many ways it is wrong to talk about the NHS restarting non-coronavirus care. A lot of it never stopped — births, for instance, cannot be delayed because of a pandemic. However, exactly what that care looks like is likely to be very different from what came before. There are more video and telephone consultations and staff treat patients from behind masks and visors. That is likely to be the case for some time, experts have told The Times. Read full story (paywalled) Source: The Times, 6 June 2020
  5. Community Post
    Do any areas of healthcare capture ALL near misses and act on them? What systems do you use?
  6. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  7. Content Article
    Findings 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 nation
  8. 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 erro
  9. 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,
  10. Content Article
    This 5 minute video, from MedStar Health, focuses on the human cost to our healthcare workforce when we fail to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events. This story has inspired conversation and can be used widely as a teaching tool. When patient harm occurs, caregivers involved are often devastated along with the patient and family, yet many have had to navigate this storm alone. A systems approach in our healthcare workplace, along with the just culture, cultivates the sharing of knowledge and helps prevent patient harm
  11. News Article
    There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the y
  12. News Article
    China has introduced a new law with the aim of preventing violence against medical workers. The announcement comes days after a female doctor was stabbed to death at a Beijing hospital. The law bans any organisation or individual from threatening or harming the personal safety or dignity of medical workers, according to state media. It will take effect on 1 June next year. Under the new law, those "disturbing the medical environment, or harming medical workers' safety and dignity" will be given administrative punishments such as detention or a fine. It will also punish peop
  13. Content Article
    This article from Nursing Open, published here by Wiley Online Library, aims to investigate whether nurse reported teamwork with physicians was associated with patient perceived consistency in staff‐to‐patient communication.
  14. Content Article
    Wrong tooth extraction has been clearly designated as a 'never event' since April 2015. However, in 2016/17, wrong tooth extraction topped the charts as being the most frequently occurring never event based on NHS England’s data. What can we do to mitigate these incidents? Based on both practical experience and research evidence, BAOS advises that the main methods for mitigation of errors are: learning from mistakes – including investigation and root cause analysis engaging the clinical team when developing 'correct site surgery' policies utilising the LocSSIPs temp
  15. Content Article
    About the authors Robert W. Proctor is a distinguished professor of Psychological Sciences at Purdue University. He is a fellow of the American Psychological Association, Association for Psychological Science, and the Human Factors and Ergonomics Society, and recipient of the Franklin V. Taylor Award for Outstanding Contributions in the Field of Applied Experimental/Engineering Psychology from Division 21 of the American Psychological Association in 2013. He is co-author of Stimulus-Response Compatibility: Data, Theory and Application, Skill Acquisition & Training, and co-editor of Ha
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