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Found 511 results
  1. Content Article
    Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism (PE), following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review: Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns. Drawing on existing data, freedom of information requests and Jenny’s case, the report raises significant patient safety concerns relating to PE care across England and Wales. Tim calculated that from April 2021 to March 2022, there was a minimum of 400 excess deaths due to pulmonary embolism misdiagnosis. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 
  2. Content Article
    Professor Mary Dixon-Woods looks at improving the quality and safety of care in hospitals, and suggests that we need to take a three-pronged approach: ensuring we are collecting the right data and interpreting it intelligently, looking at the systems we work in and finally how culture and behaviour impact on quality of care.
  3. Content Article
    This editorial by Barbara Fain, Chief Executive of the Betsy Lehman Center in Massachusetts, highlights the need to focus on system safety and moving away from a culture of individual blame, in order to improve patient safety. Referring to the case of nurse RaDonda Vaught who was convicted of negligent homicide for a medication error at a Tennessee hospital, Barbara looks at research that demonstrates that people generally believe the best way to reduce the likelihood of medical errors is by choosing the right doctor, and argues that this cultural belief played into Vaught's conviction. She highlights the need to use evidence-based strategies to communicate with healthcare professionals and the public about the wider picture of patient safety and systems thinking.
  4. Content Article
    This article, published in The international journal for quality in healthcare, looks at the Hierarchy of Risk Controls approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems.
  5. Content Article
    Cynefin, pronounced kuh-nev-in, is a Welsh word that signifies the multiple, intertwined factors in our environment and our experience that influence us (how we think, interpret and act) in ways we can never fully understand.  The Cynefin Framework was developed to help leaders understand their challenges and to make decisions in context. It has been applied to many different environments including healthcare and safety. To read more about the framework and to watch a 12-minute introductory film, follow the link below to the Cynefin Co website.
  6. Content Article
    What is resilience? What is resilience engineering? This 25-minute talk, published by devopsdays, will ground your understanding of those terms using the compelling example of bone.  Dr. Richard Cook is a Principal with Adaptive Capacity Labs and Research Scientist in the Department of Integrated Systems Engineering at The Ohio State University (OSU) in Columbus, Ohio.
  7. Content Article
    Resilience Engineering refers to building complex systems that are resilient to change and disruption. In this blog, the author reflects on his own reading around the topic and how we might apply resilience engineering.
  8. Content Article
    Weaknesses resulting from a patchwork of patient safety processes developed by individual healthcare organisations over the past quarter-century, exposed by the Covid-19 pandemic, can be remedied through both local systems design support and widespread best practices uniformity.
  9. Content Article
    A report by Lord Young of Graffham to the Prime Minister (David Cameron) following a Whitehall‑wide review of the operation of health and safety laws and the growth of the compensation culture.
  10. Content Article
    This study, published in the Journal of Patient Safety, tells how Mackenzie Health responded to low safety culture scores by implementing a zero-harm strategy.
  11. Content Article
    In this article, Roger Kline, Research Fellow at Middlesex University, explains what caused the sinking of the Herald of Free Enterprise ferry. The sinking of the Herald of Free Enterprise on March 6 1987 with the loss of 198 lives was an accident waiting to happen, highlighting the devastating consequences of abandoning safe working practices in the name of financial savings. Human factors science learned from the Herald disaster is widely applied in sectors as diverse as nuclear power stations and healthcare.
  12. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
  13. Content Article
    Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system. This article explores how HFE can be used to improve patient safety, in particular using the Systems Engineering Initiative for Patient Safety (SEIPS) model, which depicts key characteristics and interactions between three core components: work system process outcomes
  14. Content Article
    This blog is part of a series in which Steven Shorrock, an interdisciplinary humanistic, systems and design practitioner, outlines seven ‘archetypes of human work’. This blog looks specifically at 'The Messy Reality' archetype, which is characterised by adjustments, adaptations, variations, trade-offs, compromises and workarounds that are hard to prescribe and hard to identify, but that can become accepted and unremarkable for insiders. Steven examines what 'The Messy Reality' is, why it exists and highlights some examples from the aviation and healthcare industries.
  15. Content Article
    The third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
  16. Content Article
    This article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
  17. Content Article
    In this review, Jane Carthey and colleagues discuss human factors research in cardiac surgery and other medical domains. The authors describe a systems approach to understanding human factors in cardiac surgery and summarise the lessons that have been learned about critical incident and near-miss reporting in other high technology industries that are pertinent to this field.
  18. Content Article
    This is a summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey to discuss the Patient Safety Incident Response Framework (PSIRF) to the law firm Browne Jacobsen. The session covered key elements of PSIRF, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust,
  19. Content Article
    Radar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
  20. News Article
    A trust chief executive says the Care Quality Commission’s (CQC) inspection regime is still overly focussed on individual organisations, rather than systems, and this is driving the “risk aversion” which is partly responsible for the emergency care crisis. Mid Yorkshire Hospitals Trust CEO Len Richards acknowledged the CQC has started to scrutinise system-wide issues but suggested the “heat” of its regulation is still on individual providers. Mr Richards told the House of Lords’ public services committee on Wednesday that care homes and nursing homes in his area have declined to take patients ready to be discharged from hospital, due to concerns it would put their CQC accreditation at risk. He said: “[Last winter] we asked nursing homes and care homes to take patients and they couldn’t take them beyond a certain limit because it would put their accreditation at risk. “We went to the CQC to try and create some flexibility. Their perspective was very much of an independent regulatory body that would look at the organisation and not look at the system. I think we’ve got an awful long way to go there. “I think regulation does drive risk aversion… [and] the heat of regulation right at the moment is on individual organisations. “Therefore, when the CQC come and look at my organisation, they will talk about congestion in the A&E department. They won’t talk about the assessment that we made around there being a greater risk in the community if we didn’t offload ambulances.” Read full story (paywalled) Source: HSJ, 28 October 2022
  21. News Article
    A care home that will close after admitting "shortcomings in care" and failures in leadership has been labelled "not safe" by inspectors. The Elms in Whittlesey, Cambridgeshire will shut later this month, and the Care Quality Commission (CQC) has found the service to be inadequate. In May, the BBC first reported the concerns of relatives about The Elms after their loved ones died in 2019, weeks after a meeting in which worries were raised about "poor care". Inquests into the deaths of the residents - George Lowlett, Margaret Canham and David Poole - remain ongoing. HC-One also apologised to the family of Joyce Parrott, who died in April 2020. Inspectors found "people were not safe and were at risk of avoidable harm" and described multiple occasions when people had "not received their medicines as prescribed". Other findings included: Staff had not referred all potential safeguarding events to the local authority A failure to "establish systems to ensure people were effectively safeguarded from abuse" The provider had failed to learn when things went wrong "Widespread and significant shortfalls" in leadership No reliable record of the staff that had worked at the home and a reliance upon agency staff, which "resulted in people not receiving consistent care" Read full story Source: BBC News, 5 October 2022
  22. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation focuses on the systems used by healthcare providers to book patient appointments for clinical investigations, such as diagnostic tests and scans. ‘Clinical investigation booking systems’ are used throughout the NHS to support the delivery of patient care. Healthcare services use paper-based or fully electronic systems, or a combination of the two (hybrid systems), to communicate to patients the time, date and location of their appointment. These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems. This investigation examines the safety implications of patient communications, produced by booking systems, that do not account for the needs of the patient. In addition, it looks at why patients are ‘lost to follow-up’ after an appointment is cancelled, rescheduled or not attended. Lost to follow-up is the term used to describe a patient who does not return for planned appointments (whether for continued care or evaluations) or is no longer being tracked in the healthcare system when they should be.
  23. Content Article
    In 2023, research suggested adverse events occur in about one-fourth of hospital admissions, prompting NEJM Catalyst to seek insight from leaders on how healthcare organisations can get more strategic around patient safety and quality improvement.  Thomas Lee, MD, editor-in-chief and editorial board co-chair of the NEJM Catalyst Innovations in Care Delivery journal, reached out to 13 leaders in response to the study findings led by David Bates, MD, chief of general internal medicine at Boston-based Brigham and Women's, that indicate it is time to revamp patient safety and quality work.  This article published by Becker's Hospital Review highlights excerpts from four leaders' responses.
  24. Content Article
    On Saturday 17 September 2022, the fourth annual World Patient Safety Day took place, established as a day to call for global solidarity and concerted action to improve patient safety. Medication safety was chosen as the focused for World Patient Safety Day 2022 due to the substantial burden of medication-related harm at all levels of care. In this report, the World Health Organization (WHO) provides an overview of activities in the countries that observed World Patient Safety Day 2022 to make this event.
  25. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, chaired by Professor Ted Baker, to consider ‘what does safety look like at a system level?’ and discuss the key issues and help support the development of Integrated Care Systems. This report captures the key themes covered in this discussion.
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