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Found 511 results
  1. News Article
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation. Read full story (paywalled) Source: The Times, 5 January 2020
  2. 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 people found illegally obtaining, using or disclosing people's private healthcare information. Read full story Source: BBC News, 29 December 2019
  3. Content Article
    EZDrugID 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
  4. Content Article
    On 11 June 2019 an investigation into the death of Brooke Martin aged 19 started. Brooke was a patient at Isla House, Chadwick Lodge, Milton Keynes and was detained under the Mental Health Act. She had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder. Brooke was found hanging in her room and was taken to Milton Keynes University Hospital where she died on 11 June 2019.
  5. Content Article
    Dr 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.
  6. Content Article
    Rebuild 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.
  7. Content Article
    In 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.
  8. Content Article
    RaDonda 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.
  9. Content Article
    Blood transfusion is considered one of the safer aspects of healthcare, however potentially avoidable patient-safety incidents led to 14 deaths in the UK in 2017. Improvement initiatives often focus on staff compliance with standard operating procedures. This fails to understand adaptations made in a complex, dynamic environment, so the aim of this study from Watt et al. is to examine the extent and nature of adaptations at all stages of the vein to vein transfusion process.
  10. Content Article
    1 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.
  11. Content Article
    Patient 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.
  12. Content Article
    This 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.
  13. Content Article
    Have you ever come across a ‘problematic solution’ that was implemented in your workplace, and wondered, “How did this come to be?” Wherever you sit in an organisation, the chances are that you have. Many problematic solutions emerge from a top-down process that Steven Shorrock in this blog will call work-as-imagined solutioneering. In this post, he outlines a typical process of 10 steps by which problematic solutions come into being. Some of the steps may be skipped, but with the same outcome: a problematic solution. At the end of the post, you will find 10 ‘solutions’ from healthcare, provided by healthcare practitioners.
  14. Content Article
    Medication 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.
  15. Content Article
    This chapter from the book 'Learning from High Reliability Organisations' focuses on a systems-based technique for accident analysis referred to as the AcciMap approach. The technique involves the construction of a multi-layered diagram, in which the various causes of an accident are arranged according to their causal remoteness from the outcome. It is particularly useful for establishing how factors in all parts of a sociotechnical system contributed to an organisational accident and for arranging the causes into a coherent diagram that reveals how they interacted to produce that outcome. By identifying these causal factors and the interrelationships between them in this way, it is possible to identify problem areas that should be addressed to improve the safety of the system and prevent similar occurrences in the future. 
  16. Content Article
    Throughout Jens Rasmussen’s career there has been a continued emphasis on the development of methods, techniques and tools for accident analysis and investigation. In this paper, Waterson et al. focus on the evolution and development of one specific example, namely Accimaps and their use for accident analysis.
  17. Content Article
    Patient safety, staff moral and system performance are at the heart of healthcare delivery. Investigation of adverse outcomes is one strategy that enables organisations to learn and improve. Healthcare is now understood as a complex, possibly the most complex, socio-technological system. Despite this the use of a 20th century linear investigation model is still recommended for the investigation of adverse outcomes. In this review, Isherwood and Waterson use data gathered from the investigation of a real life healthcare near incident and apply three different methodologies to the analysis of this data. They compare both the methodologies themselves and the outputs generated. This illustrates how different methodologies generate different system level recommendations. The authors conclude that system based models generate the strongest barriers to improve future performance. Healthcare providers and their regulatory bodies need to embrace system based methodologies if they are to effectively learn from, and reduce future, adverse outcomes.
  18. Content Article
    Unsafe 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.
  19. Content Article
    In 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.
  20. Content Article
    The 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.
  21. Content Article
    The 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
  22. Content Article
    In this opinion piece, Kath Sansom, founder of the Sling the Mesh campaign, highlights the many issues that women face when trying to get pelvic mesh slings surgically removed. She calls for the NHS to give patients a voice and to develop a robust and consistent plan to tackle the issues faced by patients harmed by surgical mesh.
  23. Content Article
    This study in The British Journal of General Practice aimed to quantify the time GPs spend on different activities during clinical sessions, to identify the number of operational failures they encounter and to define the nature of operational failures and their impact for GPs.
  24. Content Article
    This webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch  Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust
  25. Content Article
    This document outlines the Royal College of Emergency Medicine’s (RCEM) systemwide plan to improve patient care. The RCEM CARES campaign addresses pressing issues facing emergency departments (EDs) so that staff can deliver safe and timely care for patients. The campaign focuses on five key areas: Crowding, Access, Retention, Experience, and Safety.
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