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Showing results for tags 'System safety'.
Found 518 results
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Content ArticleReliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
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Content ArticleThis document outlines how Health Education England (HEE) hopes to expand the role of simulation and immersive learning technologies in the education and training of the NHS workforce. Simulation is defined as ‘a technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully safe, instructive and interactive fashion’. This document considers how existing techniques and technologies can benefit wider policy and strategy goals in health and care, outlining HEE's intention to: promote and strengthen the dialogue between different system and stakeholder organisations, networks, and communities to enable and evaluate opportunities for sharing intelligence and innovation provide a platform for collaboration on common themes of work generate evidence of impact that will help support the transformation in health and care that is required for the future needs of patients and society.
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News Article
Residents 'not safe' at four-inquest care home
Patient Safety Learning posted a news article in News
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 -
EventThis 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 re-designed in line with the new Patient Safety Syllabus. It 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
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EventThis 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 re-designed in line with the new Patient Safety Syllabus. It 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 errors and designing system-based solutions to improve patient safety. Key learning objectives: Understand what Human Factors are Learning from incidents Designing system-based solutions Preventing human error Blame and psychological safety Just culture Register
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Event
Safety-II Practical Applications conference
Patient Safety Learning posted an event in Community Calendar
untilThe 2023 Safety-II Practical Applications Conference is an opportunity for shared learning to advance organisational safety maturity. Traditional methods for safety management, while important, are limiting and often reactive. Many safety professionals have focused on Safety-II as an expanded, more proactive approach that focuses on maximizing learning. The intent of this conference is to provide practical tools for implementation of Safety-II and other next generation strategies. Major themes: Maximising proactive learning opportunities. Developing effective management and cultural systems. Observing and managing high-risk and/or error-likely situations. Learning to shift narratives and distinctions to influence culture. Case studies from many organisations. Register -
Content ArticleThe US President’s Council of Advisors on Science and Technology (PCAST) consists of individuals from sectors outside of the US Federal Government who advise the President on policy matters where the understanding of science, technology and innovation is key. This is the recording of a live-streamed meeting of PCAST, where invited speakers presented opportunities to advance scientific innovation, including improving patient safety.
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Content ArticleSepsis is the leading killer of infants and children worldwide and kills more than 250,000 Americans each year. On 1 April 2012, 12-year-old Rory Staunton died from sepsis after grazing his arm while playing basketball at school. This account by Rory's parents Orlaith and Ciaran Staunton describes the multiple errors by the school and different healthcare professionals that led to their son's death - from the wound not being cleaned by the school, to Rory's paediatrician missing key sepsis warning signs and the ER's failure to read Rory's blood test results that showed he was seriously ill. The article also includes a link to a short video where Orlaith and Ciaran describe what happened to Rory.
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Content Article
In this opinion piece, Kath Sansom, Founder of the Sling the Mesh Campaign, argues that when health services fail to engage meaningfully with patients it causes patient safety issues. Drawing on her own experience as a patient and the founder of a large patient support group, she talks about the invaluable perspective that patients who have experienced healthcare harm can offer policymakers. She also explains why it is important to hear from a wide group of patients who have experienced a variety of issues.- Posted
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Content Article
Patient Safety Now: safety II and maternity (September 2022)
Patient-Safety-Learning posted an article in Maternity
Safety II moves away from simply looking at what went wrong, and aims to understand the realities of everyday work in a constructive and positive way. It focuses on the system as a whole, rather than the end result of the work done. In this blog, Professor Suzette Woodward, Professional and Clinical Advisor in Patient Safety, looks at the role of the Safety II approach in making maternity services safer. She outlines the importance of asking and listening to staff about how to reduce complexity and reform areas of the system that are prone to error. -
Content ArticleSerious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study from Mary Dixon-Woods and colleagues aimed to use the Human Factors Analysis Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports.
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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. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care. -
Content Article
In this blog, Patient Safety Learning marks World Patient Safety Day 2022. It sets out the scale of avoidable harm in health and social care, the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, medication safety. -
Content ArticleToo often in health and social care poor medication practices and inadequate system infrastructure result in patient harm, with as many as 1 in 10 hospitalisations in OECD countries potentially caused by a medication related event. This report considers the human impact and the economic costs of medication safety events, exploring opportunities to improve systems and policies and how to improve medication safety at a national level.
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Content ArticlePatients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organisations where safe care is delivered consistently over time, which is in most cases. In this article, Ioana Popescu discusses patient safety in Canada. While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary.
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Content ArticleThis worksheet produced by NHS Education for Scotland is designed to be used by healthcare teams as a prompt to highlight the various system-wide factors that contribute to an issue. It aims to help teams understand how these factors relate and interact to produce different outcomes.
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Content ArticleTo provide high quality services in increasingly complex, constantly changing circumstances, healthcare organisations worldwide need a high level of resilience, to adapt and respond to challenges and changes at all system levels. For healthcare organisations to strengthen their resilience, a significant level of continuous learning is required. Given the interdependence required amongst healthcare professionals and stakeholders when providing healthcare, this learning needs to be collaborative, as a prerequisite to operationalising resilience in healthcare. As particular elements of collaborative working, and learning are likely to promote resilience, there is a need to explore the underlying collaborative learning mechanisms and how and why collaborations occur during adaptations and responses. The aim of this study from Haraldseid-Driftland et al. was to describe collaborative learning processes in relation to resilient healthcare based on an investigation of narratives developed from studies representing diverse healthcare contexts and levels.
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Content Article
In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.- Posted
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EventuntilWhat we’re getting wrong about the “Five rights of medication use” and other safety myths Despite decades of focus, medication errors, which result from weak medication systems and human factors, constitute the greatest proportion of total preventable harm. Yet across decades of efforts to improve medication safety, a disproportionate burden continues to be placed on human performance, while examination and focus on improving systems and the cultures in which humans work is often limited and reactive. In recognition of World Patient Safety Day, this free Institute for Healthcare Improvement (IHI) webinar examines how traditional approaches to medication safety continue to impede progress. Interprofessional faculty with expertise in systems thinking and human factors engineering will share insights on reorienting our thinking and approaches to medication safety. This webinar will provide fresh ideas for engaging a cross-disciplinary, systems perspective and harnessing team members in the improvement of systems to support medication safety. What you'll learn Review commonly held myths about humans that limit progress in medication safety, including the “Five Rights of Medication Use.” Discuss how human factors design and interventions support human performance and improvements in medication safety. Identify at least one idea for change that you can consider for improving medication safety in your organization. Register This webinar will take place at 12:00-13:00 ET (17:00-18:00 BST)
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Content Article
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Last week the Professional Standards Authority for Health and Social Care (PSA) published a new report, Safer care for all – solutions from professional regulation and beyond, which examines the current state of professional health and care regulation in the UK. In this blog, Patient Safety Learning considers this report from a patient safety perspective. PSA's chief executive, Alan Clamp, has also written a blog for the hub on the report, which can be read here. -
Content Article
In a recent report, the Professional Standards Authority (PSA) for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. In this blog, Alan Clamp, PSA's chief executive, summarises these challenges and the possible solutions. You can also read Patient Safety Learning's reflections on the PSA report here.- Posted
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Content ArticleThe General Pharmaceutical Council (GPhC) has written via email to pharmacists and owners of pharmacies with the GPhC’s voluntary internet pharmacy logo, to address ongoing patient safety concerns affecting the online sector. The emails highlight that over 30% of the GPhC's open Fitness to Practise cases relate to online pharmacy—a disproportionate number for the sector of the market that online services occupy. Common issues raised in these cases include: medicines being prescribed to patients on the basis of an online questionnaire alone, with no direct interaction between the prescriber and either the patient or their GP . prescribing of high-risk medications or medications which require monitoring without adequate safeguards. prescribing of medicines outside the prescriber’s scope of practice. high volumes of prescriptions being issued by the prescriber in short periods of time. The emails also recognise the benefits and risks of online pharmacies, outline how the GPhC may take enforcement action against an online pharmacy, and recommend what actions pharmacists and pharmacy owners should take in response to the patient safety concerns raised. You can view the emails in full: Email to owners of pharmacies with the internet pharmacy logo Email to pharmacists
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Content Article
This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety - here we list six helpful reads related to medication safety in hospital settings. -
Content Article
What is safety management system? (31 August 2022)
Patient Safety Learning posted an article in Organisational
Safety Management System (SMS) is a collection of structured, company-wide processes that provide effective risk-based decision-making for daily business functions. A SMS helps organisations offer products or services at the highest level of safety and maintain safe operations. This article explains more.
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