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Found 518 results
  1. Content Article
    Professor Alison Leary, Patient Safety Learning Trustee, is Chair of the Healthcare & Workforce Modelling at London South Bank University. In this interview with Patient Safety Learning, Alison discusses why she got involved in patient safety and what needs to change to enable the NHS to become a high performing organisation.
  2. Content Article
    Emergency departments (EDs) are under ever increasing pressure, with performance in winter reaching new lows every year; putting both patient safety and staff morale at risk. While a significant increase in resources, for both the NHS and social care, is clearly needed there are actions that health service leaders and boards can take to help their systems maintain safety and improve performance over winter. 
  3. Content Article
    The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation.
  4. Content Article
    Sir Stephen Moss, Patient Safety Learning Trustee, is the former Chairman of Mid Staffordshire Hospitals NHS Trust, following their damming Healthcare Commission report of 2009. In this interview with Patient Safety Learning, Sir Stephen tells us about lessons learnt and what more needs to be achieved to make the NHS one of the safest healthcare systems in the world. View video (15 minutes)
  5. Content Article
    A report from the WISH patient safety forum held in 2015 about transforming patient safety using a sector-wide systems approach. WISH is a global healthcare community dedicated to capturing and disseminating the best evidence-based ideas and practices.
  6. Content Article
    Kathryn recalls her personal experience of temporary paralysis and respiratory arrest after residual anaesthetic drugs were not flushed from her lines and cannulae following surgery. The video supports the Patient Safety Alert 'Confirming removal or flushing of lines and cannulae after procedures' issued by NHS Improvement in November 2017. More recently, the Healthcare Safety Investigation Branch (HSIB) have carried out an investigation looking at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines and made a series of recommendations.
  7. Content Article
    A great animated video brought to you by No More Throw Away People – voiced by Brian Blessed, this tale of blobs and squares paints an accurate picture of how co-production matters. This short animation shows why its vitally important to engage and include our patients and service users in clinical system design.  It explains simply what may happen if we don't listen to all parts of our system to make care safer.
  8. Content Article
    To Err Is Human breaks the silence that has surrounded medical errors and their consequence – but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda – with state and local implications – for reducing medical errors and improving patient safety through the design of a safer health system.
  9. Content Article
    In this talk, Steven Shorrock outlines seven fallacies of work-as-imagined, concerning outcomes happen, how people work, how we design and implement, and how we think. A number of examples provided by healthcare workers are given. The talk was given at the HSJ Patient Safety Congress 2019.
  10. Content Article
    Patient Safety Learning speaks to Ben Tipney, Managing Director of MedLed and the hub topic lead in Human Factors, about how healthcare can achieve high performance and learn from other industries, including from the sports industry. 
  11. Community Post
    Do any areas of healthcare capture ALL near misses and act on them? What systems do you use?
  12. Community Post
    How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?
  13. Content Article
    NHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
  14. Content Article
    The review makes recommendations to support a more just and learning culture in the healthcare system. This rapid policy review into gross negligence manslaughter in healthcare was chaired by Professor Sir Norman Williams. The review was set up to look at the wider patient safety impact of concerns among healthcare professionals that simple errors could result in prosecution for gross negligence manslaughter, even if they happen in the context of broader organisation and system failings.
  15. Content Article
    Healthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
  16. Content Article
    Risk management has a number of accident causation models that have been used for a number of years. Dr Nancy Leveson has developed a new model of accidents using a systems approach. The new model is called Systems Theoretic Accident Modeling and Processes (STAMP). It incorporates three basic components: constraints, hierarchical levels of control, and process loops. In this model, accidents are examined in terms of why the controls that were in place did not prevent or detect the hazard(s) and why these controls were not adequate to enforcing the system safety constraints. Altabbakh et al. present STAMP accident analysis and its usefulness in evaluating system safety is compared to more traditional risk models. STAMP is applied to a case study in the oil and gas industry to demonstrate both practicality and validity of the model. The model successfully identified both direct and indirect violations against existing safety constraints that resulted in the accident at each level of the organisation.
  17. Content Article
    This directive alert has been issued on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure.
  18. Content Article
    We launched our green paper, 'A Patient-Safe Future’, in September 2018 for two reasons: first to help us develop our strategy and work programme to ensure we are focused on areas that will help make a real difference and, second, to develop a clear and consistent message about how the wider system needs to change to better support patient-safe care.
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