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Found 511 results
  1. 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.
  2. Content Article
    In this webinar, Jane O'Hara, Professor of Healthcare Quality and Safety at the University of Leeds, outlines how understanding of the role of patients and families in supporting patient safety has developed over the past few years. She highlights the work of the Yorkshire Quality and Safety Research Group (YQSR) and looks at research demonstrating the role patients and families can play in improving the safety of healthcare systems.
  3. 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.
  4. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply the Systems Engineering for Patient Safety (SEIPS) approach. This 2.5 hour masterclass will focus on using SEIPS in maternity. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. The course costs £50 per person. Pre and post class materials will be provided. Book a place
  5. 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.
  6. Content Article
    Sometimes after an incident, a system-wide change is implemented that makes work more difficult and creates new problems. This story from aviation is one such example, which contains useful lessons for responding to rare events. Steven Shorrock recounts the tale. 
  7. Content Article
    The Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
  8. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, considering ‘What does safety look like at a system level?’. The round table was chaired by Professor Ted Baker, who led the discussion around the key issues facing Integrated Care Systems and how we can help support their development.
  9. Content Article
    This video offers an introduction to the Systems Engineering Initiative for Patient Safety (SEIPS) framework, an approach that looks at work systems and processes from a systems-based perspective. SEIPS is the main model used within the Patient Safety Incident Response Framework (PSIRF) adopted by the NHS. This video includes an explanation of the model and a dramatisation of the process of making a round of tea in a staff room, illustrating the error traps and design issues present in the environment.
  10. Content Article
    In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.
  11. News Article
    Covid-19 may not have taken as great a toll on the mental health of most people as earlier research has indicated, a new study suggests. The pandemic resulted in “minimal” changes in mental health symptoms among the general population, according to a review of 137 studies from around the world led by researchers at McGill University in Canada, and published in the British Medical Journal. Brett Thombs, a psychiatry professor at McGill University and senior author, said some of the public narrative around the mental health impacts of Covid-19 were based on “poor-quality studies and anecdotes”, which became “self-fulfilling prophecies”, adding that there was a need for more “rigorous science”. However, some experts disputed this, warning such readings could obscure the impact on individual groups such as children, women and people with low incomes or pre-existing mental health problems. They also said other robust studies had reached different conclusions. Read full story Source: The Guardian, 8 March 2023
  12. Content Article
    In this commentary, published by UK in a Changing Europe, Mark Dayan assesses the impact of Brexit on the health service, looking at the effect on funding, the workforce and medicine supplies. 
  13. Content Article
    In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries. In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign.
  14. Content Article
    Patient safety continues to be a significant issue in healthcare and a focus of both quality improvement and academic research. The NHS published its first Patient Safety Strategy in July 2019. As part of this, it was agreed that the first NHS-wide Patient Safety Syllabus would support a transformation in patient safety education and training in the NHS. The Patient Safety Strategy includes ambitions to develop training in the fundamentals of patient safety that would be relevant to all NHS staff, clinical and non-clinical, as well as more detailed training and education that could be incorporated into clinical and non-clinical undergraduate and postgraduate healthcare education and continuing professional development. T The syllabus is designed for all NHS staff and is structured to provide both a technical understanding of safety in complex systems and a suite of tools and approaches that will: Build safety for patients. Reduce the risks created by systems and practices. Develop a genuine culture of patient safety. The patient safety syllabus comprises five sequential domains of safety and forms the basis of the detailed curriculum guidance designed for specific levels of the NHS.
  15. Content Article
    This animation explains systems thinking and the principles of human factors in simple terms. Aimed at healthcare managers and clinicians involved in local level incident investigation, the film uses an example scenario–the incorrect prescription of medications–to introduce the concept of systems thinking and how to use it in healthcare safety investigations.
  16. Content Article
    This editorial, published in BMJ Quality & Safety, the author notes that the involvement of medical trainees in patient care means it is vital that the impact of changes to medical training programmes on patient outcomes are assessed with well-designed studies. They take a look at the impact of medical education on patient safety specifically.
  17. Content Article
    After attending a Safety II workshop, Paul Stretton discusses what the future holds for the Safety II/Resilience Engineering community.
  18. 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. Rob talks to us about his passion for using human factors to improve safety in emergency departments, how allowing doctors to choose their own shifts can make staffing safer and how better integrating technology could help doctors diagnose and treat patients more safely and effectively.
  19. Content Article
    Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.
  20. Content Article
    System working (which includes health and care) is the only way the NHS can address the interlinked problems of struggling primary care, elective backlog, ambulance and emergency department overload, and delayed discharge. In this HSJ article, Len Richards explains how system working grows from the right culture, clinical leadership and systemwide joined up, real-time data.
  21. Content Article
    Quality improvement is a methodology used routinely in emergency departments (EDs) to bring about change to improve outcomes such as waiting times, time to treatment and patient safety. However, introducing the changes needed to transform the system in this way is seldom straightforward with the risk of “not seeing the forest for the trees” when attempting to make changes. This article in Annals of Emergency Medicine aims to demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem (“the forest”) and to support quality improvement planning, identifying priorities and patient safety risks.
  22. Content Article
    Against the backdrop of the Covid-19 pandemic, ensuring the safety of health and social care services remains a serious, ongoing challenge. This report examines how patient safety governance mechanisms in Organisation for Economic Co-Operation and Development (OECD) countries have withstood the test of Covid-19. It provides recommendations for further improving patient safety governance and strengthening health system resilience in OECD countries. This working paper was produced by the OECD for the 5th Global Ministerial Summit on Patient Safety, held in Montreux, Switzerland in February 2023.
  23. Content Article
    After Steve Burrow’s mother was harmed by medical care in Wisconsin, he took time out from his successful film career to advocate for her. In this episode of Lit Health, he touches upon his fascinating career, why stories matter, and delves deeply into his experience with the medical system, its need for policy reform and the role he has taken on as an advocate in this space with host, Tracy Granzyk. Lit Health podcasts interview authors, healthcare leaders, and policymakers working to create a healthcare environment that is equitable, transparent, and that welcomes the needs of every patient – especially our vulnerable populations including the mentally ill, people of colour and women who feel they are at risk in our current system, the elderly, and anyone who feels bias or the isms affect their health and quality of life. You can also watch Steve Burrow's documentary: Bleed Out,
  24. Content Article
    Fatigue has increasingly been viewed by society as a safety hazard. This has lead to increased regulation of fatigue by governments. The most common control process has been compliance with prescriptive hours of service (HOS) rule sets. Despite the frequent use of prescriptive rule sets, there is an emerging consensus that they are an ineffective hazard control, based on poor scientific defensibility and lack of operational flexibility. In exploring potential alternatives, we propose a shift from prescriptive HOS limitations toward a broader Safety management system (SMS) approach. Rather than limiting HOS, this approach provides multiple layers of defence, whereby fatigue-related incidents are the final layer of many in an error trajectory. This review presents a conceptual basis for managing the first two levels of an error trajectory for fatigue.
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