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Found 511 results
  1. Content Article
    The Health Services Safety Investigations Body (HSSIB) was established by the Health and Care Act 2022 as a new non-departmental arm's length body, replacing the former Healthcare Safety Investigation Branch. HSSIB exists to help reduce patient harm by understanding the complex interactions that exist within healthcare that may lead to patient safety events occurring. In other safety critical industries, a safety management system (SMS) approach is used to help enable proactive assessments of risks, specification of how risks should be managed, and set clear lines of accountability and responsibility in addressing risks. This research paper published in the Journal of Patient Safety and Risk Management, shows how HSSIB has begun to explore how an SMS may operate in healthcare to help better equip the system to identify, respond, and proactively identify emerging and recurring concerns that may impact on the safety of patients.
  2. Content Article
    As representatives of the European Patient Safety Foundation, the authors share with the wider patient safety community some current perspectives from across Europe. As the title suggests, in their view, the healthcare systems are dominated by the reality of having to deal with what are seen as multiple crises at the same time, and somehow keep patient safety on the agenda and come up with strategies and initiatives to make improvements. The situation is made even more complex by the fact that these crises take an additional toll on those responsible for delivering safe care, healthcare staff themselves, who already have to cope with difficult working conditions in normal times. This article was published by the Journal of Patient Safety and Risk Management.
  3. Content Article
    Professor Joe McDonald, Principal Associate for health system collaboration for Ethical Healthcare Consulting, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.
  4. Content Article
    The PreAccident Podcast is a bi-weekly discussion of the New View of safety, Systems Safety, Safety Differently and building a community of practice and thought. Hosted by Todd Conklin, this episode examines the idea that a tolerance for failure is a precondition to success.
  5. Content Article
    In the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate. In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the NHS in England, manufacturers of health information technology have been required to submit clinical safety cases since 2013. However, this is a domain with a narrow technological focus and limited organisational support.  Mark Sujan and Ibrahim Habli discuss why they think safety cases would be a valuable addition to Safer Clinical Systems and patient safety practice?
  6. Content Article
    The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management.  Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making.
  7. Content Article
    In this essay for Interactions magazine, Donald A Norman argues that human-centred design has become such a dominant theme in design that it is now accepted by interface and application designers automatically, without thought, let alone criticism. He believes this as a dangerous state and his essay aims provoke thought, discussion and reconsideration of some of the fundamental principles of human-centred design.
  8. Content Article
    In a report published in 2000 by the UK's Chief Medical Officer, it was estimated that 400 people in the UK die or are seriously injured each year in adverse events involving medical devices, and that harm to patients arising from medical errors occurs in around 10% of admissions—or at a rate in excess of 850 000 per year. The cost to the NHS in additional hospital stays alone is estimated at around £2 billion a year. This article examines system safety in healthcare and suggests a 20-item checklist for assessing institutional resilience (CAIR).
  9. Content Article
    In this series of blogs, Stephen Shorrock looks at different interpretations of the term 'human factors'. He outlines four key ideas that seem to exist, each of which has a somewhat different meaning and implications. The human factor Factors of humans Factors affecting humans Socio-technical system interaction
  10. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and some of the key patient safety developments in the past 12 months and looks ahead to 2024.
  11. Content Article
    In this blog, Dr Nadeem Moghal looks at the recent case of a 30 year-old patient who died after a physician associate (PA) at her GP surgery failed to diagnose her with a pulmonary embolism. He outlines a recent debate about the role of PAs in general practice and why employing them has become an attractive option for GP partnerships, which run as businesses. He highlights the need for PAs to be adequately trained and supervised to ensure patient safety and argues that the role is here to stay as PAs play an important role in tackling gaps in the NHS workforce.
  12. Content Article
    In this report authors make a case for the urgent need to improve communication within the NHS. We demonstrate how fundamental good communication is to the quality of care and  treatment that people receive and the levels of trust and satisfaction they feel. They argue that communication and supporting administration should not be seen as a ‘nice to have’, but as fundamental to the functioning of the NHS. DEMOS delivered this work and this publication with our partners, the Patients Association and the PMA. Calls to action: 1. An expansion of the system of care coordinators and improving access to clinicians with oversight of all the care received by people with complex conditions. 2. An expansion of the system of care navigators in GP surgeries across the country, helping people to navigate complex systems and linking people up with the right services. 3. Improvements to the uptake and use of the NHS App through improved functionality and greater publicity Read the full report via the link below.
  13. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. 
  14. Content Article
    The government recently published terms of reference for the Thirlwall Inquiry following the crimes committed by former neonatal nurse Lucy Letby while working for the Countess of Chester Hospital NHS Foundation Trust. As well as examining the detail of the offences, the inquiry will also probe whether the trust’s culture, management, governance structures and processes contributed to the failure to protect babies. In the wake of this tragedy, it became apparent that staff had sounded the alarm about Lucy Letby, but that their concerns were not acted on. The case has propelled the issue of NHS management structures and the regulation of managers back into the headlines and made it the subject of political debate. 
  15. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.
  16. Content Article
    In this article, Stephen Shorrock, Chartered Ergonomist and human factors specialist, shares some some insights on the concept of ‘human error and the idea of ‘honest mistakes’. He outlines the problem with thinking of errors as ‘causing’ unwanted events such as accidents, arguing that this approach ignores all of the other relevant ‘causes’, especially in high-hazard, safety-critical systems,
  17. Content Article
    This article in the British Journal of Anaesthesia argues that the criminalisation of medical accidents leaves clinicians scared to report systemic causes and contributors to bad outcomes, removing a foundational pillar of patient safety. Looking at the case of RaDonda Vaught, a nurse who was found guilty of criminally negligent homicide for a fatal medication accident, the authors highlight the need to move away from seeing adverse incidents in healthcare as being easily avoided through greater attention, trying harder or adherence to rules. They call on healthcare organisations to learn from the case and argue that healthcare systems need to be collaboratively redesigned with a systems perspective.
  18. Content Article
    To improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesising information from a patient's history and physical examination or from a handoff, performing tests or procedures, administering medications and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results, but sometimes this work does not unfold in the way that was anticipated. This article, originally published in Pennsylvania Patient Safety Advisory, argues that efforts to improve healthcare work will not succeed without recognising that there is a difference between a theoretical construct of "work-as-imagined" and the reality of "work-as-done".
  19. Content Article
    Stephen Shorrock looks at how we use deficit-based taxonomies when describing incidents in healthcare and why neutralised taxonomies may be more flexible and useful.
  20. Content Article
    The National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system. SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes. SIPs are delivered by local healthcare providers working directly with the National Patient Safety Improvement Programmes Team and through 15 regionally-based Patient Safety Collaboratives. The five National Patient Safety Improvement Programmes (NatPatSIP) are as follows: Managing Deterioration Safety Improvement Programme (ManDetSIP) Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) Medicines Safety Improvement Programme (MedSIP) Adoption and Spread Safety Improvement Programme (A&S-SIP) Mental Health Safety Improvement Programme (MH-SIP) This report summarises the progress of the National Patient Safety Improvement Programmes.
  21. Content Article
    This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network.
  22. Content Article
    This research report by the Energy Institute is intended for senior management and specialists charged with designing and implementing indicators for major accident hazards safety, or responsible for operating such systems. The report provides an introduction to the Health and Safety Executive (HSE) human factors key topics, and proposes ways in which these might be measured. It also sets out a process for identifying relevant PIs. The research report incorporates findings related to current thinking on safety PIs, in particular for human factors, how organisations currently monitor human factors in practice, and what processes are used to ensure appropriate indicators are selected.
  23. Content Article
    Those who work in health and care are keenly aware of the need to identify and manage risks to protect patients from harm. But we are not the only industry that must take safety seriously. This video from the Healthcare Services Safety Investigation Branch (HSSIB) we compare notes with other safety-conscious industries – oil and gas, shipping, aviation, rail, road, nuclear and NASA – to understand their approach to safety management. In these fields, systems for organising and coordinating safety are often called Safety Management Systems (SMSs). See also HSSIB's report: Safety management systems: an introduction for healthcare.
  24. News Article
    Britain’s top family doctor is calling for a “black alert” system to be introduced in general practice so that doctors can warn when surgeries are dangerously over capacity. It comes as a report reveals that almost half of GPs can no longer guarantee safe care for millions of patients, as a shortage of medics means they are unable to cope with soaring demand. Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners (RCGP), which represents 54,000 family doctors across the UK, wants a patient safety alert system introduced that is modelled on the operational pressures escalation levels (Opel) warnings – known as “black alerts” – already used by hospitals. It would enable practices and GPs to flag unsafe levels of workload, triggering support from their local health system. GP surgeries would be able to temporarily suspend non-priority activities – including some regular health checkups, certain routine but mandatory staff training and non-urgent paperwork – during periods of excessive workload. This would allow surgeries to reprioritise routine and non-urgent activity and ensure patient safety is prioritised. Hawthorne said: “General practice is a safety-critical industry yet GPs have none of the mechanisms that other safety-critical professions, such as the air traffic industry, have in place to protect them. “Our number one priority is the safety of our patients, but GPs are doing more and more to try to meet the rising demand for our services. When you’re fatigued, you’re more likely to make mistakes and our survey shows that many GPs are no longer able to guarantee that the care they are providing to their patients is as safe as it could be.” Read full story Source: The Guardian, 17 October 2023
  25. 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.
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