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Found 147 results
  1. Content Article
    Working with colleagues across the health service community, they are focusing on these key areas: Safer Care through NEWS2 (National Early Warning Score) Emergency Department Safety Checklist Emergency Laparotomy Collaborative Structured Mortality Reviews.
  2. Community Post
    Hi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione
  3. 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?
  4. Content Article
    Minimal Information Model: The WHO Minimal Information Model for Patient Safety is a simple tool which contains the core data categories required for analysis, that can be used by any institution that is looking to set up, or improve, their reporting and learning system. International Classification for Patient Safety: The Conceptual Framework for the International Classification for Patient Safety, developed in 2009, defines and harmonises patient safety concepts into an internationally agreed classification.
  5. Content Article
    In this talk, Rob Hackett, director of The PatientSafeNetwork, takes a look at the medical error problem, why it exists, why it persists, what we can do through working together to overcome it and create the best environment for patient care.
  6. Content Article
    The authors examine how patient harm can be minimised effectively and efficiently. This is informed by a snapshot survey of a panel of eminent academic and policy experts in patient safety. System-level and organisational-level initiatives were seen as vital to provide a foundation for the more local interventions targeting specific types of harm. The overarching requirement was a culture conducive to safety.
  7. Content Article
    The transport of the ICU patient is a complicated process and can lead to patient harm. In the Department of Critical Care Medicine, Calgary Health Region, staff underestimated the risks of intrahospital transport, which led to the two adverse events mentioned above. This article published in Healthcare Quarterly has describes the development of an ICU patient transport decision scorecard to support the safe transport of ICU patients for diagnostic testing. The scorecard is a visual assessment tool. Each item on it is a decision point and a simple reminder to ensure that appropriate resources are available prior to transport. Outcome measures have been added to begin to measure the effectiveness of the tool. Several lessons were learned from the development of this tool: the need to form a subgroup with team members from all sites and disciplines to ensure early buy-in; the involvement of a human factors expert to make the tool easier to use; and the need to continuously retest the tool using PDSA cycles.
  8. Content Article
    In an interview for the Institute for Healthcare Improvement (IHI), Executive Director and patient safety expert Frank Federico describes the keys to success for using health technology safely. He discusses some common safety risks such as clinical alarm safety (now a Joint Commission National Patient Safety Goal), poor training and support systems for new users of technology, and workarounds.
  9. Content Article
    The Curriculum Guide is comprised of two parts. Part A is a teachers’ guide designed to introduce patient safety concepts to educators. It relates to building capacity for patient safety education, programme planning and design of the courses. Part B provides all-inclusive, ready-to-teach, topic-based patient safety courses that can be used as a whole, or on a per topic basis. There are 11 patient safety topics, each designed to feature a variety of ideas and methods for patient safety learning. Universities are encouraged to start with Part A which provides comprehensive advice on how to introduce and build patient safety courses. The associated resources include teaching slides on the following topics: What is Patient Safety? Why applying human factors is important for patient safety Understanding systems and the effect of complexity on patient care Being an effective team player Learning from errors to prevent harm Understanding and managing clinical risk Using quality-improvement methods to improve care Engaging with patients and carers Infection prevention and control Patient safety and invasive procedures Improving medication safety.
  10. Content Article
    Currently, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. The Each baby counts project team will, for the first time, bring together the results of these local investigations to understand the bigger picture and share the lessons learned. From 2015, they began collecting and analysing data from all UK units to identify lessons learned to improve future care. They will then be able to make recommendations on how to improve practice at a national level. This page brings together all of the information and resources about the Each baby counts programme.
  11. Content Article
    This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse. It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again. This video report was streamed live on ITV News on 4th February 2020.
  12. Content Article
    A few years back, I was a guest speaker at a healthcare quality improvement conference where I was approached by a doctor who said he had come to learn “what all this patient safety stuff is about". He had approached me after my presentation and, with more than a little arrogance in the tone of his voice, stated, “if only the nurses would do their jobs and follow my orders correctly, all of these errors would simply go away!” Hmmm…, a damaged and lost soul! My first reaction was to wonder what kind of slimy rock this chap had crawled out from under. However, rather than get annoyed, an emotion that rarely results in improved communication, I simply mentioned that the most current analysis of injuries resulting from patient safety incidents has revealed that the majority of serious injuries, malpractice claims and settlements result from errors or delays in diagnosis and that, the last time I checked, clinical diagnosis is primarily the purview of doctors not nurses. I figured he might want to continue the conversation, but he simply turned and walked away. The truth hurts and I was left wondering how many patients he had harmed, knowingly or unknowingly, during his career. Blaming others can be an easy out from self-examination. As I thought about this interaction later that evening, putting his insulting arrogance aside, it occurred to me that his complacency about his role as a contributor to the patient safety conundrum, and the challenges of assuring diagnostic accuracy specifically, is probably much more common than many would like to admit. Fortunately, his degree of professional arrogance is generally not the rule among compassionate professionals. Still, there is something to learn from his arrogance and from what he said. Complacency, subtle, unrecognised and perhaps pernicious, can become a malignant force. We are all prone to this. We all know that caring for patients, especially for vulnerable patients, is fraught with hazards. We work in highly complex environments, interacting with innumerable patients and professionals every day, each of whom brings strengths and liabilities into the equation we call healthcare. We all acknowledge that there are deficiencies in the structures and processes of healthcare systems and these numerous deficiencies can contribute to patient harm. Anyone who has spent time working in healthcare settings can point to examples of poor leadership, unsafe and unjust cultures, demand-based management and flawed or inadequate healthcare processes that may adversely affect the provision of care and can degrade professional morale. We have all been there. Well-documented deficiencies in the structures and processes of healthcare certainly encumber those working to actually provide care. Frontline staff working under pressure can and will make mistakes; even in institutions where robust efforts have been made to support staff and specifically improve the working environment on the frontlines, mistakes will still occur. Human beings make mistakes, and even though our processes can be standardised to reduce variability and enhance ease of performance, mistakes still will occur, especially in the domain of diagnostic accuracy where standardisation is not so robust and cognitive insufficiencies and biases abound. Caring for patients is complicated stuff! Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. Often we do not even recognise our own liabilities or are unaware of the environmental factors that can enhance them. Workplace complexities and associated stressors such as fatigue, hunger, patient volume and acuity complexity can all contribute to distractions in an already task-saturated environment. If we also factor in outside family, social and economic pressures of various kinds, which we rarely leave at home entirely, the stage is often set for mistakes to occur, sometimes very serious mistakes. The aviation industry is an example of a highly reliable industry where safety is paramount and is often held up as a standard of performance to strive for in healthcare. But an A&E unit is a much more complex and relatively uncontrolled environment than the flight deck of an Airbus 320. In my view, the aviation metaphor commonly falls short when compared to healthcare. As a physician who has also worked in the aviation community for part of my career, I feel that although important lessons can be learned and shared from the aviation industry, the aviation environment is not a mirror image of the healthcare environment. Anyone out there ever made a mistake when caring for a patient? I have made many, I suspect, most unknown to me and of little or no consequence to my patients. I did make a more serious mistake once and my patient, a 9-month-old child, was dangerously but not permanently harmed. When oncologists make mistakes, the consequences can be catastrophic as chemotherapy agents are dangerous. The truth is, I was complacent and didn’t see the potential for harm coming right at me; my fault – or at least that was how I viewed things. I became a ‘second’ victim as a result of this incident and it still resonates with me, all these years later. Hospitals with strong committed leadership are attempting to address the challenges that those on the frontlines must face every day, especially in settings such as A&E units, but one cannot simply design out all of the confounders. There are some excellent examples of robust, patient and staff-focused leadership, safe and just cultures and collaborative management, and these should be emulated nationwide. This all brings me back to the arrogant doctor who wanted to blame the nurses for “all this patient safety stuff”, and his inherent failure to recognise his own singular, important role in the patient safety conundrum. I suspect that this is a natural tendency, as healthcare professionals do not ordinarily see themselves as sources of harm, a concept that is counterintuitive to who we think we are and the excellence in care we strive to provide. The fact is that we may all suffer from some degree of professional complacency. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities, and, thus, the risks we bring into the healthcare environment. Though we all recognise how complex the provision of healthcare can be, we may not fully appreciate that we are also part of that complexity. Our inability to recognise the often subtle but inherent risks we bring to our patients in all healthcare settings is surely an independent variable in the calculus of providing patient safe care. So, I propose the following for all healthcare professionals – each day, before we enter our hospital or surgery, care home or whatever, please pause and repeat the following mantra: “I am a kind and caring professional about to enter a complex healthcare environment where patients may be harmed every day. I admit to myself that although I always intend to serve my patients as best I can, I also inherently represent a source of risk for them and I may make mistakes that can result in harm. Though I may wish to deflect responsibility onto insufficiencies in structures, processes, leadership, culture, managers and even other colleagues, the fact is that I am also a unique risk to my patients. I will be very careful, every day, in every way, with every patient under my care, all the time; and I will strive to be even better tomorrow.” Read Dan's full length article: Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care
  13. Content Article
    Q: Alison, please tell us about yourself? A: I started out as an engineer and then went on to become a registered nurse. I worked in cancer for about 15 years and became an Advanced Nurse Practitioner. I also studied PG medicine and data science so have an eclectic background. I spend a lot of my time researching the relationship between workforces and safety. Q: What got you involved in patient safety? A: As a registered nurse, safety is a core part of the job and I’ve always worked in industries which take safety seriously. For some time, I was calculating optimum caseloads for people like specialist nurses and various people approached me to see if it could be done for the wider workforce. I like looking at complex issues, so I’ve worked on several problems. Q: You have had a varied career – which role has been the most challenging and why? A: Nursing has been the most challenging because nursing generally isn’t valued or seen for the contribution it brings. I struggle to communicate to decision makers/policy makers the risk of diluting the skill of the frontline workforce. Q: We often hear in healthcare that we can learn from other industries – what needs to change to enable the NHS to become a high performing organisation? A: Mostly a shift in culture – being more open when things don’t go well, learning from issues and experiences as they arise and learning from when things do go well. I think employers need to change their view of the people they employ – too often they are seen as some kind of expensive burden instead of an essential asset. Q: Who inspires you, and why? A: A lot of people inspire me. I think really though I keep doing this because I see people going to work everyday under quite difficult conditions. A lot of patients and families who have suffered but still campaign, like Sara Ryan and Julie Bailey, have given tremendous insight into to the very real challenge we face. I think we are fortunate that people who work in patient safety tend to have a real passion for it. Q: How do you envisage patient safety in the future, and how are you playing a part? A: I'd like to see the same legislative framework that other industries have. My part is largely modelling using data – I'd like to see an improvement in the quality of healthcare data so that it's more sensitive to things like workloads and safety. A: If you had a magic wand, what would you add to make safer care for patients? Q: If I could wave a magic wand, I would introduce safety legislation and a proper safety management system into health. As someone at NASA said to me “people shouldn’t need courage to come to work”.
  14. Community Post
    Hi I have been working in a presentation we are giving at ASPiH in November around the work we have done using simulation to test systems and processes. we have done this in two ways. Firstly as a by-product of an educational in situ simulation in s clinical environment where a latent threat has been identified. In this case we will work with the area in looking at just what contributes to the threat and ways that may help. The second way (and with my HF head on, more exciting) has been setting out to test a process. We have done this several times now and have had some real successes in demonstrating the work as done v work as imagined theory. has anyone else used simulation in this way? looking forward to your replies. Phil
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