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Found 223 results
  1. Content Article
    Findings: Most of these risk controls – 35 out of 42 – would be classified as ‘administrative’ by the HoC, and thus considered weak. The risk controls that fell into this ‘administrative’ category included training, standardising processes and procedures, and changing the design and organisation of care. Since other evidence shows these approaches can sometimes be very successful in healthcare, it is probably a mistake to automatically assume they are weak. Completely eliminating reliance on human behaviour is very difficult in the healthcare context and would introduc
  2. Content Article
    To share learning from clinical negligence claims with healthcare professionals, NHS Resolution has now published a suite of six information leaflets relating to medication errors. The ‘Did You Know’ series covers: Maternity Heparin and anticoagulants Extravasation High-level medication errors General Practice medication errors Anti-infective medication errors
  3. Content Article
    They conclude there is sufficient reason to question the use of the Independent Double Check process. Following their findings they felt confident in returning to a single check process. Read the full paper via the link below.
  4. News Article
    A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a differen
  5. Event
    This 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 saf
  6. Content Article
    The authors performed a content analysis of 126 investigation reports from a multi-site NHS trust and used a HFACS-based framework that was modified through inductive analysis of the data. Using the modified HFACS framework, ‘unsafe actions’ were the most commonly identified hierarchical level of contributory factors in investigation reports, which were identified 282 times across 99 (79%) incidents. ‘Preconditions to unsafe acts’ (identified 223 times in 91 (72%) incidents) included miscommunication and environmental factors. Supervisory factors were identified 73 times across 40 (31%) i
  7. News Article
    A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery. Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019. The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired". Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had bee
  8. Content Article
    Saturday 17 September 2022 marks the fourth annual World Patient Safety Day. This event was established by World Health Organization (WHO) as a day to call for global solidarity and concerted action to improve patient safety. It aims to bring together patients, families, carers, healthcare professionals and policymakers to show their commitment to patient safety. Avoidable harm in health and social care What is patient safety? Simply put, patient safety is concerned with avoiding unintended harm to people during their care and treatment. WHO describes it as follows: “Patient safe
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