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Found 80 results
  1. Content Article
    More information about "The challenges of navigating the healthcare system: David's story"
    We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, having to travel miles for appointments, miscommunication, diagnostic errors, or having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, David* shares his story about his elderly sister and a mix up with an urgent referral which led to a near miss. Background My sister has cancer and she's got a diagnosis of dementia too. The cancer is very aggressive and it causes her a lot of pain. Her care team are managing her pain very well. Due to her age and frailty, chemotherapy was out of the question but she had surgery and it seemed to go well. She was having routine check ups post-op to monitor her. An urgent referral A few months later unfortunately the cancer came back and we got an urgent referral from her GP for her to see her consultant. So when within a couple of weeks we got an invite to the hospital for an appointment we assumed it was for her urgent cancer referral. When we got to the appointment, neither the consultant or her advanced nurse practitioner team, who were all familiar with her diagnosis and history, were there. Instead there was a junior doctor on his own. He asked my sister how she had been since her surgery and was she doing well. When my sister said, well no, the tumour had grown significantly and we think the cancer had come back, he went white and rushed out of the room saying he needed to speak to someone else. Communication issues He came back and said my sister would need 20 days of successive radiotherapy in the hospital (which is at least a two-hour round trip). We had many questions we wanted to ask but he wasn’t able to answer them, and I was very concerned whether this was the right course of treatment for her. There were a number of issues—I had questions about how aggressive the cancer was, whether the cancer had spread elsewhere, whether this was palliative or curative treatment, what impact this would have on my sister’s health. Radiotherapy is harsh and my sister was physically very frail. In the end, because I phoned the advanced nurse practitioner and explained what had happened and my concerns, we were invited back for another appointment, and a few days later we saw the consultant. On the advice given, my sister was told about the significant risks and unsuitability of radiotherapy because of her co-morbidities and she decided not to go ahead with the radiotherapy. This was a relief as I didn’t want her to have unnecessary treatment, especially treatment that would not address her cancer and make her remaining months painful and distressing. The consultant was wonderful, and I’ve written him a lovely letter thanking him, but there has been a big communication issue here which could have led to a different outcome altogether. A 'near miss' The issues here, as I see them, are that the urgent referral got mixed up with the routine post-op appointment, which led to a doctor in training being placed in a situation for which he was untrained and unprepared in making significant treatment decisions. The advice he received and acted upon was from an unnamed consultant who didn’t even speak with or examine my sister. There is also the fact that they didn’t have a conversation with my sister about her options and they just told her she needed the radiotherapy. This is not informed consent! If we hadn't been there with her and questioned it, would she have had that course of treatment, accepted the radiotherapy, even though it was completely unnecessary, which would have led to avoidable harm? This really is a big ‘near miss’. What would have happened if she hadn’t had anyone there to intervene and advocate for her. She has absolute confidence in the health system but, for her family trying to navigate the system, this was incredibly stressful. What happens to the patients who haven’t got a family around to support and advocate for them? We need to look at the whole care pathway and try to design it from the patient and family’s perspective. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: Margaret's story The challenges of navigating the healthcare system: Sue's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses
  2. Community Post
    Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh [email protected]
  3. Content Article
    Underreporting of adverse events and near misses results in incomplete data for patient safety improvement efforts. This review sought to identify factors contributing to nurses' decisions to report medication errors and near misses. The main factor contributing to decision-to-report is the expected reaction of superiors, colleagues, and patients. Fear of retaliation or poor grades prevented reporting by nurses and nursing students, respectively.
  4. Content Article
    Near misses are incidents that could have led to harm but were detected and addressed before reaching the patient. Learning from these incidents reveals processes that help in detecting errors and also illuminates opportunities for continuous quality improvement. At present, limited Canadian data are available concerning interventions by community pharmacy teams to correct errors before they reach the patient (also known as “good catches”). The multi-incident analysis reported here highlights practices and processes that resulted in successful interception of errors in the community pharmacy setting.
  5. Content Article
    More information about "Near misses or great catches? A blog by Emma Walker"
    After attending a recent Patient Safety Management Network session, Emma Walker reflects on reporting on near misses. I was on one of the great Patient Safety Management Network drop-ins the other week, where they were sharing the learning from a safety observation session. The Session had been in a busy A&E department and at one point the observer flagged that a patient hadn’t been given a name tag for their wrist. The observer stepped in, identified the harm and it was rectified. I asked in the meeting chat if the organisation in question had flagged this as a near miss? "No, I don’t think so" was the response – "there are just too many near misses, and we are just too busy to report every one." Many folk on the call agreed. I was surprised to hear this. Having spent nearly 20 years married to a chemical engineer and spending a lot of my free time with engineers from across industry, I know that this behaviour would be totally unacceptable across the organisational cultures they work in, and potentially a reportable/disciplinary issue. Interestingly, their ingrained behaviours and cultures are such that it doesn’t usually get to that stage as everyone just knows what the right thing to do is and there are systems and cultures to make it easy. However, not the NHS it seems. As my husband said when we discussed this later, "this is free learning, and there are hundreds of firms across the country willing to show you tools and techniques to make reporting quick and easy". A colleague of mine, who was recently clinical, mentioned how ‘busy’ and ‘longwinded’ some reporting forms are... having to log into a computer (if one is available) while so busy: "I used to do mine at the end of a shift, not getting home till after 10 at night despite finishing at 20:15". Going back to the PSMN drop-in, what was really interesting was a nurse from the USA at the meeting was one of the few who agreed that not reporting near misses was really poor safety culture. She talked about how they are an aspiring high reliability organisation and how "we love near misses – we call them great catches". What can you do today to start changing your safety culture? How can you make it easy for all staff to do the right thing? A culture that doesn’t blame with easy, quick processes to follow, and support for staff to do just that. Go and make a great catch and prevent the next patient/member of staff suffering the same harm. As we know, a great catch missed today could become something far worse tomorrow. Do you have a 'good catch' reporting system? Share your experiences and questions in our Community thread or comment below You'll need to register for free first. . Related reading: Near-Miss and Good-Catch Reporting Promote a culture of safety with good catch reports Using good catches to increase worker ownership of safety 5 Examples of good catches in healthcare and how to implement a near miss campaign
  6. Content Article
    Just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns a company’s safety philosophy into a clear reality. This article, published by Safety Management Group (SMG), looks at the importance of reporting 'good catches' and the positive impact this can have on safety culture and behaviour.
  7. Content Article
    A good catch in healthcare is recognised as an employee interception of a potential safety event before a patient is harmed. Both near misses and good catches present healthcare organisations with opportunities for learning to reduce harmful events, which is why reporting near misses in healthcare should be a priority for all organisations, regardless of type or size. It is important that all employees can recognise common examples of good catches in healthcare that prevent patient harm before it reaches the patient. This article, published by Performance Health Partners, includes five situations in which harm can likely occur when no action is taken. It also looks at how to establish a good catch program and how to recognise staff for reporting.
  8. Content Article
    In this article, published by Incident Prevention, authors define what a 'near miss' or 'good catch' is and look at why it is so important to report them.
  9. Content Article
    Wales' national policy on patient safety incident reporting and management. The National Policy on Patient Safety Incident Reporting and Management published by the Welsh Government Delivery unit can be downloaded from the attachment below. It covers the following: Section 1 – Never Events list Section 2 – Reporting processes Section 3 – Guidance on specific incident types Section 4 – Joint investigation process Section 5 – Safety II guidance Section 6 – Commissioned services flowchart – NRI reporting.
  10. Content Article
    More information about "The Family Oops and Burns First Aid eBook"
    'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.
  11. Content Article
    In this blog, After Action Review (AAR) specialist Judy Walker shares an account of a successful AAR that took place amongst a surgical team. The AAR was called after a near-miss where the anaesthetist was prevented from injecting spinal block medication into the wrong side of a patient's spine by an operating department practitioner (ODP). The story demonstrates the benefits of AAR, including accelerated learning, a no-blame approach, flattening staff hierarchy and a significant reduction in the time it takes to investigate an incident. Related reading Patient Safety Spotlight interview with Judy Walker, Senior Business Consultant, iTS Leadership Disaster recovery: restoring hope after things go wrong (Judy Walker, 5 January 2023)
  12. Content Article
    Near misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED). This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED. It was published in the Journal of Patient Safety. Authors conclude that near-miss events are relatively common (22.7% of their sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.
  13. News Article
    Physician associates have attempted to illegally prescribe drugs at dozens of NHS trusts and missed life-threatening diagnoses, a dossier claims. Doctors working across the country claim patients’ lives have been put at risk by physician associates (PAs) who they say have failed to respond appropriately to medical emergencies – alleging more than 70 instances of patient harm and “near misses”. The Telegraph has seen responses from more than 600 doctors to a survey on PAs run by Doctors’ Association UK (DAUK), a campaign group. The data suggest that at over half of England’s hospital trusts, doctors are being replaced by PAs on the rota, despite associates only completing a two-year postgraduate course and having no legal right to prescribe. A spokesperson from the Department of Health said their role “is to support doctors, not replace them”. The Telegraph has interviewed more than a dozen surveyed doctors, as well as other clinicians worried about patient safety. At Dudley Group NHS Trust, one junior doctor said a PA had missed an “obvious heart attack” on an ECG, having “just signed it as if it was normal”. A clinician in primary care alleged PAs repeatedly misdiagnosed a patient’s metastatic cancer as muscle ache – despite blood results that were “tantamount” to a cancer diagnosis. They said: “The patient could have been saved eight months of pain; their life could have been prolonged.” Read full story (paywalled) Source: The Telegraph, 27 January 2024
  14. News Article
    The NHS will start recording harm caused to patients during strike action where exemptions have been rejected by the British Medical Association (BMA). BMA council chair Phillip Banfield yesterday accused NHS England of the “weaponisation” of the strike “derogation” process, saying trusts had this week submitted more of the requests, which would permit some striking doctors to return to work, and were not providing information needed to determine if they were justified. NHS England wrote back to Professor Banfield, insisting it was only trying to prioritise safety, but also saying it would revise its own approach to derogation requests. This will include: asking trusts whose requests were rejected by the BMA “to compile a picture” of the impact on services; reinforcing requirements to report patient safety incidents during strikes and after mitigation requests, so “we can evidence harm and near misses which might have been avoided”. The letter says: “We have consistently asked local medical and other clinical leaders to consider applying to the BMA for patient safety mitigations where they have significant concerns for patient safety that cannot be mitigated through other options available to them, and where they can make a strong evidential case that the return of a limited number of junior doctors would address these risks. “We have done this, in part, because we have received a number of reports over previous periods of action that some teams have been put off seeking patient safety mitigations because of their prior experience of having applications rejected, or not receiving a response in time. We are sure you would agree that this is an unsatisfactory position, and that where patient safety concerns exist, these should always be escalated appropriately.” Read full story (paywalled) Source: HSJ, 4 January 2024
  15. Event
    until
    This free webinar will explore near misses in three different sectors and how controls can, or cannot, be developed to prevent future events. It will start with an introduction to the concept of near misses in healthcare and the challenges faced in learning from these near misses to improve safety. You will then hear how near misses are approached in rail and nuclear and how controls are developed in their processes. At this event, you’ll: Gain valuable insights from all three sectors: healthcare, rail and nuclear. Hear discussion about defining near misses with respect to controls. Learn how to build barriers in systems. Who will this be of interest to? This webinar will be of interest to anyone involved in the management of safety events in their industry/ organisation, and especially human factors practitioners, safety investigators, policy leads and regulators. Register
  16. Community Post
    What do hub members think about use of the term "near miss" vs "close call" vs "good catch" to describe errors that are caught before the reach or harm the patient? If you have a favorite, can you say why?
  17. Community Post
    Do any areas of healthcare capture ALL near misses and act on them? What systems do you use?
  18. 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?
  19. Content Article
    AHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety.  Case submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above, describe how the error was recognized) Recommendations (describe your suggestions for how providers or systems might prevent similar errors from happening in the future) Responses to each of the above areas are limited to 250 words. Please note that submissions may be extensively edited for consistency with PSNet’s style, without changing important clinical details. Case selection criteria The editorial team reviews submitted cases regularly and judges cases using the following criteria: How interesting is the case from a medical error/patient safety standpoint? Is the case an important example of a common error, or is it unique but nevertheless raises some key issues of general interest? Does the case have sufficient clinical detail to inform practicing clinicians? Does the case have significant educational value? Does the case highlight important systems issues? If you are interested in submitted a case, please visit: https://psnet.ahrq.gov/webmm/submit-case. You may be contacted if further information is needed to judge your case submission.
  20. Content Article
    This document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales. National guidance for the investigation of any patient safety incidents identified as either a Serious Incident (SI) or No Surprises/Sensitive Issue relating to the provision of digital health care services in Wales
  21. Content Article
    Psychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that highlight both resilience (“we avoided failure”) and vulnerability (“we nearly failed”). Near misses offer learning opportunities for addressing underlying causes of potential incidents, and it is crucial to understand what facilitates near-miss reporting. This study by Jung et al. found near misses are not processed and reported equally. The effect of psychological safety on reporting near misses becomes stronger with their increasing proximity to a negative outcome. Educating healthcare workers to properly identify near misses and fostering psychological safety may increase near-miss reporting and improve patient safety.
  22. Content Article
    Maternal near miss is a major global health issue; approximately 7 million women worldwide experience it each year. Maternal near miss can have several different health consequences and can affect the women’s quality of life, yet little is known about the size and magnitude of this association. The aim of this study from von Rosen et al. was to assess the evidence of the association between women who have experienced maternal near miss and quality of life and women who had an uncomplicated pregnancy and delivery.
  23. Content Article
    More information about "Royal Pharmaceutical Society: Revised Competency Framework for all Prescribers (September 2021)"
    This competency framework has been developed and updated to support prescribers in expanding their knowledge, skills, motives and personal traits, to continually improve their performance, and work safely and effectively. 'To support all prescribers in prescribing safely and effectively, a single prescribing competency framework was originally published by the National Prescribing Centre/National Institute for Health and Care Excellence (NICE) in 2012. NICE and Health Education England approached the Royal Pharmaceutical Society (RPS) to manage the update of the framework on behalf of all the prescribing professions in the UK. A Competency Framework for all Prescribers was first published by the RPS in July 2016. Going forward, the RPS will continue to maintain and publish this framework in collaboration with a multi-disciplinary group with representatives from professional regulators, professional organisations, prescribers from all prescribing professions, lay representatives and other relevant and interested stakeholder groups from across the UK. ' Since the 2016 framework, there have been various changes that needed to be included in the update of the framework, these include: Legislation changes introducing paramedic prescribers in April 2018. Current prescribing topics, such as remote prescribing, social prescribing, psychosocial assessment and eco-directed sustainable prescribing. Publication of the RPS Competency Framework for Designated Prescribing Practitioners in December 2019; for further information, please see 'A competency framework for designated prescribing practitioners'. Supporting tools
  24. Content Article
    This study, published in the Journal of Advanced Nursing, investigates the processes through which personnel understaffing and expertise understaffing jointly shape near misses among nurses during the Covid-19 pandemic. It looks at survey data collected from 120 nurses in the United States of America working in hospitals during the pandemic. The authors conclude that the challenges created by understaffing of nurses have been amplified by the pandemic. They suggest that understanding the mechanisms through which safety outcomes are affected by understaffing can help healthcare organisations be better prepare for safety challenges that may arise when staffing shortages are experienced.
  25. News Article
    A hospital has made changes after two patients were accidentally given medical air instead of oxygen. The two incidents, which took place at the Norfolk and Norwich University Hospital (NNUH), were classed as "never events" meaning they were serious but preventable. They happened to patients in November who were being handed over to the hospital by the East of England Ambulance Service. The patients should have been given oxygen but were given medical air instead which only contains 20pc oxygen. The ambulance service said in a message to staff: "Severe harm or death can occur, if medical air is accidentally administered to patients instead of oxygen. As per NNUH's request, with immediate effect, when handing over at the NNUH, all medical equipment and oxygen should be swapped only by an emergency department doctor or registered nurse." Read full story Source: Eastern Daily Press, 2 December 2019

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