The World Health Organization (WHO) introduced the surgical safety checklist in 2009 after a successful trial in eight pilot countries; the term ‘Never Event’ has been in existence since 2001. NHS England defines a Never Event as;
“Serious incidents that are entirely preventable because guidance of safety recommendations providing strong systematic barriers are available at a national level and should have been implemented by all healthcare providers.”
The current list of Never Events still only classes three reportable intra-operative ‘Never Events’: wrong site surgery, wrong imp
The webinar starts 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. You will: 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.
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
The focus of CORESS is on detecting and learning from no-harm, near-miss and low harm events encountered during routine surgical practice. The programme collects reports of such events, analyses them and disseminates the learning contained within them to a wide surgical audience and other agencies involved in Patient Safety matters. These events are known collectively as ‘Accident Precursor Events’ or simply ‘Precursors’.
See previous reports below.
Summer 2021 - Unrecognised limb ischemia following trauma, differences of opinion in management for tongue laceration, lack of communica
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,
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?
During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities.
An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit.
In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution
What’s the worst thing you have ever seen?
For those that work on the frontline in healthcare you may have heard this question asked many times… usually by friends or people you meet when you are trying to relax outside of work.
They often want to hear some awful blood and guts story, something unusual being stuck in an unfortunate person’s orifice or a heroic story of a dramatic rescue. We all have something to tell along these lines. Especially when you work in ED, like me.
Yep, they are awful episodes, especially for those involved, these awful stories often happen in ED. Car
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
Content includes: Patient Safety: We’ve Come a Long Way National Patient Safety Consortium: Learning from Large-Scale CollaborationPatient Engagement in a Large-Scale Change Initiative: “As Safe as Possible, as Soon as Possible” Commentary: Three Ideas About “Post-Vention” Patient Safety Never Events: Cross-Canada Checkup Empowering Patients: 5 Questions to Ask About Your Medications Accelerating Post-Surgical Best Practices Using Enhanced Recovery After Surgery Patient Safety Culture Bundle for CEOs and Senior Leaders Commentary: We Must Look at Multiple Per
In this five minute video, the authors chose to focus on the main theme – the human cost to healthcare workforce when there is a failure to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events.