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Found 44 results
  1. Content Article
    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, de
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    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
  4. 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 deplo
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  6. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NH
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  8. 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?
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    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
  12. Content Article
    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
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  16. Community Post
    Do any areas of healthcare capture ALL near misses and act on them? What systems do you use?
  17. Content Article
    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
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    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.
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    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 occ
  25. Content Article
    National data from SHOT (Serious Hazards of Transfusion) indicates there were 792 ‘wrong blood in tube’ near misses (where the error was spotted in time and no patient suffered harm) relating to blood transfusion samples, in 2018 across England. This doesn’t account for blood samples taken for any other purpose. The HSIB report showed why these incidents happen and most importantly what can be done to reduce the risk of it happening again. The investigation looked at all the factors involved and found evidence to show that electronic systems could help staff in busy environments, by makin
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