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Found 125 results
  1. Content Article
    No adverse event should ever occur anywhere in the world if the knowledge exists to prevent it from happening. However, such knowledge is of little use if it is not put into practice. Translating knowledge into practical solutions is the ultimate foundation of the safety solutions action area of the World Alliance for Patient Safety. In April 2007, the International Steering Committee approved nine solutions for dissemination: Look-Alike, Sound-Alike Medication Names (PDF) Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. Patient Identification (PDF) The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. Communication During Patient Hand-Overs (PDF) Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. Performance of Correct Procedure at Correct Body Site (PDF) Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. Control of Concentrated Electrolyte Solutions (PDF) While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. Assuring Medication Accuracy at Transitions in Care (PDF) Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. Avoiding Catheter and Tubing Mis-Connections (PDF) The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. Single Use of Injection Devices (PDF) One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI) (PDF) It is estimated that at any point in time more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Effective hand hygiene is the primary preventive measure for avoiding this problem.
  2. Content Article
    On Wednesday 1 May 2024, the National NatSSIPs Network hosted a webinar to discuss the NHS England consultation on the Never Events framework. The consultation is concerned with whether the existing framework is an effective mechanism to drive patient safety improvement. This blog gives an overview of the discussion at this webinar, which had over 200 participants. The NHS England Never Events policy and framework defines Never Events as: “Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Strong systemic protective barriers are defined as barriers that must be successful, reliable and comprehensive safeguards or remedies—for example, a uniquely designed connector that stops a medicine being given by the wrong route.” In February 2024 a consultation was opened seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. This follows the findings of reports such as the Care Quality Commission’s Opening the door to change and the former Healthcare Safety Investigations Branch’s analysis of Never Events, which highlighted that for several types and sub-types of Never Events, the existing barriers were not strong enough to make an incident wholly preventable. Considering its effectiveness, the consultation asks respondents which of the following options they would prefer for the future of the Never Events framework: Option 1: No change; continue with the current framework. Option 2: Abolish the Never Events framework and list. Option 3: Revise the list of Never Events to only include those with current barriers that are ‘strong, systemic, protective’. Option 4: Revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’. Webinar panel This webinar, held to discuss these proposals, was chaired by Dr Annie Hunningher, Consultant in Anaesthesia and Group Safety Lead at Barts Health NHS Trust. She was joined by the following panel: Claire Cox, Patient Safety Lead at King's College Hospital NHS Foundation Trust and Founder of the Patient Safety Management Network. Dr Claire Morgan, Consultant in Restorative Dentistry, Patient Safety Specialist at Royal London Hospital, Barts Health NHS Trust and Deputy Chair for the Patient Safety Group for the Royal College of Surgeons of Edinburgh. Helen Hughes, Chief Executive of Patient Safety Learning. Professor Iain Moppett, Professor of Anaesthesia and Perioperative Medicine and Honorary Consultant Anaesthetist at the University of Nottingham and Nottingham University Hospitals NHS Trust. Kellie Bryan, Head of Patient Safety Investigations and Patient Safety Specialist at University Hospitals Sussex NHS Foundation Trust. Dr Samantha Machen, Associate Director of Patient Safety and Head of Patient Safety Incident Response at University Hospitals Sussex NHS Foundation Trust. Initial opinions At the beginning of the webinar, a poll was conducted to ascertain initial views on which of the four options in the consultation attendees favoured. The results, pictured below, showed that the fourth option had the greatest support among those in attendance. Attendees were also asked to state the first word that came to mind when asked the question ‘Is the Never Events Framework an effective mechanism to drive patient safety improvement?’ Their responses resulted in the word cloud pictured below. Key themes and issues Subsequently, each of the panellists was asked to set out their views on the Never Events framework and consultation proposals. This was interspersed with and followed by comments and questions from attendees of the webinar and conversations between the panel. There was a consensus that protecting patients from avoidable harm is the number one priority, but the question was how to do this within the current healthcare system and environment. Below are some of the themes and issues that emerged from this lively and engaging debate. ‘Wholly preventable’ incidents Reflecting on a key issue raised by option 4 in the consultation, whether Never Events need to be revised so that they are not required to be ‘wholly preventable’, there were a number of comments by panel members and attendees. There was a suggestion that making this change would not be a significant departure from the status quo, but simply a recognition of the practical reality that many of these events are not ‘wholly preventable’. The difference between ‘work as imagined’ and ‘work as done’ in relation one specific type of Never Event, the scalding of patients, was also discussed. It was noted that while in principle hospitals should be able to put in place a series of mitigations to reduce the risk of this, what is done in practice can be significantly limited in ageing hospital estates with outdated infrastructure. These challenges are not recognised by the existing framework when considering this type of incident as ‘wholly preventable’. Another example given by one of the presenters considered a case study of wrong intraocular lenses, a type of wrong implant/prothesis Never Event. Although initially this may appear ‘wholly preventable’, an investigative approach revealed a significant degree of complexity that is not adequately addressed or mitigated by existing checking procedures. Indicators of patient safety There was considerable discussion around how the reporting of Never Events is currently used and whether this is a useful means of measuring overall patient safety in an organisation. It was noted that Never Events data only represents a small part of all the healthcare and patient safety activity in an organisation. Furthermore, it is focused on specific areas of care, with three surgical Never Events broadly accounting for around 80% of all Never Events in total. It was suggested that this narrow scope means that organisations’ performance in relation to Never Events, good or bad, is not necessarily a reliable indicator of the approach to safety across an organisation. The issue was also raised that the current incidents listed as Never Events apply to procedures that are much more frequent in Acute Trusts. So, while you would be likely to have significantly fewer Never Events at a Mental Health or Community Trust, this isn’t an indicator of higher levels of safety at those organisations, just of a measure being set by NHS England. Public visibility and transparency Panellists and attendees discussed the level of public attention and focus that Never Events received compared to other patient safety incidents, highlighting the following points: The purpose and benefit of publishing the names of organisations and their numbers of Never Events in the public domain is unclear. There is no context or nuance to help the public understand or find balance (such as numbers of surgeries performed or the size and complexities of the Trust, for example, teaching hospitals). Public awareness of Never Events appears to be low. One attendee noted that people do not tend to look at this data until they are impacted by it, at which point it is too late. The patients and families that do look at Never Events do so because they have suffered from one of these incidents. Simply publishing the number of incidents alone is not a good measure of safety. The data as currently published does not consider responses to these incidents or accompanying plans for improvement. The term ‘Never Event’ A prominent issue of discussion was the appropriateness of the description ‘Never Event’ itself. Some in attendance suggested it felt disingenuous to patients, staff and public given the consistent number of these incidents that continue to occur, implying that this can be reduced to zero. Alternative names were posited, such as ‘Priority Safety Events’. It was noted that ‘never’ is not often used in other safety critical industries, and hazard management phrases including 'as low as reasonably practical' should be considered. The point was also raised by several participants that the term itself could be seen as punitive, contributing to a blame culture. In a counterpoint, it was suggested that this stemmed from wider issues of a lack of safety culture in parts of the NHS. In this context, changing the name of Never Events will not address the problem. Level of attention and focus on Never Events Another significant area of discussion in the webinar concerned whether too much emphasis is placed on Never Events, distracting from other areas of patient safety focus. It was noted that although a significant amount of time and resources is invested into investigating Never Events, there is little evidence to suggest this is translating into wider system level improvement. In the context of this, it was suggested by some participants that the current approach to Never Events could be seen as disproportionate. It was suggested that this may be particularly the case under the new Patient Safety Incident Response Framework (PSIRF) where all Never Events, regardless of the level of harm, will require a full Patient Safety Incident Investigation (PSII). An example was given that if a patient had an incorrect mole removed, this would be classed as a Never Event (a form of wrong site surgery) requiring a full PSII, despite being a low harm event. Under PSIRF, this may be prioritised for investigation at the exclusion of a full investigation of missed diagnosis of a serious condition, despite the latter potentially resulting in a much more significant level of patient harm. There were also points raised about the opportunity cost of focusing significant resources on Never Events. Examples of this include: Not looking more closely at the majority of cases when Never Events do not happen, learning from when things go right and the activities and behaviours that lead to this. Whether a focus on Never Events lets system leaders ‘off the hook’ for significant safety issues elsewhere by defining events in such a narrow way. Not considering near misses more closely. A participant suggested that reporting of these can low because of the lack of capacity to report these and insufficient capacity in patient safety teams. Consequences of abolishing Never Events Reflecting on a key issue raised by one of the four options in the consultation, whether Never Events should be abolished, there were a number of comments by panel members and attendees. There were concerns about the negative perception this may create, including: Even if there is a strong rationale for removing this term, it could be seen as a reduction in transparency around the occurrence and frequency of these incidents. It could be interpreted as a signal that we are giving up the ambition of that these types of incidents should never occur. For a patient or family member involved in a Never Event with serious life altering consequences, it was noted it would be difficult to see how such a change could be viewed positively and not undermine their trust in the healthcare system. A concern was also raised that with some of these incidents being so rare, abolition of the Never Events framework may result in a loss of visibility for serious patient safety incidents. It was suggested this may reduce leadership focus on issues such as wrong site surgery and retained foreign objects. This could potentially reduce opportunities for investigation and improvement. Redefining Never Events At the beginning of the webinar, the proposed consultation option to revise the definition of Never Events was most favoured among attendees. Considering what this might look like, the following points were made: There should be a focus and priority given to the level of harm, rather than simply the type of incident. Events with catastrophic implications for patients should be prioritised. Focus should not be simply on reporting the number of events, but how they are responded to. What corresponding investment and training is put in place to address problems that have been identified? The events included in the definition should be expanded. Suggestions of this included types of incorrect medicine administration and surgical fires. Concluding views During the webinar, a poll asked whether participants had ever been involved in a Never Event, which produced the results pictured below. To close the webinar, another quick poll was conducted to ascertain whether participants’ views on the four options in the consultation had changed. The results, pictured below, showed a significant growth in support for the second option, ‘Abolish the Never Events framework and list’, at the end of the debate. However, significant support remained for the fourth option to ‘Revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’. There is still time to share your views with NHS England on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. The consultation is open to responses until Sunday 5 May 2024—respond and share your views. Networks on the hub This webinar was hosted by the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. the hub hosts and supports a growing number of informal peer support networks for people involved in patient safety, providing a forum for meeting up, discussing and sharing ideas and initiatives, and learning from others. We also host the Patient Safety Management Network, an innovative network for patient safety managers and everyone working in patient safety. You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Related reading National learning report: Never Events analysis of HSIB's national investigations report (21 January 2021) How can Never Event data be used to reflect or improve hospital safety performance? (1 May 2021) The National Safety Standards for Invasive Procedures (NatSSIPs) (January 2023) Why are surgical never events still occurring: A Delphi study research sample across NHS England operating theatres (17 June 2023) You can also find a number of existing resources, tools and stories relating to Never Events on the hub.
  3. 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]
  4. Content Article
    Retained surgical items (RSI) are a never event. This article describes implementation of an evidence-based improvement project to reduce RSI and increase reporting of RSI near misses. An important aim was to improve teamwork and assertive communication between operating room (OR) team members, which was achieved through use of the TeamSTEPPS program. Change in staff attitudes about teamwork was measured using the Teamwork Attitudes Questionnaire, which showed improved perceived teamwork.
  5. Event
    until
    Nasogastric tube (NGT) safety has been a pressing issue for over two decades, with the first Patient Safety Alert (PSA) issued back in 2005, drawing attention to the dangers of misplaced NGTs. Despite subsequent alerts, reports, and detailed studies — including an investigation by the Health Service Safety Investigation Body (HSSIB) in 2020 — little progress has been made, and misplaced NGTs still rank high on the list of Never Events. Now is the time for change. This free webinar we will discuss the latest developments and actionable strategies to address these ongoing challenges. Register
  6. Event
    until
    NHS England is currently seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. Never Events are defined as patient safety incidents that are ‘wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’. This webinar, hosted by the National NatSSIPs Network and supported by Patient Safety Learning, will feature a panel discussion on the Never Events framework and the proposals set out in this consultation. The National NatSSIPs Network is a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Speakers: Helen Hughes Dr Annie Hunningher Dr Sam Machen Claire Cox Guest Speaker Guest Speaker Register
  7. 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.
  8. Content Article
    On Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar. The first half of the webinar featured the following subjects and speakers: Introduction - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. The CPOC Perspective - Professor Scarlett McNally, CPOC Deputy Director. The Patient Safety Learning Perspective - Helen Hughes, Chief Exuecutive of Patient Safety Learning. Photo review of why NatSSIPs matters and what is new in NatSIPPs 2 - Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. The Patient Perspective - Susanna Stanford, NatSSIPs 2 Patient Lead. The second half of the webinar featured the following subjects and speakers: Our NatSSIPs 2 workshop and how to consider a NatSSIPs gap analysis - Joe Allen, Suffolk and North East Essex Integrated Care Trust. Team Training for NatSSIPs 2 - Philip Gamston, Perfusion Service Manager at Barts Health NHS Trust. Resources to support NatSSIPs 2 implementation - Dr Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. Q&A - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. Are you a healthcare professional interested in learning more about NatSSIPs? On the hub we host the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSSIPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email [email protected].
  9. Content Article
    The extent to which postintensive care unit (ICU) clinics may improve patient safety for those discharged after receiving intensive care remains unclear. This observational cohort study from Karlick et al., conducted at an academic, tertiary care medical centre, used qualitative survey data analysed via conventional content analysis to describe patient safety threats encountered in the post-ICU clinic. For 83 included patients, safety threats were identified for 60 patients resulting in 96 separate safety threats. These were categorised into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviours (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). Of the 96 safety threats, 41% were preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable. Nearly 3 out of 4 patients within a post-ICU clinic had an identifiable safety threat. Medication errors and delayed medical follow-up were the most common safety threats identified; most were either preventable or ameliorable.
  10. Content Article
    The PIT stop (prosthesis/implant timeout) checklist is Birmingham Women's and Children's NHS Trust's visual and aid memoir. It was launched to limit 'human error' and thus preventing never events (wrong implant/prosthesis). The four steps cover the intra-operative stages when implants are required. It works by recording what is requested on a small, hand held white board, and works in harness with the NatSSIPs 8, specifically step 5 of the infographic that has been previously developed. Download the checklist in Word from the attachment below:
  11. Content Article
    Tony Clarke suffered from a chronic inflammatory skin disease, hidradenitis suppurativa. In September 2020, Tony underwent surgery to remove infected tissue on one side of his body. When he entered the operating theatre, Tony’s surgical team first covered part of his body with an alcohol-based solution, to keep the area clean. Then, when the operation began, the surgeons began cutting off the infected tissue using a diathermy pen, a device that targets electrically-induced heat to stop wounds from bleeding. However, shortly into the surgery, disaster struck: heat from the surgical pen had ignited the alcohol on Tony’s body. “But because alcohol burns so hot, no fire was seen,” says Tony, recalling an explanation he later received from the hospital.  “The surgeons were concentrating on the right side of my body. The left side was left burning for about 20 minutes.” For the next four months, Tony travelled back to the hospital every three days, to get his injuries checked and bandages changed. During that time, Tony describes himself as ‘totally disabled.’ In September this year, Tony, as a patient ambassador for prevention of surgical fires, spoke at a conference held in York by the Association for Perioperative Practice (AFPP). There, perioperative practitioners from across the country gathered to listen to Tony’s experience. “I was speaking to lots and lots of different professionals in the medical service and they'd never heard of it [being set on fire during surgery]. It was a rarity for them,” Tony says. Tony’s now working with different health agencies, with the aim of stopping preventable surgical burns entirely.
  12. Content Article
    This paper from Roberts et al. examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
  13. Content Article
    This investigation explores the patient safety risk of unintended retention of surgical swabs after surgery. Surgical swabs are sterile pieces of gauze which are used to absorb bodily fluids, such as blood, during a surgical procedure. The investigation will: explore the factors associated with unintentional retained surgical swab events identify alternative safety controls to reduce the likelihood of foreign objects being unintentionally retained. The interim report analyses the findings of 31 NHS trust serious incident reports. Reference event The reference event involves a patient who had undergone a triple coronary artery bypass graft surgery (heart surgery). Following their surgery, a chest X-ray identified that a surgical swab had been retained. The patient returned to theatre and the surgical swab was removed. A subsequent chest X-ray identified that a further surgical swab remained in situ, in the same location within the chest. The patient returned to theatre and the second surgical swab was removed. Safety recommendations HSSIB recommends that NHS England incorporates the findings of this interim report into its review of the Never Events policy, with specific focus on considering removing retained surgical swabs as a sub-set of retained foreign object Never Events. Safety observation Organisations can improve patient safety by using consistent terminology in national and local guidance when describing the responsibility for the reconciliation of items used in surgery and invasive areas, including swabs. Local-level observation: Healthcare providers can improve patient safety by using the findings of this report to consider potential challenges in their own systems and processes for unintentionally retained swabs following invasive procedures. This can help organisations to understand what people focused and system focused barriers may be implemented to help further mitigate against retained swab events.
  14. News Article
    NHS staff are carrying out the equivalent of one 'never-event' every day, figures show. This is despite the Government ordering a crackdown on the mistakes, which cost hospitals an estimated £800million in compensation each year. Experts today demanded further action on 'unacceptable' levels of never-events, blaming inadequate staffing levels and a lack of investment in the NHS. A MailOnline audit of a decade's worth of NHS data found a colossal 4,328 never-events have occurred in England since 2013. This equates to roughly eight a week. Shocking incidents uncovered include women getting parts of their reproductive anatomy cut out instead of an appendix, men getting unwanted circumcisions and laser procedures to the wrong eye. The Royal College of Surgeons said the level of never-events was 'unacceptable' and blamed NHS staffing levels for increasing the risk to patients. "Surgeons will be working hard to do their best for patients, but they do so in difficult circumstances," a spokesperson said. "The NHS is overstretched, with staff shortages, a workforce suffering from burn-out and pressure to get record waiting times down. "This increases the risk of mistakes happening." Read full story Source: MailOnline, 10 October 2023
  15. 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)
  16. Content Article
    Can you imagine the distress of going to hospital for an operation and having to return to theatre to have forceps removed because they were left inside your abdomen. Or going in for a left hip operation because of years of agonising pain and waking up to find out they had operated on your good hip. Or having surgery to preserve your ovaries — but they are accidentally removed. Or, worst of all, realising you have had a procedure intended for a different patient. Fanciful stories made up for a TV drama? Sadly not. These were just some of the awful mishaps that occurred in hospitals in England over the space of just ten months. Professor Rob Galloway, writing for the Daily Mail, shares his tips on what patients can you do to protect themselves.
  17. Content Article
    National Education for Scotland research and evaluation work has shown wide variations in the standard of significant event analysis (SEAs) undertaken by frontline healthcare teams. The direct implication is that there are many missed opportunities to learn from and improve the safety of patient care. As a consequence, NES developed a robust educational model to enable clinicians, managers and healthcare teams to submit SEA reports for feedback from trained peer groups.
  18. Content Article
    A Human Factors approach to significant event analysis for more meaningful improvement implementation to minimise the risks of the event happening again. Enhanced SEA is a National Education Scotland innovation (funded by the Health Foundation 2012 SHINE programme) which aims to guide health care teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved. Taking this approach will help individual clinicians and care teams to openly, honestly and objectively analyse patient safety incidents, particularly more difficult or sensitive safety cases, by ‘depersonalising’ the incident and searching for deeper, systems-based reasons for why the significant event happened.
  19. News Article
    A new mum was confused for another patient and mistakenly fitted with a contraceptive coil after a C-section. Another patient in north Wales almost had the wrong toe removed during surgery to amputate two others. A third incident happened when a patient, unable to swallow oral medication, had it crushed, mixed with water and administered with a syringe. These so-called "never events" happened at hospitals in the Betsi Cadwaladr health board area in February. In a report into the three incidents in February, Betsi Cadwaladr health board outlined how a patient had a coil - an intrauterine device which prevents pregnancy - inserted after undergoing a Caesarean section. Described in the report as "wrong procedure", it had been planned for a different patient but a mistake had been made after the "list order was changed due to the increase in category for this patient". Another incident, described in the report as "wrong site surgery", described a patient who was due to have their second and third toes amputated. However, an incision was made in their fourth toe by accident. Luckily, the error was spotted and the correct toes were amputated. In the third never event, described as "wrong route", the report details the case of a patient who was unable to swallow oral medication. To administer it, a member of staff crushed it, mixed it with water and "inadvertently" gave it intravenously, according to the report. Read full story Source: BBC News, 28 March 2024
  20. Event
    Understanding human factors will allow surgical teams to enhance performance, culture and organisation of operating theatres. This one day masterclass will concentrate on human factors within the operating room. This is aimed at all theatre staff. 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 systems to improve patient safety as well as looking at never events and how to learn from them using a human factors approach. Key learning objectives: Safety culture Human factors Leadership Never events This masterclass is aimed at all theatre staff. Register hub members receive 20% discount using code hcuk20kh.
  21. Event
    Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. The masterclass will look at how Never Events have been investigated and at Human Factors approaches to improving learning and the systems to reduce harm. It will compare our experiences with learning from serious incidents from other countries. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/learning-from-never-events or email [email protected]. hub members receive a 20% discount, Email [email protected] for discount code.
  22. Event
    Never Events and serious Incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commision (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified and errors attributed to processes and individual staff. In this webinar, we welcome representatives from the CQC and the National Orthopaedic Alliance (NOA) to discuss learning from never events and serious incidents. Register
  23. Event
    until
    This Q Community session: Introduces the concepts and origins of ‘never events’ and ‘zero harm’ as safety interventions. Explores and debates the usefulness of ‘never event’ and ‘zero harm’ initiatives as effective safety management strategies in healthcare. Reflects on and considers alternative approaches to managing risks of serious harm to as low as reasonably practicable. Further information Register
  24. News Article
    Women in labour at a London maternity unit deemed “inadequate” were left alone with unsupervised support workers who were not given any guidance, an NHS safety watchdog has found. In a scathing report of North Middlesex Hospital’s maternity services, the Care Quality Commission also found examples of delays to induction of birth for women, and one case of a woman with a still-born baby who was left waiting for the unit to call her in for an induction. Inspectors have downgraded the maternity unit from “good” to the lowest possible rating “inadequate” following an inspection earlier this year. Staff reportedly told inspectors they felt they were “criticised” or “bullied” when reporting safety incidents within the unit. “We heard that the criticism or bullying was worse if the incident reported was relative to other staff and their perceived behaviours,” the report said. There was also evidence the hospital was not recording the severity of safety incidents correctly for example two “never events”, which are among the highest category incidents, were categorised as “low harm”. Other findings included women and babies came to harm as the hospitals did not follow standards to language interpretation despite covering a higher than average minority ethnic population. Read full story Source: The Independent, 11 December 2023
  25. News Article
    A teaching trust has reported six ‘never events’ in less than two months, including incidents in a specialty already under review for errors. The incidents occurred at University Hospitals Birmingham between 26 July and 10 September, including two wrong-side lesion biopsies in dermatology, two incorrect blood transfusions, one injection to the incorrect eye, and one misplaced nasogastric tube. The two incorrect blood transfusions involved the same patient at Heartlands Hospital and were reported after a biomedical scientist carried out a retrospective investigation into the case. On both occasions, the patient was transfused with incorrect red blood cells. It brings the total number of blood transfusion events reported at UHB to seven since 2020-21. The issue is already subject to a review by the Royal College of Physicians after Mike Bewick identified concerns in his review of patient safety at the trust. It comes after clinicians working within the haematology specialty raised multiple concerns over patient safety in 2021 and intervention from the General Medical Council over concerns around junior doctors. John Atherton, chair of UHB’s clinical quality and safety committee, told the board a preliminary review into never events had identified that “maybe we weren’t addressing these [incidents] seriously enough”. Read full story (paywalled) Source: HSJ, 1 December 2023
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