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Showing results for tags 'Patient safety incident'.
Found 439 results
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Content ArticleIssue 10: Unsafe management of sepsis Issue 9: Medicines management - assessment Issue 8: Hypothermia Issue 7: Falls from windows Issue 6: Caring for people at risk of choking Issue 5: Safe management of medicines - treatment Issue 4: Burns from hot water or surfaces Issue 3: Fire risk from use of emollient creams Issue 2: Unsafe use of bed rails Issue 1: Falls from improper use of equipment
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Learning from patient safety incidents including Human Factors
Patient Safety Learning posted a calendar event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Tr -
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EventSEIPS 2.0 is the most widely used model in human factors in healthcare. This one day masterclass will look at the model itself and how it can be applied to healthcare departments. It will look at real world examples as well as the literature. SEIPS 2.0 is the next-generation healthcare human factors model , which embraces 3 principles of Systems orientation, Person-centeredness and Design-driven improvement. Key learning objectives What is SEIPS 2.0? How does SEIPS link to Patient Safety? How to use SEIPS 2.0 clinically? • How to improve technology? En
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Content ArticleThe 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
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Content ArticleTwenty-seven papers were eligible. The perspectives of patients and families, healthcare professionals, nonclinical staff, and legal staff were sought across acute, mental health and maternity settings. Most patients and families valued being involved; however, it was important that investigations were flexible and sensitive to both clinical and emotional aspects of care to avoid compounding harm. This included the following: early active listening with empathy for trauma, sincere and timely apology, fostering trust and transparency, making realistic timelines clear, and establishing effe
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Content Article"I’d like to see health care make a significant effort to identify which processes are universally critical to the delivery of care and develop uniform standards — not just here in Massachusetts but across the country. That is why I think the Betsy Lehman Center and the Massachusetts Coalition for the Prevention of Medical Errors are so important. I wish every state had similar groups. A national coalition of these groups could join together and start doing this very important work." "I’m convinced we can drive unnecessary variation out of health care, but it will take leadership to help
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News Article
Burnout in doctors doubles chances of patient safety problems, study finds
Patient Safety Learning posted a news article in News
Doctors suffering from burnout are far more likely to be involved in incidents where patients’ safety is compromised, a global study has found. Burned-out medics are also much more likely to consider quitting, regret choosing medicine as their career, be dissatisfied with their job and receive low satisfaction ratings from patients. The findings, published in the BMJ, have raised fresh concern over the welfare and pressures on doctors in the NHS, given the extensive evidence that many are experiencing stress and exhaustion due to overwork. A joint team of British and Greek resea -
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As part of implementing the NHS Patient Safety Strategy, there are currently a number of new initiatives being rolled out across the NHS which are intended to achieve its vision of continuously improving patient safety. This includes the development of the Learn from patient safety events (LFPSE) service, for recording and analysing patient safety incidents, a new framework for involving patients in patient safety and the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to p -
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Nuffield Trust: Safety culture in the NHS (25 August 2022)
Mark Hughes posted an article in Culture
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Content ArticleTools and guides Patient safety incident investigation report template Introduction to SEIPS Four tools to help in the initial stages of a learning response Four guides to inform a response to a patient safety incident or cluster of incidents Four guides to support the exploration of everyday work Two tools to enable organisations to respond to broad patient safety issues Two tools to support information gathering and synthesis of information Developing safety actions
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