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Showing results for tags 'Patient safety incident'.
Found 488 results
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Content ArticleThe report highlights that, based on analysis of NHS data, there has been a 30% increase in the number of patient safety incidents in surgery – instances that did or could have led to injury or death – since 2015. The analysis also shows that there were 407 ‘Never Events’ in the last year, with no reduction in the number of these incidents since 2015. The report includes results from a survey of 1,500 people who have had surgery in the last five years, with more than three quarters (76%) of the patients surveyed reporting safety concerns during the surgery process. Of those who were worri
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Content ArticleAt Patient Safety Learning we seek to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. The scale of this challenge remains immense. Each year, millions of patients suffer injuries or die because of avoidable harm in healthcare. The World Health Organization (WHO) states that in high-income countries 1 in every 10 patients is harmed when receiving hospital care.[1] In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths a
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News Article
Trust CEOs could ‘end up in prison’ because of ‘unsafe’ hospitals, warns chief
Patient Safety Learning posted a news article in News
An acute trust chief executive has criticised the lack of communication during last month’s nursing strike, warning that he and other accountable officers could face manslaughter charges if patients are put in danger by decisions made by senior colleagues elsewhere in the system. Matthew Hopkins told a board meeting that Worcestershire Royal Hospital’s emergency department was “pushed to the extreme” on 20 December, with 176 people squeezed into a facility originally built for 50. He said that without warning from regional colleagues, an additional 18 people were brought in to the ho -
News Article
Police and CQC investigate serious incidents at trust
Patient Safety Learning posted a news article in News
A series of concerns about serious incidents at a mental health trust are being investigated by the Care Quality Commission, with a referral also made to the police, HSJ has learned. HSJ understands that various incidents at Black Country Healthcare Foundation Trust have been raised with the Care Quality Commission by whistleblowers. According to a well-placed source, one of the alleged incidents involved alleged inappropriate sexual behaviour, and this has been referred to West Midlands police. Other complaints are understood to include staff using mental health inpatients’ roo -
Event
ISMP Canada: Incident analysis and proactive risk assessment
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register -
Event
ISMP Canada: Incident analysis and proactive risk assessment
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register -
Event
ISMP Canada: Incident analysis and proactive risk assessment
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register -
Content ArticleThis study looked at the frequency and types of harm in 11 hospitals in Massachusetts, considering a sample of 2809 randomly selected admissions. It identified at least one adverse event in 23.6% of these admissions. Among the adverse events, around 22.7% of these were judged to be preventable. Discussing the findings, the authors note that preventable adverse events were identified in approximately 7% of all admissions in this sample, with those categorised as serious, life-threatening or fatal identified in approximately 1%. The most common type of event was adverse drug events (39%), f
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News Article
Inquiry into deaths after Northern Ireland ambulance delays
Patient Safety Learning posted a news article in News
The Northern Ireland Ambulance Service (NIAS) is investigating whether a delayed response contributed to the deaths of eight people in recent weeks. All eight deaths occurred between 12 December and the start of January. The NIAS is treating four of the deaths as serious adverse incidents, which is defined as an incident that led to unintended or unexpected harm. The remaining four deaths are being investigated to see whether they meet that criteria. The patients' identities have not been disclosed, but it is understood one of the eight people was a man who waited more than -
News Article
Record number of 'foreign objects' left inside patients after surgical blunders
Patient Safety Learning posted a news article in News
A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who sp -
Content Article
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Content Article
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I love and support the NHS. But when things go wrong for patients and service users, the system is often too slow to change or respond effectively. I have been through complaints, the Ombudsman and Inquest processes around the poor end of life care of my late mother. Those processes took years and were almost as stressful as those last few days of my mother’s life. I would not do it again. At the time, I reported the incident in detail to the CQC (inspectors), to the CCG (commissioners), to Healthwatch (local and national), but I noted no evidence of change. In fact, the CQC continued for- Posted
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Content Article
HSIB: Safety investigation jargon buster
Patient Safety Learning posted an article in HSIB investigations
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Event
Learning from Never Events
Patient Safety Learning posted a calendar event in Community Calendar
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 an -
Content Article1. Learning from transitioned providers – adopting the LFPSE service in an acute trust Jackson Stubbs from University Hospitals of Morecambe Bay (UHMB) NHS Foundation Trust, describes his experience of leading his trust's switch from the NRLS) to the LFPSE service, his top tips, and what to avoid when planning your transition. 2. Learning from transitioned providers – adopting the LFPSE service in a mental health trust The team at Cumbria, Northumberland, Tyne and Wear (CNTW) NHS FT share how they have found the switch from NRLS to the LFPSE service, their key learning points fr
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Content ArticleLFPSE is a new central national service for recording and analysing patient safety events that occur in healthcare. Some NHS organisations are now using this system, instead of the NRLS, and all organisations will be expected to transition to this by 30 September 2023. Concerns about the development and implementation of LFPSE Patient Safety Learning welcomes much of the ambition behind the development of the new LFPSE service and its aim of creating a system from all parts of health and social care. However, in recent months staff have raised with us concerns about the development an
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EventuntilThe NHS England National Patient Safety Team are hosting two workshops to support Integrated Care Boards to prepare to transition to the new Patient Safety Incident Response Framework (PSIRF). The workshops will be held across two dates Monday 16 January 2023 and Tuesday 17 January 2023 to create smaller group sizes for discussion. The content will be the same across both dates. The webinar will cover: Introduction and latest updates on PSIRF. How oversight changes under PSIRF. The new role of the ICB. Working collaboratively with providers. Training requir
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Event
PSIRF transition webinar: from discovery to governance
Patient Safety Learning posted a calendar event in Community Calendar
untilThis is the second in a series of practical webinars from NHS England to support organisations to transition to the Patient Safety Incident Response Framework (PSIRF). Following the PSIRF preparation guide, this webinar coincides with the transition from the ‘Discovery and diagnostic’ phase, to the ‘Governance and quality monitoring’ phase. The agenda includes: Update from the national patient safety team. Look back at the ‘Diagnostic and discovery’ phase and look forward to the ‘Governance and quality monitoring phase’ with examples of challenges and successes. -
Content ArticleThe Learn Together project engaged with, and learnt from, the experiences of everyone involved in investigations – patients, families, staff, investigators, policy makers, and other key stakeholders – to find out their needs during, and experiences of, the investigation process. Together, they have co-designed new guidance to make investigations more human and meaningful for those involved, and support better organisational learning. The project has created investigation resources to support you if you are involved in a Patient Safety Incident Investigation either as a patient, famil
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News Article
Over 1000 'adverse events' in women and infants' care in Scotland
Patient Safety Learning posted a news article in News
More than 1000 investigations have been launched in Scotland over the past decade into adverse events affecting women and infants' healthcare. Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (Saers) have been initiated by health boards since 2012 following "near misses" or instances of unexpected harm or death in relation to obstetrics, maternity, gynaecology or neonatal services. The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards -
News Article
USA: House Bill establishes Federal Agency dedicated to patient safety
Patient Safety Learning posted a news article in News
Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board (NPSB) as a non-punitive, collaborative, independent agency to address safety in healthcare. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions. Prior to the COVID-19 pandemic, medical error was the third leadi -
Content ArticleWhat is the National Patient Safety Board? Since early 2021 there has been a growing coalition of healthcare organisations and groups calling to create the National Patient Safety Board in the United States.[1] This is a proposed federal agency with the goal of preventing and reducing patient safety events in healthcare settings, modelled after the National Transportation Board and the Commercial Aviation Safety Team.[2] Legislative proposal Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended
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EventThe publication of the New Patient Safety Incident Response Framework in August 2022 has shifted the focus towards identifying and investigating patient safety incidents and events that have the greatest potential to lead to learning and improvement. This conference focuses on patient safety learning – maximising learning and improvement from patient safety insight and events. The conference will support you to identify incidents and insight that has the greatest potential for improvement and use a range of system-based approaches for learning from patient safety incidents. The conference will
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Event
Patient involvement & partnership for patient safety
Patient Safety Learning posted a calendar event in Community Calendar
This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework published in August 2022. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety.
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