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Found 660 results
  1. News Article
    A patient in north Wales suffered "catastrophic" consequences when staff didn't connect their oxygen supply correctly. The Betsi Cadwaladr health board, which was caring for the patient at the time, is investigating and says it was one of a small number of recent similar incidents. But it refused to say whether the patient died, or to explain what the “catastrophic” consequences were. It says it is working to improve staff training to avoid similar incidents happening again. On Tuesday, Wales' health minister Eluned Morgan said the health board still had "a lot to do," before it could be taken out of special measures. A report to the committee said: “Further patient safety incidents have occurred in the health board related to the preparation and administration of oxygen using portable cylinders. “On review, the cylinder had not been prepared correctly, resulting in no flow of oxygen to the patient. “One incident had a catastrophic outcome and is under investigation.” Read full story Source: BBC News, 20 February 2024
  2. Content Article
    Although several studies have tried to quantify the cost of ‘adverse events’ in healthcare, the true costs remain unknown. To understand the ‘true cost’ of serious incidents, Jane Carthey argues we need to consider:The cost of additional treatment for the affected patient.The opportunity costs that accrue from reporting and managing incidents, claims and complaintsBusiness costs that accrue when, for example, healthcare staff are suspended.Costs resulting from implementing the duty of candour process, andPenalties and sanctions imposedIn other industries, the HSE’s Incident Cost Calculator is used to quantify the true costs of incidents. Inspired by this tool, Jane developed the Healthcare Serious Incident Cost Calculator. Available via the link below.
  3. Content Article
    A swarm is designed to start as soon as possible after a patient safety incident occurs. Healthcare organisations in the US1 and UK2 have used swarm-based huddles to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. They can prevent: those affected forgetting key information because there is a time delay before their perspective on what happened is sought fear, gossip and blame; by providing an opportunity to remind those involved that the aim following an incident is learning and improvement information about what happened and ‘work as done’ being lost because those affected leave the organisation where the incident occurred. This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done). 
  4. Content Article
    Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In the article 'Truth and compassion' (page 20-21), David Alderson considers the patient’s perspective on mistakes.
  5. Content Article
    This article in the Nursing Times explores reflective practice in community nursing, focusing on a stressful incident in which a patient who had not been contactable during a home visit was later found to have died. The article emphasises the necessity of structured reflection, utilising Rolfe’s reflective model, to explore nurses’ feelings. It delves into the model’s stages, its impact on critical thinking and guiding reflection through questions, and highlights the importance of reflective practice, emphasising its role in learning, professional development and improving patient outcomes. The article concludes by showcasing the successful implementation of a new model and its positive impact on patient safety in home visits, providing a structured approach for nurses and health professionals.
  6. Content Article
    SHOT is the UK’s independent, professionally-led haemovigilance scheme. It collects and analyses anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. This document contains updated information on reporting categories and what to report to the scheme.
  7. Content Article
    Sentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organisations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives.
  8. Content Article
    The aim of this study was to investigate the incident reporting process (IR1s), to calculate the costs of reporting incidents in this context and to gain an indication of how economic the process was and whether it could be improved to yield better outcomes.
  9. Content Article
    One way to understand the links between unwanted events, conditions and interventions is via causal loop diagrams. These represent how situations perpetuate in 'causal loops'. They are depicted as words and phrases for events and conditions, and arrows with a plus or minus sign to indicate the direction of causal influence. Causal loop diagrams can assist a conversation via the gradual building of each loop. They can otherwise represent data from research and practice.  Steven Shorrock illustrate the progressive build of a causal loop diagram concerning reactions to unwanted events, including fixes that fail, based on practice and research. This might be useful to professionals seeking to understand why unwanted events continue to occur despite, or because of, interventions. The diagram is not ‘complete’ and would be drawn differently for different purposes, contexts and situations.
  10. Content Article
    Doctors At Work is a series of video podcasts hosted by Dr Mat Daniel. In this episode, Dr Gordon Caldwell shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everyone to speak up. His top tips for preventing errors is to create systems, checklists and routines that ensure a focus on all aspects of care not just the obvious and urgent.
  11. Content Article
    This safety article aims to outline the actions taken by the patient safety team at NHS Improvement in response to a reported incident and to highlight potential for harm to babies from knitted items. Related reading on the hub: Finger injuries from infant mittens; a continuing but preventable hazard (April 1996) Notes from a Patient Safety Education Network discussion on a similar incident. (This is a group for UK hub members involved in patient safety education/training in their organisations and members of the hub can join by emailing support@PSLhub.org.)
  12. Content Article
    During the last 4 years, three infants have presented with finger-tip injuries secondary to entrapment in woollen/synthetic mittens. The accident happened at home in one case but the other two occurred in different neonatal units. Spontaneous amputation of the terminal phalanx of the index finger occurred in two patients but in the other there was complete healing. This problem may be avoided by restricting the use of mittens, by changing their design, and by a greater awareness of this hazard. Related reading on the hub: Knitted items – potential for harm to babies? (2018) Notes from a Patient Safety Education Network discussion on a similar incident. (This is a group for UK hub members involved in patient safety education/training in their organisations and members of the hub can join by emailing support@PSLhub.org.)
  13. Content Article
    Sharing his own personal experiences of harm, Richard highlights four routes where patients and families can report patient safety incidents to ensure patients' voices can be heard and, most importantly, acted upon.
  14. Content Article
    The systems engineering initiative for patient safety (SEIPS) is a framework to help us understand outcomes within complex socio-technical systems, like healthcare. SEIPS has developed over a number of academic papers and offers a range of tools that can help an investigator to understand why things happen. Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when planning and undertaking patient safety investigations.
  15. Event
    The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  16. Content Article
    Hospitals are complex adaptive systems. They are industrial environments where it isn't always possible to expect predictable responses to inputs. Patient safety management practices need to adapt to align with the environment in which events occur. It is time to reimagine safety event reporting and management solutions that guide, not prescribe, investigations and improvement actions.
  17. Content Article
    Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade. The aim of this study from Eldridge et al. was to determine the change in the rate of adverse events in hospitalised patients. The study found that in the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures, and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.
  18. Event
    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register
  19. News Article
    At least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged. The total is based on research of both media reports of inquests and settled claims. Before Christmas, a review by the Irish Examiner revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021. However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period. In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court. At least 18 of the inquests resulted in a verdict of medical misadventure. As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training. In at least seven cases, mothers’ concerns were ignored. Read full story Source: Irish Examiner, 29 December 2023
  20. Content Article
    Professor Joe McDonald, Principal Associate for health system collaboration for Ethical Healthcare Consulting, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.
  21. Content Article
    Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade. This study determined the change in the rate of adverse events in hospitalised patients. The study found that in the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.
  22. Content Article
    Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice, but little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the Covid-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which can be accessed via the link to the paper). These provide: an introduction to the AAR facilitation process a simulation of a facilitated formal AAR techniques for handling challenging situations that may arise in an AAR reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.
  23. Content Article
    A second victim is a healthcare worker who is traumatised by an unexpected adverse patient case, therapeutic mistake, or patient-associated injury that has not been anticipated. Often, the second victim experiences direct guilt for the harm caused to the patients. Healthcare organisations are often unaware of the emotional toll that adverse events can have on healthcare providers (HCPs) who can be harmed by the same incidents that harm their patients. This study aims to examine the second victim phenomenon among healthcare providers at Al-Ahsa hospitals, its prevalence, symptoms, associated factors, and support strategies.
  24. Content Article
    A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time.  This NHS England document provides an overview of patient safety incident investigation stages, tips and suggested structure for analysis.
  25. 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
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