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Showing results for tags 'Reporting'.
Found 178 results
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NHS England set up a handful of specialist mesh centres in April 2021 to offer treatment and support to women harmed by vaginal mesh surgery. But they aren’t achieving what they need to, and this failure is leaving thousands of women harmed by mesh without help to deal with their life-changing complications, and without hope that their pain will ever be taken seriously. Here are ten problems with specialist mesh centres, identified through my regular contact with thousands of women suffering from mesh complications. 1. There are long waiting lists of sometimes more than a year just f -
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Content ArticleMyth 1: HSE and LAs still have enforcement responsibilities for the safety of patients and people who use services. Myth 2: A specialised team in CQC is responsible for taking enforcement action. Myth 3: HSE and LAs still respond to RIDDORs. Myth 4: CQC inspectors don't need to gather evidence any differently to how they do currently, Myth 5: CQC inspectors share information with Local Authorities and Environmental Health Officers, Myth 6: CQC doesn't use incident selection criteria to decide when to proceed to enforcement,
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Content ArticleThe mission of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is to maximise the safe use of medications and to increase awareness of medication errors through open communication, increased reporting and promotion of medication error prevention strategies. Goals Stimulate the development and use of reporting and evaluation systems by individual health care organisations. Stimulate reporting to a national system for review, analysis, and development of recommendations to reduce and ultimately prevent medication errors. Examine
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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 ArticleSemi-structured interviews were conducted with eleven key stakeholders involved in the implementation and/or use of online patient feedback. Data were analysed using deductive thematic analysis with Normalisation Process Theory used as the analytical framework. Participants viewed the implementation of online feedback as an opportunity to learn, change and improve. Factors found to facilitate implementation were often linked to engagement, support and promotion. Although less frequently described, barriers to implementation included staff anxieties about time pressures, moderation processes an
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Content ArticleAlex Gillespie and Tom W. Reader developed an automated language analysis method for measuring the likelihood of patient-reported safety incidents in online patient feedback. Feedback from patients and families in England were analysed. They found that the automated measure had good precision and excellent recall in identifying incidents; was independent of staff-reported incidents and was associated with hospital-level mortality rates. The identified safety incidents were often reported as unnoticed or unresolved, suggesting that patients use online platforms to give visibility to safety
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Content ArticlePatients for Patient Safety (PFPSUS) is a network of people and organisations aligned with the World Health Organization (WHO) and focused on making healthcare safe in the United States. In this article they explain why Vanderbilt University should be held accountable for their faults. PFPSUS have requested that the U.S. Office of the Inspector General investigate Vanderbilt, the Tennessee Department of Health and CMS to determine if they followed appropriate laws and procedures related to the reporting of this error. Among the questions posed are: Did the Tennessee Departm
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Can being open and transparent make us more opaque?
Anonymous posted an article in Florence in the Machine
Health organisations regularly state that in the spirit of openness and transparency they put things in the public domain – if something has gone wrong they are open and transparent with patients, their relatives and/or carers, and they want staff to be open and transparent if they see things which are wrong, or if something happens unexpected. But what does being open and transparent mean? If we say an individual is transparent it has a negativity about it – they are see-through and potentially have ulterior motives. Sayings such as ‘hidden in plain sight’ or ‘a good day to bury bad -
Content ArticleKey findings The environmental scan revealed that while patient safety events, overall, were characterised by racial and ethnic disparities, methodological challenges—primarily related to data availability—limited in-depth analysis of this finding. The environmental scan also indicated that racism and its impact on patient safety events was more often discussed in editorials than in peer-reviewed and grey literature. Subject-matter expert interviews indicated that various levels of racism ranging from internalized and interpersonal to institutional and systemic directly impa
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Content ArticleThe study found that of the 60 268 adverse incidents, falls were the most common event (36%), followed by behaviour-related events (33%), other impacts and injuries (22%) and medication errors (9%). The number of adverse incidents per resident ranged from 0 (42%) to 171, with a median of 2. Women and residents with low care needs were significantly less likely to adverse incidents compared with men and residents with high care needs respectively. This study demonstrates that data already collected within electronic management systems can provide crucial baseline information about the risk
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EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the new Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Summer 2022. Local systems and organisations outside of the early adopter areas
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Content ArticleThe vision-based patient monitoring and management system described in this article has been deployed, or scheduled for deployment, in 18 Mental Health Trusts in NHS England (in April 2020). The system is not a replacement for nursing skills. Rather, it provides an enhancement to nursing practice. As with the adoption of any new technology into clinical workflows, it is important for practitioners to learn how to manage the cultural shift required to take advantage of a vision-based patient monitoring and management system. The engineering framework described in this article will help the
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Multiple reporting systems undermine patient safety, says watchdog
Patient Safety Learning posted a news article in News
A single system to report patient safety concerns would “keep people safer”, a newly appointed NHS watchdog has told HSJ. Henrietta Hughes – who will take up the post of patient safety commissioner in September – said both clinicians and patients faced a bewildering choice when looking to raise a safety concern, and that there was a need for a “report once” system. She said that when ”exhausted” clinicians “come to the end of a 12-hour shift, they don’t want to have to do a Datix report and a yellow card report, and if they’ve got a safeguarding concern or a concern about an individu
