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Found 192 results
  1. Content Article
    This 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
  2. Content Article
    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
  3. Content Article
    1. 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
  4. Content Article
    LFPSE 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
  5. Content Article
    Articles and themes in this issue Speak up... a powerful psychological safety indicator (Amy Edmonson) Empty bags or to be filled? An article about medication safety by the mother of a person with autism living in adult residence Patient safety report: Medstar health quality and safety vision A bird in the hand is worth two in the bush. By a mobile intensive care unit composed of a nurse, an ED doctor and a driver A vision of the health system in 10 years (Johannes Wacker) Implementation of an innovative training program promoting checklists in intensive c
  6. Content Article
    The NHS has been prioritising patient safety for the last few years, with the patient safety strategy focusing on three main aims: insight, involvement and improvement. Because of this, 1,000 extra lives could be saved along with a reduction of £100 million in care costs each year from 2023/24. Secondary care is yet to catch up on these goals. Radar Healthcare commissioned this report to get a glimpse into where we are today in regards to reporting, and to look into how we can work towards making improvements. Whatever the topic of the event, incident reporting provides vital insight
  7. Content Article
    What has changed? There have been a lot of conversations about the timeline, with many people saying that the initial date of March 2023 to switch was too challenging. There was also concern that there wouldn’t be enough time to transition to an approved LFPSE supplier if they needed to. NHS England announced on 18 October that there will now be an optional six-month extension to the original transition timeline of 31 March 2023; however, there are still things which must be in place by this date despite the extension. What you need to know By 31 March 2023, providers must ha
  8. Event
    Frontline staff often perceive event reporting as a black hole where no information exits once it enters. Join Andy Moyer, BSN, RN-BC, patient safety informatics specialist at Penn State Health Milton S. Hershey Medical Center, where he will help you tackle this perception by providing reporters better feedback. Moyer will also demonstrate ways to increase the quantity and quality of reported events. Register
  9. News Article
    The deadline for the NHS to move to a new system for safety incident reporting has been delayed after widespread concerns the rollout could be a ‘disaster’. A memo from NHS England to local teams yesterday, seen by HSJ, says the deadline to transition to the new “learning from patient safety events” database has been pushed back by six months to September 2023. The creation of LFPSE is a key strand of NHSE’s safety strategy, along with the overhaul of how serious incidents are investigated. It aims to make it easier for staff across all healthcare settings to record safety events, as
  10. Content Article
    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