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Found 286 results
  1. Content Article
    Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" programme, and leadership support for staff who submit reports.
  2. Event
    The overall objective of this masterclass is to build good governance commitment, capacity, and resilience in the face of severe resource constraints and complex staff, patient, political and regulatory expectations. The programme is interactive, developmental, based on best practice and focused on achievable improvement of practice, behaviours and outcomes. The course includes online access to the relevant CQG e-learning module for 12 months and a discount code to purchase additional modules. This masterclass is one of a series that will help enhance your understanding and application of governance in healthcare, this module is designed to help boards avoid silo thinking, over-complex agendas or multiple reports by exploring the three elements of Integrated Governance which are: Integrated thinking, systems, and reporting. At the completion of this module, the participant will be able to: Appreciate the value of integrated thinking Recognise the importance of building integrated systems Understand the importance of integrated reporting to inform management, the board, and stakeholders Apply the learning to the participant’s own organisation using the CQG Maturity Matrix. Register
  3. Content Article
    This report examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. 
  4. Content Article
    Central venous catheters (CVCs) are widely used in US critical care settings for medication administration, monitoring and reliable venous access. Despite the benefits of CVCs, complications, particularly infections, have become a major focus of US hospital quality improvement efforts due to federal and state initiatives that emphasise patient safety, transparency and accountability. In this commentary in JAMA Network, the authors look at recent research surrounding CVC complications and highlight approaches to help tackle these issues.
  5. Content Article
    In this article, investigative journalist Scilla Alecci reports on a court case brought against medical tech company Medtronic by a US whistleblower. Former Medtronic sales representative Leanne Houston alleges that between 2016 and 2018 she witnessed the company engaging in “unlawful conduct” by offering several US hospitals free equipment in exchange for the exclusive use of Medtronic products. She also claims that the company failed to acknowledge and deal with reports from surgeons that one of its surgical staple devices was causing harm to patients.
  6. Content Article
    Over the past decade, the implementation of simulation education in health care has increased exponentially. Simulation-based education allows learners to practice patient care in a controlled, psychologically safe environment without the risk of harming a patient. Facilitators may identify medical errors during instruction, aiding in developing targeted education programs leading to improved patient safety. However, medical errors that occur during simulated health care may not be reported broadly in the simulation literature. This study in the Journal of Patient Safety aimed to identify and categorise the type and frequency of reported medical errors in healthcare simulation.
  7. Content Article
    A growing awareness of sex and gender bias in evidence has resulted in the development of new tools to address this concern. The Sex and Gender Equity in Research (SAGER) guidelines and the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) are two initiatives designed to foster more transparent research and reporting practices that bridge the gender evidence gap. These tools enable researchers to unravel the complexities that underpin health risks and outcomes and generate more accurate and relevant findings that can inform effective and equitable policies for better health outcomes. This Lancet article looks at the World Health Organization's (WHO's) adoption of GATHER and the SAGER guidelines to tackle sporadic and suboptimal reporting of sex and gender data. The authors argue that this move is pivotal within WHO's broader strategic agenda, which it outlined in the Roadmap to Advance Gender Equality, Human Rights and Health Equity 2023–2030, launched in December 2023.
  8. Content Article
    In this letter to Health Secretary Steve Brine MP, members of the All Party Parliamentary Group (APPG) on Pandemic Response and Recovery raise serious concerns about the approach of the Medicines and Healthcare Products Regulatory Agency (MHRA) to patient safety. They outline problems within the MHRA that continue to put patients at serious risk of harm. The letter also highlights the role of the Independent Medicines and Medical Devices Safety Review (IMMDS), in its thorough investigation of Primodos, sodium valproate and pelvic mesh in bringing some of these concerns to the fore. It points to recent evidence presented to the APPG that indicates that the MHRA is at the heart of wider endemic failings, with issues uncovered so far being "the tip of a sizeable iceberg of failure." The letter outlines concerns about the following areas: The Yellow Card Scheme Conflicts of interest and transparency History of regulatory failures in the MHRA It calls on the Health and Social Care Select Committee to investigate these issues and make recommendations to the government on: legislative changes as to who is obligated to report adverse drug reactions. funding changes to the MHRA. separation of regulatory approval duties from post marketing pharmacovigilance. more inclusion of patients. greater transparency across the board. proper enforcement of Part 14 of the Human Medicines Regulations 2012.
  9. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Kevin talks to us about the role research plays in improving staff and patient safety. He explains how his own research has uncovered the extent of violence experienced by student nurses and the underreporting of sharps injuries among healthcare students. He also highlights how research can help universities improve awareness of issues facing students across all healthcare courses and provide more effective support.
  10. Content Article
    Studies have reported evidence on sharps injuries among nursing, medical and dental students but little is known about the amount, type and causes of sharps injuries affecting other healthcare students. This narrative review aimed to identify the extent, type and causes of sharps injuries sustained by healthcare students, especially those not in nursing, medicine or dentistry. The review highlights that some groups of healthcare students, including those studying pharmacy, physiotherapy and radiography, sustain sharps injuries from similar devices as reported in research on such injuries in nursing, medical and nursing students. Sharps injuries happen in a range of healthcare environments, and many were not reported by students. The main cause of a sharps injury identified was a lack of knowledge.
  11. 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.
  12. 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.
  13. Content Article
    'Failure to rescue' is the rate of death amongst patients with postoperative complications and has been proposed as a perioperative quality indicator. However, there may be significant variation in its definition between research studies. This study in the journal Surgery systematically reviewed all surgical literature reporting failure to rescue rates and examined variations in the definition of the ‘numerator,’ ‘denominator’ and timing of failure to rescue measurement. The authors found that failure to rescue is an important concept in the study of postoperative outcomes, but its definition is highly variable and poorly reported. They highlight that researchers should be aware of the advantages and disadvantages of different approaches to defining failure to rescue.
  14. Content Article
    Thomas Ithell was aged 77 at the time of his death on 20 November 2022. He was diagnosed with prostate cancer in September 2017 and biopsies revealed bilateral adenocarcinoma of the prostate. He underwent radiotherapy in 2018 and hormone deprivation treatment. From April 2021 onwards his PSA levels increased periodically. In October 2021 his level was 5.5ng/ml having been 1.5ng/m lin April 2021 and 2.7ng/m in July 2021 indicating a recurrence of the cancer and likely incurable. Thomas Ithell was reluctant to undergo further hormone treatment as he found tolerating the side effects difficult. He did not then have his PSA levels tested after November 2021 and was not reviewed at all due to becoming missed to follow up. After he had been seen by the nurse practitioner on 5 November 2021, the letter written by the nurse practitioner for advice from the consultant did not reach the consultant. He was reviewed by a consultant on 22 October 2022 after an urgent suspected cancer GP referral following routine set of blood tests in September 2022, some 10 months later. Mr Ithell died in hospital on 20 November 2022 having been admitted with shortness of breath, the malignancy having caused his death.
  15. 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.
  16. News Article
    A hospital trust has been breaching national guidance by excluding some long waiters from its reported waiting list figures, in a move experts warned could put patient safety at serious risk. The practice appears to have helped Sandwell and West Birmingham Hospitals report zero patients waiting more than two years for treatment during most of last year. Its policy means cases that unexpectedly “pop up” as two-year waits in its datasets are temporarily removed. The trust will then review whether the cases are data errors or genuine two-year waits, and if genuine, aim to provide treatment within a month. If not treated within a month, the cases would be added back to the reported waiting list the following month. Rob Findlay, an expert on RTT waiting lists, said the implications of the SWBH policy are far more serious than simply reporting incomplete numbers for a month. He said allowing a month to deal with the pop-up without declaring it “relieves them of pressure to solve the problems that are causing patients to be lost in the first place”. He added: “Some patients – the hospital would never know – might never pop up and be lost from the waiting list forever. “[This is] a serious patient safety issue which could potentially have a significant impact on how long patients are waiting for treatment.” Read full story (paywalled) Source: HSJ, 19 January 2024
  17. Content Article
    Error management is a systematic approach aimed at identifying and learning from critical incidents by reporting, documenting and analysing them. However, almost nothing is known about the incidents doctors in outpatient care consider to be critical and how they deal with them. This interview study aimed to to explore outpatient doctors’ views on error management, discover what they regard as critical incidents and find out how error management is put into practice in ambulatory care.
  18. 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.
  19. Content Article
    Patients treated and transported by Helicopter Emergency Medical Services (HEMS) are prone to both flight and medical hazards, but incident reporting differs substantially between flight organisations and healthcare, and the extent of patient safety incidents is still unclear. This study in the Journal of Patient Safety is based on in-depth interviews with eight experienced Norwegian HEMS physicians from four different bases from February to July 2020. The study aimed to explore the physicians’ experience with incident reporting and their perceived areas of risk in HEMS. The authors concluded that sparse, informal and fragmented incident reporting provides a poor overview of patient safety risks in HEMS. A focus on organisational factors and system responsibility is needed to further improve patient safety in HEMS, alongside research on environmental and contextual factors.
  20. Content Article
    Reporting behaviour associated with safety-related accidents, incidents and hazards is a concern for many managers, regulators, safety specialists, operational staff and patients. In this blog, Stephen Shorrock looks at the many influences on reporting behaviour and how these influences are interrelated.
  21. Content Article
    NHS organisations are able to record patient safety events to the Learning From Patient Safety Events (LFPSE) system via the online recording form or via LFPSE service compliant risk management software. This web page provides details on which organisations have connected to the LFPSE service via their local risk management system.
  22. Content Article
    In this opinion piece for the BMJ, Scarlett McNally looks at the issue of sexual assault and harassment by and against NHS staff. She argues that rather than focusing solely on reporting mechanisms, there needs to be more emphasis on prevention. In order to change the culture in NHS workplaces, all members of the team need to consider how they may contribute to a culture that allows sexual misconduct to happen.
  23. Content Article
    Learn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. Homerton University Hospital have shared a presentation on how they are going to implement LFPSE into Datix, a quick reference guide and a screen saver they are using to introduce it to staff. Others may find the resources useful and can adopt/adapt them in their own organisations. They can be downloaded from the attachments below. Additional resources on the hub: CSH Surrey share their presentation slides on LFPSE and Datix.
  24. Content Article
    In her latest blog, Patient Safety Commissioner Henrietta Hughes discusses MHRA's Yellow Card reporting system and why, until we have mandatory reporting, including for devices that are working as designed, we will continue to see avoidable harm occurring to patients. She stresses that it is vital that the voices and views of patients, clinicians, manufacturer, and health providers participate in the design and delivery of devices. 
  25. Content Article
    The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This website provides information about inquiry team, terms of reference and publications relating to this.
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