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Content ArticleThis qualitative study looked at whether oncologists should ask children with cancer and their parents about their communication preferences before telling them about their prognosis. The results suggest that patients, parents and oncologists recommend asking patient and parent communication preferences in advance. Research participants provided advice for achieving this goal, relating to the questions that should be asked, giving multiple options and considering delivery and tone.
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News Article
AI outperforms surgeons in writing post-op reports
Patient Safety Learning posted a news article in News
A study has demonstrated that AI can create more accurate operative reports than surgeons. Published in the Journal of the American College of Surgeons, it is the first report on fully automated, video-based AI surgical documentation. The research highlights the potential of AI-driven solutions to reduce administrative burdens and improve surgical documentation. Surgeons frequently regard the creation of operative reports as essential yet time-consuming. These reports are inevitably subjective and may contain inaccuracies or incomplete information. The administrative task of documentation has also been recognised as a potential factor in physician burnout. Recent advancements in AI, especially in computer vision, have allowed automated systems to accurately detect surgical steps from video footage. Researchers aimed to create a platform that automates the generation of video-based AI surgical operative reports for robotic-assisted radical prostatectomy (RARP). Using an AI-powered algorithm, surgical steps were automatically identified in video recordings and mapped to pre-specified text to generate narrative AI operative reports. The accuracy of these AI-generated reports was then compared to traditional surgeon-written reports using an expert review of raw surgical video footage as the gold standard. The findings suggest that AI-driven operative reporting can enhance accuracy, reduce the documentation burden, and improve transparency in surgical procedures. Read full story Source: Surgery News, 24 March 2025 -
Content Article
The challenges of navigating the healthcare system: Sue's story
Anonymous posted an article in By patients and public
We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, having to travel miles for appointments, missing appointments because the letter didn’t arrive on time, or having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, Sue* shares her and her husband's experiences of trying to coordinate the healthcare system and highlights the challenges and frustrations they continuously face. Difficulties getting a diagnosis My husband Neil* has a very rare chronic condition that means unfortunately he is not managed in the area we live at as it’s a regional centre some miles away. We live in North Yorkshire, one of the largest geographical areas in the country, and we feed into various health economies. It took over 4 years and three different healthcare organisations before Neil got his diagnosis. Every time we see someone new we have to go through all of Neil’s medical history again, and then they often say that it’s not their area of expertise because they only deal directly with one area or speciality; they don't think of the patient as a whole. Whilst waiting to get the diagnosis, Neil had a heart attack so he was initially treated more locally to us but it was still over 40 miles away from where we live. When we called an ambulance for a second time he was taken to a different hospital from the first one he was treated in. So he was taken to two different geographical areas not even under the same trust. To add to this, Neil is also under lots of different specialities, i.e. rheumatology, general surgery, dermatology, respiratory and lipids. So he is being treated and has appointments in numerous places. Coordinating appointments and results With all these different specialties, even if they are within the same regional centre, none of the information is joined up or accessible, including blood results from the GP. We find that things are incorrect all the time and we spend a lot of time trying to coordinate Neil’s care and following up on test results, appointments, etc. Neil receives appointments in various ways—emails, phone calls, texts, letters, messages left on his answer phone. You might get a phone call followed by a letter, or you could get a message to say ignore the letter. You may miss a call but you don’t know which department to ring back because it usually comes up as an unknown number. Recently, Neil received a text message which said he was on a waiting list, but it didn’t say what it was for or what specialist department it was from. It said in the text that if you no longer wanted the appointment and wanted to cancel it, to follow a link, but we had no idea what the appointment was referring to or where it came from! As a patient you want to have some control over your health and be able to see all blood test results, scan results and letters from the hospitals. For example, it would be so much easier to look at Neil’s medications and patient letters if they were all in one place but you can't look at the medical records to see what's been said. The only way we can get it is waiting for the letter to be seen by the GP and then, eventually, added on to their system, but it's not always quick because again it's a different geographical area and systems that are disconnected. As a patient with a new disorder, you’re not familiar with the system. Neil was referred to other specialities from rheumatology. Unfortunately, the treatment plan. including tests or length of wait for appointments, isn’t shared directly with us. We rely on my note taking to ensure everything is completed and followed up. Often we end up going to an appointment without the tests Neil needs to have done due to the length of wait for the test, or the test being triaged and cancelled but this not communicated either to us or the referring doctor. The waiting for test results at the moment are long for some of these tests but if it was in your capacity to be able to seek or understand when you might possibly get them, you wouldn't then end up wasting an appointment. You would wait until you've had the results back or know when it might be. It could take us over two hours travelling time for a wasted appointment. We don’t want to waste our time and the time of others. Lack of communication Neil has radiotherapy coming up shortly and we've had no communications regarding it. I ended up making a phone call to inquire and was given a date. But we’ve still not received a phone call, no email, no letter or anything about it, even though they've got the date and time in their books. You can’t make plans, for example if you are trying to go away for the summer. If you’re waiting for a treatment, which on the NHS may take a while, you want to know when to expect the appointment. It’s a lot easier to manage your condition or diagnosis if you have the knowledge of when something's going to happen and you can manage your own expectations. Navigating the various healthcare apps To try and help with all of this we’ve been really keen to try and find a way to get all of Neil’s medical information, from many different organisations, together in one place and to rationalise appointments. We signed up to the NHS app which then put us on to System Online and then Neil was directed to AirMid UK. We've also found the Patients Know Best app which has been set up and says that you can access all your records but it seems to be only if an organisation has signed up to it. So we’ve got four apps to supposedly access the information but not one of them has all of Neil's information. We are actively looking for an online place which has all the information but none of it ties up. None of the apps give you the same information. We’ve asked our GP but he couldn’t help and hadn’t heard of some of the apps we’d found. A system that isn't working These are just a few examples of what we’re dealing with. I’m lucky as I have some medical knowledge so I know when we're missing something or waiting for something and I will chase up, but not everyone will have this knowledge. If it’s an older patient, or someone who hasn’t got family to support them, then they are on their own to navigate a very complex system. A system that isn't working. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Margaret's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses- Posted
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News ArticleLoughborough University researchers have developed an artificial intelligence (AI) tool that identifies the key human factors influencing maternity care outcomes, supporting ongoing efforts to improve safety for mothers and babies. Developed by AI and data scientist Professor Georgina Cosma and human factors and complex systems expert Professor Patrick Waterson, the tool analyses maternity incident reports to highlight key human factors – such as communication, teamwork, and decision-making – that may have impacted care outcomes, providing insights into areas that could benefit from additional support. When an adverse maternity incident occurs in England, detailed investigation reports are produced to identify opportunities for learning and enhancing safety. Currently, experts must carry out manual reviews to extract human factor insights from incident reports. This process is resource-intensive, time-consuming, and relies on individual interpretation and expertise, which can lead to varying conclusions. The AI tool addresses these challenges by identifying and categorising human factors in reports quickly and consistently. Its standardised approach allows it to analyse multiple reports and identify recurring factors, helping pinpoint areas that would benefit most from additional support. The AI model was trained and tested on data from 188 real maternity incident reports. It successfully identified human factors in each report and analysed them collectively, providing insights into where extra support could improve outcomes. "AI has transformed our analysis of maternity safety reports. We've uncovered crucial insights far quicker than manual methods," said Professor Cosma. “This has enabled us to gather a comprehensive understanding of where there are areas for improvement in maternity care, and these insights can help identify ways to enhance patient safety and improve outcomes for mothers and babies." Read full story Source: Loughborough University, 20 November 2024
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News Article
Thérèse Coffey scraps promised paper on health inequality
Patient Safety Learning posted a news article in News
Thérèse Coffey is ditching the government’s long-promised white paper on health inequalities, despite the 19-year gap in life expectancy between rich and poor, the Guardian has been told. The health secretary has decided to not publish a document that was due to set out plans to address the stark inequalities in health that the Covid-19 pandemic exposed. It was meant to appear by last spring and be a key part of then prime minister Boris Johnson’s declared mission to level up Britain. It was due to set out “bold action” to narrow the wide inequalities in health outcomes that exist between deprived and well-off areas, between white and BAME populations, and between the north and south of England. "It’s dead. It’s never going to appear. The white paper is being canned,” said one source familiar with the situation. Health experts reacted with dismay to reports of the paper being scrapped. “We expect the government to keep its commitment to addressing health disparities in an upcoming white paper and would have grave concerns if this long-planned paper were delayed or shelved,” said Dr Habib Naqvi, director of the NHS Race and Health Observatory. “We need to see priorities and an action plan set out to address a number of serious and longstanding health inequalities. This should be a priority, particularly given the cost of living crisis and the impact this is having on diverse communities.” Read full story Source: The Guardian, 29 September 2022 -
News ArticleFamilies have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit. A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year. Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an 'external report' into the deaths. A pre-inquest hearing into the death of Rowan - who used the pronoun 'they' - heard that the full report would be available for the coroner to read 'on or around September 30'. Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust "always act on the wishes of the family regarding publication of reports," adding "and so in line with this we have no immediate plans to make the report public." But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie's mother, Sam, said: "We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public - and the parents of other young people who are being treated in that unit." Read full story Source: The Manchester News, 13 September 2022
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Content ArticleClosed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm. This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer. The case study suggests safety actions that should be considered to prevent this error from happening again.
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Content ArticleThis editorial in BMJ Quality & Safety looks at the need for urgent improvement in the test result management and communication process in primary care. The authors highlight the inconsistency in tracking and communicating test results and look at potential solutions to reduce the patient safety risks associated with test results. They look at the evidence surrounding automated alerts built into provider IT systems and giving patient direct access to test results through apps, highlighting the growing importance of patients in safeguarding their own care through actively pursuing test results.
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News Article
Trust fined following patient’s death linked to ‘outdated’ IT system
Patient Safety Learning posted a news article in News
A Norfolk hospital trust has been fined £60,000 after pleading guilty to criminal charges of exposing a 28-year-old patient who died to significant risk of avoidable harm. Queen Elizabeth Hospital King’s Lynn Foundation Trust was sentenced on Thursday 8 December at Chelmsford Magistrates’ Court, as a result of a prosecution brought by the Care Quality Commission. The dilapidated hospital’s “outdated” computer system, which is long overdue a major upgrade, was cited as a factor in the young patient’s death, which followed a mix-up over scans. Lucas Allard, who was awaiting heart surgery, had attended the hospital’s emergency department on 12 March 2019 with chest pain. He was sent home after staff determined his computerised tomography scan results meant he was fit for discharge. But two days later, a consultant discovered staff had been looking at the wrong scan, and the correct report showed significant abnormality. Mr Allard was urgently called back to the hospital but suffered a cardiac arrest shortly after arriving, and died despite attempted resuscitation. Read full story (paywalled) Source: HSJ, 9 December 2022 -
News Article
Medical jargon putting patients in harm's way
Patient Safety Learning posted a news article in News
Patients are struggling to understand their doctors because of confusing medical jargon, a study has found. Almost 80% of people do not know that the word 'impressive' actually means 'worrying' in a medical context. Critics said using the word borders on 'disrespectful' because 'we're describing something as impressive that is causing real harm for patients'. More than one in five of respondents could not work out the phrase 'your tumour is progressing', which means a patient's cancer is worsening. And the majority of participants failed to recognise that 'positive lymph nodes' meant the cancer had spread. The word 'impressive' means something admirable to most people. But when physicians describe a chest X-ray as impressive, they actually mean it is worrying. Some 79% of study participants did not get this meaning. Only 44 participants correctly understood that a clinician was actually giving them bad news. Read full story Source: Mail Online, 1 December 2022 -
Content ArticleThis study from Gotlieb et al. looked at how well adults understand common phrases clinicians use when communicating with patients. The study surveyed 215 adults in the USA and found that participants frequently misunderstood and often assigned meaning opposite to what the clinician intended. These findings suggest that use of common medical phrases may lead to confusion among patients affecting health outcomes.
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Content ArticleAn expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future. The report identified: Poor practice including a lack of proper clinical investigation. Inaccurate diagnosis. Poor prescribing practices. Poor record keeping. Lack of openness and effective communication. Inappropriate treatment The risks of clinicians working in isolation. The expert panel has made specific recommendations for RQIA including: Ensuring that patients have direct access to doctors’ letters. Ensuring proper multidisciplinary team working. Tackling isolation in clinicians working alone. These important recommendations are at the heart of addressing the failings of the care and treatment provided. Clinicians must be supported to adopt good practice, especially in using up to date best practice routes to diagnosis and treatments. They should be encouraged and facilitated to seek the support of peers and others to challenge and review their analysis and thinking. These are issues, not only for neurology services, but throughout the health and social care system.
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Content ArticleStudy into patient attitudes and perspectives related to viewing immediately released test results through an online patient portal. In this survey study of 8139 respondents at four US academic medical centres, 96% of patients preferred receiving immediately released test results online even if their healthcare practitioner had not yet reviewed the result. However a subset of respondents experienced increased worry after receiving abnormal results.
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Content ArticleThis article by Till Bruckner of Transparimed outlines how a new UK law will affect how clinical trial results are reported. The UK Government will introduce a legal requirement to make the results of all clinical trials public within 12 months of trial completion. Any company or university breaking the law will be refused permission to start new trials.
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Content ArticleThis article tells the story of 61 year-old Susannah Constantine who was diagnosed with a rare neurological condition after her MRI was not looked at by her GP surgery for over a year. Susannah decided to have a private MRI when doctors couldn't diagnose why she’d been suffering from tinnitus and pins and needles in the fingers of her left hand. The results were sent to her GP, and Susannah heard no more, so struggled on for another year—she gradually became weaker and her muscles atrophied. She called her GP surgery to check if the MRI held any clues and learnt no one there had ever looked at the results—they had just been sat there for a year. She was told she needed to see a neurosurgeon immediately and was diagnosed with arteriovenous malformation (AVM), a rare neurological condition that disrupts the flow of blood and oxygen to the brain. If not spotted and treated in good time there is a one in three chance of suffering a brain haemorrhage, paralysis or stroke.
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Content ArticleWhile some patients fully embrace access to test results as soon as they become available, those who may be less informed or receiving results for the first time may find reading results without the guidance of a doctor or oncologist to be fear-inducing and anxiety provoking. The intention of this poster from Tambre Leighn, presented at AACR2023, is to raise awareness and generate conversations about gaps in the process that create barriers and concerns along with potential strategies to improve the overall experience for patients, caregivers and their doctors without interfering with those patients who want to know without delay.
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Content ArticleIncidental imaging findings (IIFs) are things that show up on a diagnostic image that are not related to the reason a healthcare professional ordered the test. Inadequate follow-up of IIFs can result in poor patient outcomes, patient dissatisfaction and provider malpractice. In an effort to improve awareness of IIFs, this study aimed to investigate communication of IIFs on inpatient discharge summaries after implementation of a new electronic health record (EHR) notification system. The results showed that IIFs were included in 51% of discharge summaries. The authors identified that lack of inclusion of IIFs on discharge summaries could be related to transitions of care within hospitalisation, provider alert fatigue and many diagnostic testing results to distil. The findings demonstrate the need to improve communication of IIFs and the need for care coordinators to follow up on IIFs. This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.
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News ArticleThe latest batch of hospital patient safety ratings from America's Leapfrog Group shows a general decline among “several” hospital safety measures concurrent with the onset of the COVID-19 pandemic, according to the healthcare safety watchdog. Released Tuesday, the scores are accompanied by a report from Leapfrog that highlights a “significant” decline in the experiences of adult inpatients at acute care hospitals during the pandemic, with many areas “already in dire need” prior to the pandemic deteriorating even further. “The healthcare workforce has faced unprecedented levels of pressure during the pandemic, and as a result, patients' experience with their care appears to have suffered,” Leah Binder, president and CEO of the Leapfrog Group, said in a statement. Leapfrog’s twice-annual reports assess more than 30 patient safety measures and component measures compiled from the Centers for Medicare & Medicaid Services (CMS) and Leapfrog’s hospital surveys between July 2018 and March 2021. The most recent release assigns letter grades to nearly 3,000 US general hospitals and is the second collection of scores to incorporate safety and experience data from the COVID-19 pandemic. Read full story Source: Fierce Healthcare, 10 May 2022
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News Article
No. 10 criticised for failing to respond to damning MP report on Covid
Patient Safety Learning posted a news article in News
The government has been criticised for failing to respond to a damning parliamentary report that accused ministers of mishandling the early stages of the pandemic. The report, compiled by the Health and Science and Technology Committees, found the government’s initial response to Covid-19 “amounted in practice” to the pursuit of herd immunity, with the delayed decision to lock down ranking as one of the “most important public health failures the United Kingdom has ever experienced”. More than 50 witnesses contributed to the cross-party report, including ministers, NHS officials, government advisers and leading scientists, with the authors saying it was was “vital” that lessons were learnt from the failings of the past 18 months. The findings from the joint inquiry were published on 12 October and a deadline for an official government response was set for 12 December. However, that date has now passed and the committees have yet to formally hear back from ministers, according to the parliamentary website, which states that a response is now “overdue”. Covid-19 Bereaved Families for Justice said the government’s failure to “meet a very reasonable deadline” called into question the willingness of ministers to engage with the coming independent public inquiry into the UK’s handling of the pandemic. "The government have had months to get a response delivered to the Health and Science and Technology committees following their lessons leant from the pandemic report,” said Jo Goodmand, co-founder of the campaign group. “Unfortunately those of us who have lost loved ones are far too used to this with responses to FOIs late and it taking far too long to announce the inquiry. Read full story Source: 30 December 2021 -
News Article
HealthWatch's response to the annual CQC 'State of Care' report
Clive Flashman posted a news article in News
The Care Quality Commission (CQC) has published State of Care. The report, which draws on the experiences of care people have shared with Healthwatch England, has found that health and social care services face some highly concerning challenges, including: A workforce drained in terms of resilience and capacity, especially in social care, where the staff vacancy rate has risen; A rising number of people seeking emergency care, leading to unacceptable waiting times; and Tackling the health inequalities that the COVID-19 pandemic has exacerbated. The report welcomes the additional funding that the Government has allocated to help the NHS and social care address their challenges. However, CQC has called for the extra investment to be used to: Develop new ways of working and don’t just prop up existing approaches and plug demand in acute care; and Improve the training, career development and terms and conditions of social care workers to help attract and retain more staff. CQC has also recommended that the short-term funding - currently in place to help discharge patients who are no longer in need of hospital care but may still require care services - be extended. The HealthWatch response Responding, Sir Robert Francis QC, Chair of Healthwatch England said: “During the pandemic, people have told us about the challenges they have faced. Whether this not being able to access dental care, problems using online GP services or being discharged from the hospital without the proper support. It’s great to see this report drawing so much on the experiences people have shared with us. “We urge Government to act on this report. The health and care system upon which we all depend is facing a hard winter, but, as this report makes clear, the longer-term picture is also challenging. “The steps the CQC are recommending, like extending the extra funding to help people leave hospital safely and ensuring there is enough dental capacity, will help give services the breathing space they need to get through this winter. “However, come spring we need to grasp the opportunity to build a better NHS and social care system. A system that tackles heath inequalities head-on, ensuring that no matter who you are or where you live, you can access high-quality care that meets your needs. A system that is sustainable, is designed round the needs of people and breaks perennial cycle of winter crises.” Original source: HealthWatch CQC report here -
Content ArticleHernias are one of the most common surgical diagnoses, and general surgical operations are performed. The involvement of patients in the decision making can be limited. The aim of this study was to explore the perspectives of patients around their hernia and its management, to aid future planning of hernia services to maximise patient experience, and good outcomes for the patient. A SurveyMonkey questionnaire was developed by patient advocates with some advice from surgeons. It was promoted on Twitter and Facebook, such as all found “hernia help” groups on these platforms over a 6-week period during the summer of 2020. Demographics, the reasons for seeking a hernia repair, decision making around the choice of surgeon, hospital, mesh type, pre-habilitation, complications, and participation in a hernia registry were collected. Hernia repair is a quality of life surgery. The survey found that whether awaiting surgery or having had surgery with a good or bad outcome, patients want information about their condition and treatment, such as the effect on aspects of life, such as sex, and they wish greater involvement in their management decisions. Patients want their surgery by surgeons who can also manage complications of such surgery or recommend further treatment. A large group of “hernia surgery injured” patients feel abandoned by their general surgeon when complications ensue.
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Content ArticleThe Japan Council for Quality Health Care (JQ) has been conducting various activities, such as the Project to Collect Medical Near-Miss/Adverse Event Information and the evaluation of medical services provided at hospitals, in order to maintain public confidence in healthcare services and improve the quality of the services. In response to rising awareness and expectations of the general public as well as medical institutions concerning promotion of patient safety and medical adverse event prevention, the JQ has been actively engaged in the said activities. The JQ Division of Adverse Event Prevention has been undertaking the Project to Collect Medical Near-Miss/Adverse Event Information to prevent medical adverse events and to promote patient safety since 2004. As a neutral third-party organisation, the JQ has been publishing collected medical near-miss/adverse event information and the analyses of data in the form of periodic reports, annual reports and monthly fax newsletters for medical professionals, administrative organisations and the general public. The reports can also be browsed on JQ's website.
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Content Article
Patient Safety Authority Annual Report 2021
Sam posted an article in International patient safety
The Patient Safety Authority (PSA) share its 2021 annual report, highlighting the agency’s expansion of education and reporting efforts to improve patient safety throughout the commonwealth. PSA is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires acute care facilities to report all incidents of harm (serious events) or potential for harm (incidents). -
Content ArticleThis patient-centred report from the Regulatory Horizons Council discusses a route to more effective safety assurance through mechanisms that consider the whole product lifecycle, how adverse events are detected or a long time after use of the device and how to trace and recall patients when needed. In addition, this report also considers a number of ways in which use of data and technology can be smarter and to join up digital systems.
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Content ArticleThis document describes how the Surveillance of Surgical Site Infection: Surgical Site Infection Surveillance Service aims to better patient care by asking hospitals to use data obtained from surveillance and compare rates of surgical site infections over time and against a benchmark rate. The aim is also to encourage the use of this information to help guide clinical practice.
