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Found 140 results
  1. Event
    Join this free webinar to learn how collaboration and support for HSSIB (Health Services Safety Investigations Body) will make a difference and will promote a culture of safety in your organisation. During the course the webinar will explore what meaningful recommendations look like and how these recommendations will directly impact individual patient care, policy and strategy. Additionally, we will take a look at how the views of patients and healthcare professionals feed into building a Safety Management System. The primary aim of this webinar is to strengthen the relationship of HSSIB with those who work in the medical profession to aid understanding and future collaboration. By attending the webinar, you will: Gain and build your understanding of HSSIB. Be able to consider how we can contribute and support investigations. Be able to consider how we can contribute and support the implementation of recommendations. Register
  2. Content Article
    A new MIT study identifies six systemic factors contributing to patient hazards in laboratory diagnostics tests. By viewing the diagnostic laboratory data ecosystem as an integrated system, MIT researchers have identified specific changes that can lead to safer behaviours for healthcare workers and healthier outcomes for patients.
  3. Content Article
    Great Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
  4. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.
  5. Content Article
    It was recently reported that NHS Finance Directors were ‘incensed’ that the Health Services Safety Investigations Body (HSSIB) should think that they could be working more closely with patient safety chiefs. Whereas medical staff and clinicians represent the sharp end of healthcare delivery, the administrative functions, including finance, are the blunt end. Removed in space and time from the action, it can be hard to see how their behaviour can directly influence workplace outcomes. To understand the issue, Norman MacLeod reflects on how systems behave and the decision-making hierarchy within healthcare organisations.
  6. Content Article
    This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network.
  7. Content Article
    Those who work in health and care are keenly aware of the need to identify and manage risks to protect patients from harm. But we are not the only industry that must take safety seriously. This video from the Healthcare Services Safety Investigation Branch (HSSIB) we compare notes with other safety-conscious industries – oil and gas, shipping, aviation, rail, road, nuclear and NASA – to understand their approach to safety management. In these fields, systems for organising and coordinating safety are often called Safety Management Systems (SMSs). See also HSSIB's report: Safety management systems: an introduction for healthcare.
  8. Content Article
    Safety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
  9. Content Article
    Healthcare often uses the experience of aviation to set its patient safety agenda, and the benefits of a ‘safety management system’ (SMS) are currently being espoused, possibly because the former chief investigator for HSIB, Keith Conradi, had an aviation background. So, what does an SMS look like and would it be beneficial in healthcare? In this blog, Norman MacLeod discusses aviation's SMS, its many component parts, the four pillars of an SMS, just culture and its role in healthcare.
  10. Content Article
    In this report, Patient Safety Learning considers the roles and responsibilities of Integrated Care Systems (ICSs) in relation to patient safety, and how this fits in with the wider patient safety landscape in England. This article contains a summary of the report, which can be read in full here or from downloading the attachment below.
  11. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  12. Content Article
    Radar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
  13. Content Article
    This report by Press Ganey outlines the key trends shaping safety culture in 2023 and makes recommendations for senior healthcare leaders to create and sustain safety culture across their organisations. Based on survey data from 814,000 US healthcare professionals, it highlights that in 2022 there was an upward trend in the perception of safety culture among clinical and nonclinical staff, but perception continues to trend downwards among senior leadership and doctors.
  14. News Article
    There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed. Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues. Read full story Source: Harvard Law, 17 February 2020
  15. News Article
    A nationwide effort in the US to improve and coordinate patient safety measures will strive to make a connection between workplace and patient safety. The Institute for Healthcare Improvement (IHI) gave an update during its National Forum this week on the creation of a national patient safety plan intended to encourage better coordination of safety efforts. A key goal of the plan, expected to be released next year, was to emphasise the role of improving workforce safety. “In our view, too many systems have a separation between workforce safety and patient safety and yet we know the two are connected,” said Derek Feeley, President and CEO of IHI, in a briefing with reporters Monday before the start of the forum in Orlando, Florida. “Patient safety incidents are much less likely to occur when workers feel safe.” The steering committee developing the plan includes 27 organizations that range from patient advocates and professional societies to provider organizations and government representatives. The committee's plan hopes to target healthcare leaders and policymakers. Read full story Source: Fierce Healthcare, 10 December 2019
  16. News Article
    All healthcare leaders, providers, patients and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?” “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.” Read full story Source: Hospital News, 3 December 2019
  17. Content Article
    In this blog, PC Barry Calder, Lead of the Metropolitan Police Service Disability Staff Association COVID Peer Support Group, raises concerns about the potential impact of long COVID on staff and organisations. He highlights that organisations can take proactive steps to mitigate the consequences of staff being affected by long COVID, such as staff absences and changes to job roles. He recommends that organisations: introduce regular contingency planning activities (such as COVID Resilience meetings) ensure managers are trained to support staff living with long COVID ensure occupational health and staff wellbeing services include support relevant to long COVID consider establishing peer support groups for affected staff.
  18. Content Article
    Telemetry monitoring of heart rates and rhythms was introduced in intensive care units in the 1960s, and since then it has expanded into patient rooms and units in noncritical care settings. It allows healthcare workers to watch the condition of many patients all at once and intervene quickly when their condition changes; however, if the technology is not used appropriately or the equipment malfunctions, relying on telemetry monitoring also risks patient harm. This study from Kukielka et al. looked at real-life cases of breakdowns in the processes and procedures regarding telemetry monitoring, such as user errors and miscommunication, and equipment failures, including broken transmitters and dead batteries. The lessons learned can help improve training and best practices to improve the safety of patients being monitored.
  19. Content Article
    This assessment toolkit enables automatic calculation of infection prevention compliance scores. The tool assesses seven areas of care that are fundamental to best practice in minimising the risk of surgical site infection. After each section of the assessment there are notes providing further instructions on how to complete each element.
  20. Content Article
    In this article, Andrew Ottaway discusses the five primary components (Just Culture, Reporting Culture, Flexible Culture, Learning Culture and Challenging Culture) that forms a safety-conscious, informed and engaged organisation that is able and willing to deliver an effective Safety Management System.
  21. Content Article
    Double checking is a standard practice intended to improve patient safety. It is used in different areas of health care, such as medication administration, radiotherapy and blood transfusion. Some studies have found double checking to be a useful practice, which has been endorsed by agencies and individuals. The confidence in double checking exists in spite of the lack of evidence substantiating its effectiveness. In this study, Hewitt et al. asks: ‘How do front line practitioners conceptualise double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?’ The authors conclude that double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged.
  22. Content Article
    The CQC inspection framework now includes multidisciplinary teams (MDTs) for end of life care, tumours and weekly MDTs for people with complex needs. However lack of time and staff availability for this is a real problem. MDTs are under increasing pressure and are already seeing an erosion of their power to assure safe and appropriate care. Anecdotally, non-attendance by key MDT members is a significant quality issue for many hospitals. This is not a problem of engagement — all MDT members and are willing to provide input — but staffing pressures and the complexity of rostering makes holding these MDT meetings near-impossible. So how do we stop this degradation? How can hospitals better manage the burgeoning requirement for MDTs? One possible answer is to change the emphasis from a single meeting to a managed series of recorded opinions and decisions. If properly supported by the right workflow technology, we can move away from the ‘single-point’ MDT meeting (MDTM) to a ‘multi-point’ MDT process (MDTP) which could allow better and more auditable decisions to be made. Where significant differences of opinion exist, then a meeting can be called – but the MDT members could act independently and in parallel using a suitable recording and monitoring system. In this article, Dr D J Hamblin-Brown explains how this might work.
  23. Content Article
    Listen for weak signals to avert potential disasters, urges Columbia Business School professor, Rita Gunther McGrath. We’ve all heard the stories. The multi-patent-holding chemist at Kodak who warned of the digital revolution. The experienced research and development person at Nokia who pointed out that the bean counters had taken over and the company couldn’t get new products out the door anymore. The scary-smart top engineers at General Electric who urged the company to bet on renewable energy rather than tying its fortunes to fossil fuels.  It’s nearly always the case that someone, somewhere, saw a significant inflection point coming and tried to warn the ‘powers that be’ – to little avail. Ignoring these warnings imperils everyone. And yet, it happens over and over again. Let’s explore why, and what you as a leader might do about it.
  24. Content Article
    This article, published in the International Journal for Quality in Health Care, explores the usage of participatory engagement in patient-created and co-designed medical records for emergency admission to the hospital. It is advocated as a means to improve patient safety.
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