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Found 45 results
  1. 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.
  2. Content Article
    All patients with prosthetic mechanical heart valves require life-long oral anticoagulation with a vitamin K antagonist (VKA), usually warfarin, as these valves predispose the patient to systemic embolism. Thrombosis of a prosthetic valve is potentially life-threatening as it can result in haemodynamically severe stenosis or regurgitation and acute heart failure. The risk depends on the type of valve, its position, and other factors.  Since 1 March 2020, 14 incidents have been reported of patients with a mechanical heart valve being switched to a a low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC); two patients were hospitalised due to valve thrombosis and/or required emergency surgery and one was admitted due to severe anaemia. The reports included cases where patients’ anticoagulation was switched from warfarin in primary and in secondary care.
  3. Content Article
    Mandatory and voluntary safety reporting policies are an extremely important part of providing guidance for safety reporting in aviation safety management systems (SMS). This blog highlights the purpose of safety reporting policies, how to train employees on voluntary vs mandatory reporting, and how to encourage mandatory and voluntary safety reporting. Although written for the aviation industry, many of the principles can be applied to healthcare.
  4. Content Article
    This summary, published by the Health and Safety Executive, outlines the legal necessity of reporting and recording incidents in the workplace. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) require employers to report to the relevant enforcing authority and keep records of work-related deaths, accidents and injuries.
  5. Content Article
    This article, published on SKYbrary, discusses the importance of correct safety reporting in the aviation industry. Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies; the aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware.  Although for the aviation industry, some of the principles can be applied to healthcare.
  6. Content Article
    This consensus study report (published by the National Academies of Sciences, Engineering, and Medicine), builds upon two ground-breaking reports from the past twenty years, 'To Err Is Human: Building a Safer Health System' and 'Crossing the Quality Chasm: A New Health System for the 21st Century', which both called attention to the issues around patient safety and quality of care. This report explores the extent, consequences and contributing factors of clinician burnout. It provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.
  7. Content Article
    This study, published in the European Journal of General Practice, explores the type and nature of patient safety incidents in French primary care settings during the first wave of the Covid-19 pandemic. Its findings suggest that constraints of the first wave of the pandemic contributed towards patient safety incidents during non-Covid-19 care, with the authors suggesting a national primary care emergency response plan to support practitioners could have mitigated many of the non-Covid-19 related patient safety incidents during this period.
  8. Content Article
    Workforce burnout and resilience in the NHS and social care report describes the causes and effects of burnout among staff working within the National Health Service as well as the impact of Covid-19 on burnout. 
  9. Content Article
    A joint National Patient Safety Alert issued by the NHS England and NHS Improvement National Patient Safety Team and Royal College of Emergency Medicine, on the need for urgent assessment/treatment following ingestion of ‘super strong’ magnets.
  10. Content Article
    This article, published in the British Journal of Anaesthesia, explores how medication-related adverse events in anaesthesia care are frequent and require a deeper understanding if medication harm is to be prevented. The study looked at a Spanish incident report database over a ten-year period to conclude that harm could have been mitigated.
  11. Content Article
    This article, published in Best Practice & Research Clinical Anaesthesiology, looks at the importance of Incident Reporting Systems in improving patient safety and how they can be better used to have an improved impact.
  12. Content Article
    In this article for US magazine Consumer Reports, Rachel Rabkin Peachman looks at the incidence and impact of malfunctions and design flaws in continuous blood glucose monitors, insulin pumps and other diabetes equipment. She highlights the case of Pamela, a 64-year-old with diabetes who died when her insulin pump unintentionally gave her a massive dose of insulin overnight. The numbers of adverse events and deaths reported to the FDA regarding diabetes devices is far greater than for any other type of medical device—between January 2019 and July 2020, almost 400 deaths and 66,000 injuries in the US were linked to commonly used diabetes devices. Reports are spread across the different device manufacturers and demonstrate the complexities of trying to determine the exact cause of each adverse event. The article also includes information on how people with diabetes can protect themselves from device malfunctions and errors.
  13. Content Article
    Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers are following national guidance and safety recommendations. In this blog John Tingle, a lecturer at Birmingham Law School, raises concerns about the number of Never Events that continue to take place within health services, the lack of public awareness about Never Events and the need to develop a safety culture that allows learning from Never Events to actually take place.
  14. Content Article
    Vaginal tapes, slings and meshes are medical devices that are surgically implanted to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women. This report written on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) by York Health Economics Consortium, provides summaries of safety and adverse events related to vaginal tapes for SUI and POP. The summaries were developed using the data reported in systematic reviews of the effects and safety of vaginal tapes published in the 10 years up to 2012.
  15. Content Article
    Jeremy Hunt, former Secretary of State turned patient safety campaigner, will be joined by the newly appointed Patient Safety Commissioner, Dr Henrietta Hughes OBE as part of a panel of keynote speakers at an annual congress [15-16 September] which pledges to 'drive forward' the current national commitment of putting patient safety and quality at the heart of patient care
  16. Content Article
    This report by the US non-profit organisation the Emergency Care Research Institute (ECRI) was commissioned by the US Food and Drug Administration (FDA) to determine the safety profile of polypropylene (PP) mesh used in a variety of surgical procedures. ECRI performed a comprehensive literature search and systematic review to identify the current state of knowledge about how patients' bodies respond to PP mesh.
  17. Content Article
    In this blog, Kath Sansom, founder of the Sling the Mesh campaign, unpacks the findings of a medical device performance study into polypropylene mesh published by the Emergency Care Research Institute (ECRI) in the US. The document highlights significant gaps in evidence about the risk of complications associated with polypropylene (PP) surgical mesh.
  18. Content Article
    This German study in the Journal of Patient Safety aimed to analyse the strength of safety measures described in incident reports in outpatient care. 184 medical practices were invited to submit anonymous incident reports to the project team three times in 17 months. The authors coded the incident reports and safety measures, classifying them as as “strong” (likely to be effective and sustainable), “intermediate” (possibly effective and sustainable) or “weak” (less likely to be effective and sustainable). The study found that the proportion of weak measures was high, which indicates that practices need more support in identifying strong patient safety measures.
  19. Content Article
    This report, from the Royal College of Midwives, found that continuity of midwifery care contributes to improving quality and safety of maternity care. High quality evidence indicates that women who receive care in these models are more likely to have effective care, a better experience and improved clinical outcomes. There is some evidence of improved access to care by women who find services hard to reach and better co-ordination of care with specialist and obstetric services. Continuity of midwifery care can provide services for all women across all settings, whether women are classified as high or low risk and current evidence shows improved outcomes with no adverse effects in populations of mixed risk. In addition improved birth outcomes also result when women receiving continuity of midwifery care give birth in obstetric units.
  20. Content Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an online form for submitting a patient safety concern. The form should take around 20 minutes to complete. You can tell them about something that has happened or something that might happen. Something that has happened: this could be a one-off or a series of events where something potentially dangerous has happened, whether or not someone was actually harmed. Something that might happen: this could be a safety risk or an unsafe condition that, if not corrected, might lead to an incident which could cause harm. Follow the link below to find out more about the process, read their privacy notice or request the form in an alternative format. Note: HSIB can investigate events or risks that occurred within NHS-funded care in England after 1 April 2017.
  21. Content Article
    Very little is known about the actual harm that occurs to patients in developing or transitional countries, although the available evidence suggests that they may have an even higher risk of suffering patient harm. Understanding the magnitude of the problem and the underlying factors represents the first step towards improvement. The World Health Organization (WHO) is making a concerted effort, in different parts of the world, to identify the main issues affecting safe care in developing and transitional countries and to use these data to begin to developing and implementing effective solutions.
  22. Content Article
    This month, the Institute of Public Policy Research (IPPR) published their new Injury Prevention Policy, Better Than Cure.[1] In this report they call on the Government to make injury prevention a public health priority and to take further action to prevent the transmission of Covid-19 in the workplace. Patient Safety Learning welcomes the publication of this report and its recognition of the importance of improving patient safety. We concur with its identification of unsafe care as being driven by a range of underlying systems issues, such as the culture of fear, barriers to resource sharing and insufficient focus on patient safety training and skills. These closely relate to the six foundations of safer care we have set out in A Blueprint for Action.[2] We also agree about the importance of two core areas which they highlight for action in this respect: 1) The Government should commit to long-term safe staffing This is particularly an important issue as we return to more normal levels of care following the peak of the Covid-19 pandemic, with the need to ensure that organisations and staff transition to this safely.[3] We consider that system wide (health and social care) workforce modelling is needed to inform resourcing and ensuring safe staffing. 2) The NHS should use patient safety networks to share best practice We strongly agree about the importance of sharing learning for patient safety. We need people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. This is why we have created the hub, a patient safety learning platform. Designed with input from patient safety professionals, clinicians and patients, the hub provides a community for people to share learning about patient safety problems, experiences, and solutions. References 1. IPPR. Better Than Cure: Injury Prevention Policy, August 2020.  2. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 3. Patient Safety Learning. Patient Safety Learning’s response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, June 2020.
  23. Content Article
    Authors of this article, published by Health Europa, argue that proactive patient safety and risk prevention are key to helping healthcare organisations surveil and mitigate global and local risks.
  24. Content Article
    This report by the Center for Health and the Public Interest, brings together what is known about patient safety in private hospitals. It offers insights into the number of patient safety incidents in private hospitals, analyses the potential risks inherent in the way that these services operate, and makes recommendations to improve transparency in the private sector.
  25. Content Article
    As part of its commitment to a safe healthcare system for all South Australians (SA), the SA Department of Health and Wellbeing (DHW) has used the Safety Learning System (SLS) since 2011. This is an incident management system that allows healthcare staff to report incidents and near misses. They are reviewed, escalated where appropriate, analysed and investigated in an attempt to prevent their occurrence in the future. The SLS is a “state-wide” system which allows healthcare professionals access to report incidents in all SA public health services and related agencies such as ambulance.
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