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Showing results for tags 'Safety report'.
Found 46 results
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Content Article"When the secretary of state for health and social care, Wes Streeting, asked me to investigate the state of the NHS in England, I thought I knew what we would find. All of us who have worked in the NHS in recent years have known it was under pressure. But, as a surgeon, I am used to seeing just one piece of the puzzle. Hearing the experiences of millions of patients and staff across the country brought together left me shocked and angry." In this article for the Guardian, Lord Darzi reflects on the findings of his review and argues that making healthy life expectancy central to all government policy is the surest way of stemming demand on the health service.
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Content ArticleThis progress report outlines the contribution of Academic Health Science Networks (AHSNs) during the first year of the NHS Patient Safety Strategy. It looks at the impact it has had in improving safety in hospitals, maternity and neonatal units, care homes and the community. It also describes how AHSNs and the Patient Safety Collaboratives they host have responded to the COVID-19 pandemic, supporting programmes on tracheostomy safety and the use of pulse oximeters to safely monitor patients at home. Examples featured in the report include tools to spot and manage patients at risk of serious illness in hospitals and care homes, discharge safety bundles, and award-winning projects to support premature babies and their families.
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Content ArticleWorkforce 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.
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Content ArticleA 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.
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Content ArticleMandatory 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.
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Content ArticleThis 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.
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Content Article
SKYbrary: Safety occurrence reporting (2 October 2020)
Becky T posted an article in Implementation of improvements
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. -
Content ArticleThis 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.
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Content ArticleVery 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. The Eastern Mediterranean/African Adverse Events Study is a large scale study carried out in six Eastern Mediterranean and two African countries, to assess the number and types of incidents that can occur in their hospitals and harm patients. To carry out this study, a collaborative model was established in which 26 hospitals from eight countries, Egypt, Jordan, Kenya, Morocco, South Africa, Sudan, Tunisia and Yemen participated. This document contains the main findings of the Eastern Mediterranean/African Study. It presents some of the risks associated with harm in the participating hospitals, as well as the consequences.
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Content ArticleThis 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.
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Content ArticleThis table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment. Taken from the Pennsylvania Patient Safety Authority report:
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Content ArticleFollowing the first confirmed case of COVID-19 in Pennsylvania, facilities began submitting patient safety reports to the Pennsylvania Patient Safety Reporting System related to management of this emerging infection. Events in the analysis most often took place in the Emergency Department, on a Medical/Surgical Unit, or in the Intensive Care Unit. This is a study of 343 Event Reports From 71 Hospitals in Pennsylvania. The table within this document outlines the factors associated with patient safety concerns within COVID-19.
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Content Article
Dirty Dozen and COVID-19 (webinar, May 2020)
Claire Cox posted an article in Coronavirus (COVID-19)
There are fears around maintaining personal safety whilst ensuring patient safety. Staff need to protect both themselves and their families at home. Equally, it is essential that staff feel supported in identifying risks and the potential for errors with a robust mechanism in place to reduce, eliminate or mitigate such risks. The Human Factors 'Dirty Dozen' is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This webinar, from the Clinical Excellence Commission, looks at ways you can identify risks or 'hot spots' in your area of work and then discuss with your team at handover and huddles and plan strategies to reduce, eliminate or mitigate the risks -
Content Article
HSIB: Submit a patient safety concern
PatientSafetyLearning Team posted an article in Investigations and complaints
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. -
Content ArticleThis 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.
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Content ArticleAuthors 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.
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Content ArticleThis 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. The report also confirms that the NHS serves as a ‘safety net’ for the private sector with around 6,000 people a year transferred to NHS hospitals following treatment in private hospitals. Read the press release and coverage on BBC News, the Telegraph and Health Service Journal Read a blog on patient safety from Peter Walsh Sources of further information on patient safety private hospitals Read a blog from Colin Leys exploring the issues in the report.
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Content ArticleAs 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. This is an independent review of the SLS: 1. To consider recommendations made by the State Coroner and by independent reviews conducted in response to the Chemotherapy Underdosing that relate to incident reporting and management. 2. To determine and describe how the SLS is used across SA Health for patient incident reporting and management including: a. adoption and uptake; b. data extraction; c. reporting; d. incident management; and e. open disclosure to patients and feedback to staff. 3. To identify factors that are impeding or may impede the use of SLS, including; a. the culture of reporting and incident management, and b. the availability and uptake of training and education. 4. To determine if Datix Web, the software platform used for the SLS, meets the needs of SA Health and whether its functionality is comparable to alternative programs. 5. To make recommendation to the Chief Executive (CE), Department of Health and Wellbeing that will assist in assuring robust incident reporting and management and the sharing of learnings across SA Health.
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Content ArticleMedication errors may cause harm, including death, and increase use of health care services. This project aims to summarise the evidence on the burden of medication error, namely the number of errors occurring in the NHS in England, the costs of those errors to the NHS and the health losses due to medication error. This involves two systematic reviews, one on the incidence and prevalence of medication errors, and the other on the costs of health burden associated with errors. Additionally, economic modelling estimates the number of errors occurring in the NHS in England each year, their costs and health consequences.
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Content Article
Team of Teams: Fixing healthcare safety (June 2017)
PatientSafetyLearning Team posted an article in Systems
This article, from the Australian-based Patient Safe Network, argues that healthcare environments have become increasingly complex, existing error reporting systems based on traditional command structures are ineffective and we need to work as a ‘Team of Teams’. -
Content ArticleThere is widely shared agreement that the Canadian healthcare system needs a sharper patient safety focus. The rate of preventable harm in all care settings is alarming, yet poorly understood, leading to complacency and acceptance of patient safety risks. 2018-2019 brought about a change in the strategic direction of the Canadian Patient Safety Institute. Their aim is to inspire and advance a culture committed to sustained improvement for safer healthcare. In this first year of their new five-year business plan, they've laid the groundwork to demonstrate what works and strengthen commitment for end-to-end patient safety improvements and are using those strategic elements to make care safer. Read this annual report to learn more about their priorities and progress.
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Content ArticleThe Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high quality care and we encourage care services to improve. Their role: They register health and adult social care providers. They monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led, and we publish what we find, including quality ratings. They use our legal powers to take action where we identify poor care. They speak independently, publishing regional and national views of the major quality issues in health and social care, and encouraging improvement by highlighting good practice. This review was carried out in response to the very low numbers of investigations or reviews of deaths at Southern Health NHS Foundation Trust. Over a four-year period, fewer than 1% of deaths in Southern Health’s learning disability services and 0.3% of deaths in their mental health services for older people were investigated as a serious incident requiring investigation. Throughout this review, families and carers have told the CQC that they often have a poor experience of investigations and are not always treated with kindness, respect and honesty. This was particularly the case for families and carers of people with a mental health problem or learning disability. However, there is currently no single framework for NHS trusts that sets out what they need to do to maximise the learning from deaths that may be the result of problems in care. This means that there are a range of systems and processes in place, and that practice varies widely across providers. As a result, learning from deaths is not being given enough consideration in the NHS and opportunities to improve care for future patients are being missed. This reports sets out the next steps.
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Content ArticleThis joint report by the Prison Reform Trust (PRT), INQUEST and Pact (the Prison Advice and Care Trust) reveals that most prisons in England and Wales are failing in their duty to ensure that emergency phone lines are in place for families to share urgent concerns about self-harm and suicide risks of relatives in prison. This is in serious breach of government policy that families should be able to share concerns ‘without delay’. The new research maps the provision of safer custody telephone lines across the prison estate - dedicated phone lines which enable family members and others to pass on urgent information when they have concerns. It finds that provision is patchy, under-resourced and even non-existent in some prisons, leaving families struggling to share their concerns with prison staff. The report reveals that: Almost two in five (37%) prisons in England and Wales appeared to have no functioning dedicated safer custody telephone lines for families to get in touch. Of these, nearly one in five prisons (18%) had no publicly advertised number for a dedicated safer custody telephone line. A further 18% of prisons advertised a dedicated line, but when called the number either wasn’t operational, was not answered, or went through to a general prison switchboard. Of the 75 dedicated safer custody telephone lines that went through to safer custody departments, only 13 (17%) were answered by a member of staff. Over 80% of dedicated safer custody lines that went through to safer custody departments (62 prisons in total) put the caller straight through to an answer machine.
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Content ArticleMark Chassin, M.D., president and CEO of The Joint Commission, sat on the Institute of Medicine committee that authored the landmark 1999 report, To Err is Human. In this podcast, he speaks to Nancy Foster, AHA vice president for quality and patient safety, about its impact on health care safety. He speaks about the need to reflect more on the type of culture that exists within zero harm organisations. He also argues that we need to ensure people feel free to speak up and ensure that everyone is accountable for consistently upholding safety processes and standards.
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Content ArticleThe Patients Association welcomed our publication of ‘A Patient-Safe Future’, which provides a well-founded critique of the shortcomings in safety in our NHS. This is their full response.
