At Patient Safety Learning we seek to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm.
The scale of this challenge remains immense. Each year, millions of patients suffer injuries or die because of avoidable harm in healthcare. The World Health Organization (WHO) states that in high-income countries 1 in every 10 patients is harmed when receiving hospital care. In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths a
This one-day virtual course is suitable those engaged or interested in patient safety, quality improvement & service delivery.
On this interactive virtual course we will explore how human factors and ergonomics impact everyday working practices & patient safety. This material aligns with key focuses of the National Patient Safety Strategy, PSIRF & several domains of the National Patient Safety Syllabus 2.0. This course is equivalent to 6 hours of education.
It will show you how to take a systems approach to respond to patient safety investigations using the SEIPS Model. P
In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes.
Read the full blog on the National Voices website.
Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards)
Jenny, and why we must learn from her misdiagnosis of pulmonary embolism
Pulmonary embolism misdiagnosis
1. Design of medical equipment should include input from human factors experts at an early stage. The medical equipment procurement process should include human factors assessments.
2. Design of drug ampoules and packaging should incorporate human factors principles to optimise readability and reduce the risk of mis-selection: anaesthetists, pharmacists and procurement departments should ensure that these principles are prioritised during their purchasing processes.
3. Design of safe working environments should incorporate human factors principles. Regu
In 2015 the Government introduced a Freedom to Speak Up Guardian and a system of Local Speak Up Guardians in response to the recommendations made by Sir Robert Frances following the scandal at Mid Staffordshire.
From the outset, this system has attracted significant criticism and the APPG has heard from whistleblowers who have been failed by local guardians sharing their experiences that included the disclosure of their identity to hospital management and boards – resulting in retaliation. The APPG has also heard from Local Guardians who were not supported and themselves the target of ret
A systemic problem
Pulmonary embolism misdiagnosis unfortunately appears a systemic issue to our nation. The recent Healthcare Safety Investigation Branch (HSIB) report  details that clinical best practice for pulmonary embolism diagnosis is out of step with European standards  and, alarmingly, is often not being followed.
A Royal College of Radiologists briefing  indicates there is a lack of available scanning equipment required to assess the extent of blood clots, in a safe fashion. The NHS’ own Getting it Right First Time (GIRFT) initiative – aimed at reducing variatio
James BC and colleagues. offer a brief look at patient safety progress made over the past decades, then describe the problems exposed by the Covid-19 pandemic. To correct those problems, they call for the integration of national-level uniformity of defined best practices, and local-level redevelopment and reinforcement of robust systems-level support for staffing and processes to sustain those patient safety practices.
In less than 1 year they increased patient safety incident reporting by 37% while simultaneously decreasing:
falls with injury by 39%
pressure injury rates by 37%
central line–associated blood stream infections by 34%.
They also improved medication reconciliation rate by 3.3% and decreased their irretrievable specimen rate to 0.
Finally, they noted increased awareness around patient safety within clinical teams, with open discussions about patient safety becoming a routine part of patient care.
Read the summary via the link below (full access is paywalled).
Commissioned by the Department of Health and Social Care (DHSC) in February 2020, the Independent Investigation into East Kent Maternity services published its report last month highlighting patient safety failings in maternity and neonatal care services from 2009–2020 at two hospitals: Queen Elizabeth The Queen Mother Hospital at Margate and the William Harvey Hospital in Ashford.
This is another devastating report detailing cases of serious avoidable harm and preventable deaths in the NHS, stating that it found that:
“... those responsible for the services too often provided clinic