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Showing results for tags 'System safety'.
Found 131 results
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Content ArticleFindings In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year. The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement. A varied approach to patient safety was evident on review of the corrective measures applied following the occurrence of a significant event. High efficacy corrective measures such as forcing functions, which can eliminate risk, were evident. However, in some cases, the corrective measures put in place to prevent recurrence were limited to low efficacy strategies such as re-education of staff. Undertakings should consider the risk management strategies applied to incident investigations and corrective measures to ensure they are robust and help prevent errors from reoccurring rather than punish. Overall, many of the investigation reports received by HIQA were comprehensive and showed systems based approaches to reviewing incidents. Some, however, focused on human error in isolation, without consideration of human error as a symptom of system weaknesses. Undertakings should ensure a just culture is in place where individuals feel free to report errors, assured that the response will focus on what happened, rather than who failed. This was not always evident in reports received by HIQA. Finally, it is noted that radiation incidents reported to HIQA in 2019 have involved relatively low radiation doses with limited risk to service users. The findings in this report indicate that overall the use of radiation in medicine in Ireland is generally quite safe for patients. However, radiation incidents have been reported internationally with severe detrimental effects to service users. The potential for such serious adverse events highlights the need for ongoing vigilance in relation to radiation protection and the necessity of reporting and learning frameworks. It is hoped that areas of improvement noted in this report would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland.
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News ArticleThe Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement.John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required." John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.” Read full story Source: HIQA, 9 September 2020
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News ArticleFollowing four deaths and more than 300 incidents with steroid replacement therapy involving patients with adrenal insufficiency in the past two years, patients at risk of adrenal crisis will be issued with a steroid emergency card. All adults with primary adrenal insufficiency (AI) will be issued an NHS steroid emergency card to support early recognition and treatment of adrenal crisis, a National Patient Safety Alert has said. The cards will be issued by prescribers — including community pharmacists — from 18 August 2020. AI is an endocrine disorder, such as Addison’s disease, which can lead to adrenal crisis and death if not identified and treated. Omission of steroids in patients with AI, particularly during physiological stress such as an additional illness or surgery, can also lead to an adrenal crisis. The alert has requested that “all organisations that initiate steroid prescriptions should review their processes/policies and their digital systems/software and prompts to ensure that prescribers issue a steroid emergency card to all eligible patients” by 13 May 2021. Read full story Source: The Pharmaceutical Journal, 17 August 2020
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Content ArticleThis was an explorative study, with qualitative in-depth interviews of 23 family carers of older people with suspected or diagnosed dementia. Family carers participated after receiving information primarily through health professionals working in dementia care. A semi-structured topic guide was used in a flexible way to capture participants’ experiences. A four-step inductive analysis of the transcripts was informed by hermeneutic-phenomenological analysis.
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Acute Data Alignment Programme (ADAPt)
Claire Cox posted an article in Data and insight
The aims of ADAPt: To make it easier to monitor the quality and safety of services by including private healthcare data within healthcare reporting systems. To help staff keep accurate and complete records when a patient journey spans both private and public providers. To ensure transparency for patients by publishing comparable performance measures relating to quality of care and patient safety for both privately funded and NHS funded healthcare. To identify where the burden of data collection and reporting by NHS and private care providers can be reduced. Find out via the link below. -
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Content ArticlePresentation slides Video of presentation (29:21)
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Content ArticlePDSA is a very structured four-step cycle which requires effort and discipline. It incorporates careful and detailed consideration of the following: Plan: A plan of what is to be tested including questions to be answered, predictions and answers to the questions and a plan for collection of data to answer the questions. Do: Carry out the test of change according to the plan, recording observations including unexpected outcomes/observations. Study: A comparison of the data against the predictions made in the plan and study the results. Act: Make a decision about the next course of action. Whilst the PDSA cycle originates from industry, it has been incorporated into the Model for Improvement It can be used to test ideas in the real or simulated context.
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This is the US Military Health System
Claire Cox posted an article in Stories from the front line
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Systems Approach Resources (NES)
PatientSafetyLearning Team posted an article in Improving systems of care
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NES: Safety culture discussion cards
PatientSafetyLearning Team posted an article in Good practice
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Content ArticlePractical guidance on the application of human factors in the investigation process is presented. Nine principles for incorporating human factors into learning investigations are identified: 1. Be prepared to accept a broad range of types and standards of evidence. 2. Seek opportunities for learning beyond actual loss events. 3. Avoid searching for blame. 4. Adopt a systems approach. 5. Identify and understand both the situational and contextual factors associated with the event. 6. Recognise the potential for difference between the way work is imagined and the way work is actually done. 7. Accept that learning means changing. 8. Understand that learning will only be enduring if change is embedded in a culture of learning and continuous improvement. 9. Do not confuse recommendations with solutions.
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After coronavirus, we may not recognise changed NHS
Patient Safety Learning posted a news article in News
In many ways it is wrong to talk about the NHS restarting non-coronavirus care. A lot of it never stopped — births, for instance, cannot be delayed because of a pandemic. However, exactly what that care looks like is likely to be very different from what came before. There are more video and telephone consultations and staff treat patients from behind masks and visors. That is likely to be the case for some time, experts have told The Times. Read full story (paywalled) Source: The Times, 6 June 2020 -
Content ArticleThe authors conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. They found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organisational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of “preventable causes”, the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the “big picture” of causes of accidents as a basis for further remedial actions.
