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Found 515 results
  1. Content Article
    In this blog, Tina* discusses the patient safety issues that can occur with electronic patient records, highlighting how easily errors can occur in a patient's record but how difficult they are to fix, and why patients must be involved in the digitalising of their own records. Tina gives her perspective as a clinician but also her personal perspective as a patient who has had stigmatising material propagated throughout the system while important clinical information was excluded from her record. 
  2. Event
    The federal Patient Safety and Quality Improvement Act was created in 2005 and established a national patient safety database and a system of Patient Safety Organizations (PSOs) in the US. Although PSOs have existed for more than 15 years, healthcare organisations still struggle to identify the best reporting structure and how to most effectively utilise protections in relation to patient safety work. In this ECRI webinar, Partner and Owner of Bolin Law Group, Andrew Bolin, will discuss: The establishment of a Patient Safety Evaluation System and how it relates to PSOs The differences between state protections and federal protections How to work with surveyors who request information protected under the Act Register for the webinar The webinar will take place at 13:00 ET (18:00 BST)
  3. Content Article
    In this opinion piece, Partha Kar describes patient safety issues relating to a planned increase in the number of Physician Associates (PAs) working in the NHS in England. Highlighting safety concerns being raised by healthcare professionals and members of the public, he calls for a pause to the planned expansion to allow these issues to be investigated. He outlines the need for a clear scope of practice, standardised training, full regulation and clear communication with all stakeholders, including the public.
  4. Content Article
    Clinical guidelines can contribute to medication errors but there is no overall understanding of how and where these occur. This study aimed to identify guideline-related medication errors reported via a national incident reporting system, and describe types of error, stages of medication use, guidelines, drugs, specialties and clinical locations most commonly associated with such errors.
  5. Content Article
    When Adam Luck’s mother, Ann, was admitted to hospital with a suspected stroke, it was the beginning of a distressing seven-week stay. The previously cheerful 82-year-old became stuck in a dysfunctional health system. Her story is presented here via her son Adam’s diary of her hospitalisation.
  6. Content Article
    A common administrative framework of healthcare involves focus upon costs, quality and patient satisfaction—this is known as The Triple Aim.  However, this framework does not allow the experience and human factors of providing care to be integrated into high-level decision making. This report describes the process of transition from The Triple Aim to The Quadruple Aim administrative framework of healthcare delivery at the University of Rochester Medical Center, which resulted in an integrative model of patient safety and clinician wellbeing. Developing the fourth aim of improving the experience of providing care was widely accepted and aligned with other health system goals of optimisation of safety, quality and performance by applying a human factors/ergonomic (HFE) framework that considers human capabilities and human limitations.
  7. Content Article
    Ambulances lined up outside hospital Emergency Departments (EDs) are a vivid, and politically embarrassing, indication of inadequate capacity in the NHS. Media reports of diktats demanding that hospital CEOs meet performance targets suggest a desire for action, but are the local solutions being implemented to ease the pressure in the best interest of patient safety? The use of ‘safety cases’ in healthcare has received some interest in recent years but the conclusion drawn by, for example, Leberati and her colleagues,[1] was that while they have some potential value they are "fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors". A survey of the literature suggests that there is a danger of conflating ‘safety cases’ with ‘safety management’ or ‘quality’ systems. Part of the problem might be that safety cases are more a concept rather than a methodology: there is no script to follow. In this blog, Norman MacLeod discusses whether the the current crisis in hospital capacity can be explored through the safety case lens.
  8. Content Article
    This report examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. 
  9. Content Article
    In this interview, we talk to Darren Powell, Clinical Lead for NHS England and Community Pharmacist, about medication supply issues. Darren shares his experiences of how medication shortages and tariffs are affecting patients and staff and offers insights into the complexity of the situation.  He tells us his thoughts on potential causes and barriers, as well as suggesting three actions for wider system safety. 
  10. Content Article
    Martha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.
  11. Content Article
    In this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
  12. News Article
    A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned. Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said. The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients. The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system. The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity. Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”. “It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.” Read full story (paywalled) Source: HSJ, 23 February 2024
  13. Content Article
    On 18 December 2022, Emily Harkleroad collapsed when out with a friend. She was taken by ambulance to the University Hospital of North Durham Emergency Department. Despite staff recognising that pulmonary embolism was the likely diagnosis, there were failures to provide Emily with appropriate and timely treatment for pulmonary embolism. Errors and delays in the Emily’s medical treatment resulted in her not receiving the anticoagulant treatment that she needed, and which would, on a balance of probabilities, have prevented her death. She died as a result of pulmonary embolism in the early hours of 19 December 2022 at the University Hospital of North Durham.
  14. Content Article
    In this letter to Health Secretary Steve Brine MP, members of the All Party Parliamentary Group (APPG) on Pandemic Response and Recovery raise serious concerns about the approach of the Medicines and Healthcare Products Regulatory Agency (MHRA) to patient safety. They outline problems within the MHRA that continue to put patients at serious risk of harm. The letter also highlights the role of the Independent Medicines and Medical Devices Safety Review (IMMDS), in its thorough investigation of Primodos, sodium valproate and pelvic mesh in bringing some of these concerns to the fore. It points to recent evidence presented to the APPG that indicates that the MHRA is at the heart of wider endemic failings, with issues uncovered so far being "the tip of a sizeable iceberg of failure." The letter outlines concerns about the following areas: The Yellow Card Scheme Conflicts of interest and transparency History of regulatory failures in the MHRA It calls on the Health and Social Care Select Committee to investigate these issues and make recommendations to the government on: legislative changes as to who is obligated to report adverse drug reactions. funding changes to the MHRA. separation of regulatory approval duties from post marketing pharmacovigilance. more inclusion of patients. greater transparency across the board. proper enforcement of Part 14 of the Human Medicines Regulations 2012.
  15. Content Article
    NHS England’s Worry and Concern Collaborative is looking into how hospitals can make sure the worries and concerns of patients, their family and friends about a patient in hospital are taken into account by doctors, nurses and other health professionals.  This webinar, hosted by the Patients Association explored: The role of the National Worry and Concern Collaborative and its seven pilot sites the experiences of both clinicians and patients how these services need to be designed and delivered.
  16. News Article
    Community Pharmacy Scotland (CPS) is calling for all pharmacy staff to be allowed to prepare and assemble medication without requiring supervision from a pharmacist or pharmacy technician. Its comments came in its response to a Department of Health and Social Care consultation on pharmacy supervision, published on 7 December 2023, which sets out proposals to amend the Medicines Act 1968 and The Human Medicines Regulations 2012. The consultation includes proposals to enable pharmacists to authorise pharmacy technicians to carry out, or supervise others carrying out, the preparation, assembly, dispensing, sale and supply of medicine; to enable pharmacists to authorise any member of the pharmacy team to hand out checked and bagged prescriptions in the absence of a pharmacist; and to allow pharmacy technicians to supervise the preparation, assembly and dispensing of medicines in hospital aseptic facilities In its response, the CPS disagreed with the first of these proposals, arguing that “the preparation and assembly of [pharmacy] and [prescription-only] medications can be safely carried out from a registered pharmacy premises, without requiring supervision by a Responsible Pharmacist or an authorised pharmacy technician”. CPS also said there is “a major flaw in the logic” of the government proposal because “it relies heavily on individuals rather than on safe systems”, making the proposed new way of working “vulnerable to changes in personal circumstance”. “The environment, technology, training, conditions and [standard operating procedures] in the community pharmacy setting have a bigger effect on safety of preparation and assembly than supervision by an individual,” the response said. Read full story Source: The Pharmaceutical Journal, 12 February 2024
  17. Content Article
    Despite progress on patient safety since the publication of the Institute of Medicine’s 1999 report, To Err Is Human, significant problems remain. Human factors and systems engineering (HF/SE) has been increasingly recognized and advocated for its value in understanding, improving, and redesigning processes for safer care, especially for complex interacting sociotechnical systems. However, broad awareness of HF/SE and its adoption into safety improvement work have been frustratingly slow. We provide an overview of HF/SE, its demonstrated value to a wide range of patient safety problems (in particular, medication safety), and challenges to its broader implementation across health care. We make a variety of recommendations to maximise the spread of HF/SE, including formal and informal education programmes, greater adoption of HF/SE by health care organisations, expanded funding to foster more clinician-engineer partnerships, and coordinated national efforts to design and operationalise a system for spreading HF/SE into health care nationally.
  18. 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
  19. Content Article
    This article looks at the judgements made by experts in the cases that are not covered by rules, focusing on the key role of stories and storytelling. Drawing on literature related to high-reliability theory, organisational learning and naturalistic decision-making, it examines how experts working in diverse critical contexts use stories to share and make sense of their experiences.
  20. News Article
    Jason Watkins, a British actor, has urged A&E units to look again at procedures surrounding infants as he has channels his anger at his young daughter’s death from sepsis into trying to “improve the system”. The actor said that his fury at the death of Maude aged two on New Year’s Day 2011 led him to smash up his shower. “It wasn’t anger at any individual, it was anger at fate. Why should we deserve this?” he told Andy Coulson’s Crisis What Crisis? podcast. “You feel really vulnerable and there’s a sort of rage against that. And there are all these different ways of resolving and wrestling out of this horrible dark pit that you’re in." He now campaigns for the UK Sepsis Trust. “I was never angry at any individual,” he said. “My anger was fuelled into trying to work out better ways of dealing with sepsis, or even more than that, the way that we look at infants in A&E. Because you know, it’s a funding issue, it’s an organisational issue. It’s another conversation. “Because I had identified that there wasn’t an individual at fault in the hospital, it has to be the system. So we’ve got to improve it. My anger is fuelled into that. There’s no bitterness. Nobody made a technical mistake, it’s just nobody really thought of the possibilities of what could be happening. “For me the whole of looking at infants arriving at A&E needs to be looked at again. Because if I say that Maude died twelve years ago, and that the ombudsman report about sepsis a couple of months ago said that nothing had changed about sepsis, now, that was like a body-blow, that makes me feel sick even thinking about it now, because we’ve worked so hard over that time.” Read full story Source: The Times, 1 February 2024
  21. Content Article
    Regardless of a proliferation of interest in reducing unsafe practices in healthcare, threats to patient safety (PS) remain high. Moreover, little attention has been paid towards the role of interprofessional education (IPE) in enhancing PS. This qualitative study was conducted to unfold the insights of the senior medical, dental and health sciences students at the University of Sharjah (UoS) in the United Arab Emirates (UAE) about PS in an online IPE-based workshop.
  22. Content Article
    In November 2023, the UK hosted the first global summit on artificial intelligence (AI) safety at Bletchley Park, the country house and estate in southern England that was home to the team that deciphered the Enigma code. 150 or so representatives from national governments, industry, academia and civil society attended and the focus was on frontier AI—technologies on the cutting edge and beyond. In this Lancet article, Talha Burki looks at the implications of AI for healthcare in the UK and how it may be used in medical devices and service provision. The piece highlights the risks in terms of regulation and accountability that are inherent in the use of AI.
  23. 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.
  24. Content Article
    This article in Anaesthesia Critical Care & Pain Medicine aims to provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care. The authors aimed to formulate recommendations according to the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) methodology for four different fields:communicationorganisationworking environmenttrainingThe guidelines produced include a set of recommendations to guide human factors in critical situations.
  25. 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.
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