Resources

Striking a balance between patient safety and professional autonomy is a complex issue that requires a multifaceted approach. Multiple challenges stand in the way of a balanced approach, such as...

Over the past three decades, the predominant approach to improving safety in health care has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach has been useful, it has limitations. A focus only on unfavourable outcomes can limit innovation and adaptability, not to mention undermine worker morale and engagement.

Numerous studies about the use of trigger tools to identify adverse events (AEs) have been performed in hospitals. However, the research conducted on the use of trigger tools to identify AEs in primary care is limited. 

This study developed a set of triggers for identifying adverse events in Primary Care, from health record reviews with high positive predictive value (PPV), making it easier to collect reliable information on care-related incidents in this sector. It also presents interesting data on adverse event prevalence in Primary Care.

In this webinar, Tracey Hynes, Director at Maternity Care Consulting discussed how to recognise failures in your systems.

Ensuring organisations learn from patient safety incidents is a key aim for human service organisations. The role that human factors and systems thinking can have in enabling organisations to learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems.

In his 1993 book, Managing at the Speed of Change, Daryl Connor wrote about the 1988 North Sea Piper Alpha oil rig fire – a fatal explosion of an oil drilling platform in which one survivor had to choose to jump into a sea of burning oil rather than burn on the platform. He coined the term “burning platform” as a metaphor to explain the necessity of change despite the fear of the unknown consequences. For healthcare, this metaphor aligns nicely to describe the introduction of short-notice assessments.

Here is a list of resources to help frontline clinicians become accreditation-ready every day.

Here is a list of resources to help managers and senior leaders help their teams become accreditation-ready every day.

James Reason once characterised the goal of error investigations as ‘draining the swamp, not swatting mosquitoes’. Critical incidents arise from the interplay between active failures (eg. not double-checking for allergies before administering a medication) and latent conditions (eg. workload).

Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs.