‘Staff know that what they do carries risk, but the culture in which they work is one that views itself as essentially safe, where errors are considered exceptional, and where rigid hierarchical...
The HSIB report undertook a detailed investigation focusing on NG tubes that are used to enterally feed patients and the two methods used for confirmation of NG tube tip position: pH testing and...
Under Domain 1, ‘Systems approach to patient safety’, sections include:.
‘The danger is that we do not see it. It is like the pattern on the wallpaper that we no longer see, but it is the number one predictor of staff stress and staff intention to quit. It is also the...
The skin is the largest organ in the body and there are two main divisions; the outer epidermis and deeper dermis. The epidermis is made up of five layers of cells. The dermis is divided into two main...
The National Patient Safety Syllabus is to be welcomed as it combines and integrates several important patient safety-related disciplines into a well-focused and proactive syllabus. The syllabus...
It is true to say that cultures do not change overnight but, in the case of the NHS, we are talking about decades. Some things never seem to change, and the same patient safety errors can be seen to...
The UK national haemovigilance surveillance programme, SHOT, repeatedly identifies that patient are harmed, and some die, as a result of being given the incorrect type of blood..
‘Some employers were referring nurses without any investigation at all, while half of initial enquiries to the NMC were rejected or required further work. She told The Independent this emphasis on...
End-of-life care decisions have featured prominently in the popular and professional press in recent years. For example, readers will remember the demise of the Liverpool Care Pathway (LCP), which had...
‘There is no single definition of “just culture” and most discussion of it is limited to the issue of being fair to healthcare staff.’ .
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