Patient Safety Incident Reporting And Learning Systems

Patient safety incident reporting and learning systems aim to capture patient safety incidents and provide structured learning, since this can be key to improving patient safety and preventing the occurrence of harm. This document presents the purpose and strengths of patient safety incident reporting and provides some practical guidance on establishing patient safety incident reporting and learning systems.

v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.

"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

A collection of papers presented at the PSAM 7 – ESREL ’04 conference in June 2004, reflecting a wide variety of disciplines, such as principles and theory of reliability and risk analysis, systems modelling and simulation, consequence assessment, human and organisational factors, structural reliability methods, software reliability and safety, insights and lessons from risk studies and management/decision making. This volume covers both well-established practices and open issues in these fields, identifying areas where maturity has been reached and those where more development is needed.

This book explores the various features of work environments that affect nurses' experiences of their work, their interactions with co-workers and patients, and ultimately health care quality and patient outcomes. Using a broad and comprehensive approach, the authors identify the most extensively researched and best-understood concepts in the field and presents a critical and up-to-date review of the evidence regarding causes and effects of work environment features. It then presents evidence regarding organizational interventions aimed at broad ranges of clinical practices and outcomes, such as team-based interventions and management practices to improve practice climate. The ideas, approaches, and evidence are presented by a team of researchers and experienced practitioner/leaders; taken together, they form a state-of-the-science toolkit. Unique features of this book include a systematic presentation of best practices in nursing and healthcare leadership, along with the conceptual grounding and empirical support for these approaches, and extensive demonstrations of how these practices, many of which originated in North America, apply to European contexts.

This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.

Patient safety is fundamental to the provision of health care in all settings. However, avoidable adverse events, errors and risks associated with health care remain major challenges for patient safety globally. The Seventy-second World Health Assembly in 2019 adopted resolution WHA72.6 on global action on patient safety and mandated for development of a global patient safety action plan. This global action plan was adopted by Seventy-Fourth World Health Assembly in 2021 with a vision of “a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere”. The purpose of the action plan is to provide strategic direction for all stakeholders for eliminating avoidable harm in health care and improving patient safety in different practice domains through policy actions on safety and quality of health services, as well as for implementation of recommendations at the point of care. The action plan provides a framework for countries to develop their respective national action plans on patient safety, as well to align existing strategic instruments for improving patient safety in all clinical and health-related programmes.

The first-ever WHO Report on Patient Safety, the "Global Patient Safety Report 2024", offers a comprehensive overview of patient safety implementation worldwide. Aligned with the Global Patient Safety Action Plan 2021–2030, this report explores policies, strategies, and initiatives shaping safety in health care. From analyses of country actions to in-depth summaries of burden of unsafe care, it provides crucial insights for policy-makers, health care leaders, researchers, and patient safety advocates. Explore how nations address challenges, learn from case studies and feature stories, and gain deeper understanding in priority areas for action. This report serves as a vital resource for fostering global collaboration and advancing patient safety in health care. The contents of this report encompass: - An analysis that compiles and describes actions taken by countries, including the summary of these actions across different WHO regions and income levels based on Member State survey. - An in-depth summary presenting evidence on the overall burden of unsafe health care practices, viewed broadly as well as within specific population groups, clinical domains, and according to major sources of harm. - Case studies showcasing how different countries are learning and developing patient safety solutions within their unique contexts, along with feature stories highlighting key global initiatives and interventions in patient safety. - Comparative analyses offering deeper insights into crucial areas such as patient safety policies, legal frameworks, patient involvement, educational initiatives, reporting and learning systems, and the involvement of various stakeholders.