patient safety network report

What is the Patient Safety Network?

AHRQ's Patient Safety Network features the latest news and essential resources on patient safety.

What are the academic health science networks doing to improve patient safety?

England’s 15 Academic Health Science Networks (AHSNs) and the Patient Safety Collaboratives (PSCs) they host are making a significant contribution to the NHS Patient Safety Strategy, through the PSCs’ work supporting the delivery of the National Patient Safety Improvement Programmes and the AHSNs’ focus on accelerating innovation.

What is the national healthcare Safety Network (NSN)?

CDC’s National Healthcare Safety Network is the nation’s most widely used healthcare-associated infection tracking system.

What is the patient safety strategy 2019-2025?

‘Patient safety in partnership: Our plan for a safer future 2019-2025’ has been developed to support the NHS Patient Safety Strategy published in 2019, and details how AHSNs will work more closely with health and care organisations to improve safety both in hospitals and community-based services, such as care homes.

What is patient safety?

Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.

When did WHO start working on patient safety?

WHO's work on patient safety began with the launch of the World Alliance for Patient Safety in 2004 and this work has continued to evolve over time. WHO has facilitated improvements in the safety of health care within Member States through establishment of Global Patient Safety Challenges.

Why does patient harm occur?

For example, a patient in hospital might receive a wrong medication because of a mix-up that occurs due to similar packaging. In this case, the prescription passes through different levels of care starting with the doctor in the ward, then to the pharmacy for dispensing and finally to the nurse who administers the wrong medication to the patient. Had there been safe guarding processes in place at the different levels, this error could have been quickly identified and corrected. In this situation, a lack of standard procedures for storage of medications that look alike, poor communication between the different providers, lack of verification before medication administration and lack of involvement of patients in their own care might all be underlying factors that led to the occurrence of errors. Traditionally, the individual provider who actively made the mistake (active error) would take the blame for such an incident occurring and might also be punished as a result. Unfortunately, this does not consider the factors in the system previously described that led to the occurrence of error (latent errors). It is when multiple latent errors align that an active error reaches the patient.

How many patients are harmed in primary care?

Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines (6).

What is the WHO patient safety and risk management unit?

The Patient Safety and Risk Management unit at WHO has been instrumental in advancing and shaping the patient safety agenda globally by focusing on driving improvements in some key strategic areas through:

How many people are harmed in hospitals?

In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care (2). The harm can be caused by a range of adverse events, with nearly 50% of them being preventable (3).

Why is patient safety important?

Patient safety is fundamental to delivering quality essential health services. Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred. In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient.

What is the association between nurse staffing ratios and patient safety?

Several seminal studies linked in this sentence have demonstrated the association between nurse staffing ratios and patient safety, documenting an increased risk of patient safety events, morbidity , and even mortality as the number of patients per nurse increases. The strength of these data has led several states, beginning with California in 2004, to establish legislatively mandated minimum staffing ratios. According to the American Nurses Association, only 14 states have passed nurse staffing legislation as of March 2021 and most states do not specify registered-nurse (RN)-to-patient ratios, which vary by state and are also setting-dependent.

When was PSNet updated?

April 21, 2021. Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in March 2021 by Jessamyn Phillips, DNP, FNP-C, Alex Peck Malliaris, MSN, MSHCA, FNP-C, and Debra Bakerjian PhD, APRN. PSNet primers are regularly reviewed and updated to ensure that they reflect current research ...

What are nursing sensitive measures?

These included patient-centered outcomes considered to be markers of nursing care quality (such as falls and pressure ulcers) and system-related measures including nursing skill mix, nursing care hours, measures of the quality of the nursing practice environment (which includes staffing ratios), and nursing turnover . These measures are intended to illustrate both the quality of nursing care and the degree to which an institution’s working environment supports nurses in their patient safety efforts. Nurse-sensitive indicators are a metric for the degree to which acute care hospitals provide quality, patient safety, and promote a safe and professional work environment. Nurse-sensitive measures continue to set the standard for quality and safety in care in the acute scare setting. As of 2021, there are 39-nurse sensitive measures.

What is the nurse to patient ratio?

The nurse-to-patient ratio is only one aspect of the relationship between the nursing workload and patient safety. Overall nursing workload is likely linked to patient outcomes as well. A PSNet Classic 2011 study showed that increased patient turnover was also associated with increased mortality risk, even when overall nurse staffing was considered adequate. Determining adequate nurse staffing is a very complex process that changes on a shift-by-shift basis. It requires close coordination between management and nursing and is based on patient acuity and turnover, availability of support staff and skill mix, and settings of care. The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in detail in this WebM&M commentary.

How many states have nurse staffing laws?

According to the American Nurses Association, only 14 states have passed nurse staffing legislation as of March 2021 and most states do not specify registered-nurse (RN)-to-patient ratios, which vary by state and are also setting-dependent.

Why do nurses leave the profession?

Nurses who commit errors are also at risk of becoming second victims of the error, a well -documented phenomenon that is associated with an increased risk of self-reported error and leaving the nursing profession. In their daily work, nurses are frequently exposed to disruptive or unprofessional behavior by physicians and other health care personnel, and such exposure has been demonstrated to be a key factor in nursing burnout and in nurses leaving their jobs or leaving the profession entirely.

What are the factors that affect the quality of a nurse's work?

Adequate nurse staffing depends on several factors such as lack of training, administrative demands, distractions, and interruptions that can impact nurse’s work.5

What is patient safety network?

Patient safety networks: coordinate and facilitate patient safety networks to provide the sub-regional delivery architecture for improvement.

How many patient safety collaboratives are there in England?

England’s 15 Patient Safety Collaboratives (PSCs) play an essential role in identifying and spreading safer care initiatives from within the NHS and industry, ensuring these are shared and implemented throughout the health and care system.

When was the AHSN report released?

The report was launched at Patient Safety Congress in September 2021 and you can download it here.

How many health science networks are there in England?

England’s 15 Academic Health Science Networks (AHSNs) and the Patient Safety Collaboratives (PSCs) they host are making a significant contribution to the NHS Patient Safety Strategy, through the PSCs’ work supporting the delivery of the National Patient Safety Improvement Programmes and the AHSNs’ focus on accelerating innovation.

What is the aim of the NHS?

The programme’s aim is to continually reduce error, harm and death as a result of failures in the system, so the NHS becomes comparable with the safest health care services in the world by 2025. They do this by working with maternity units, emergency departments, mental health trusts, GP practices and care homes in the following areas:

What is NatPatSIP?

They deliver the National Patient Safety Improvement Programmes (NatPatSIP), which are a key part of the NHS Patient Safety Strategy, and collectively form the largest safety initiative in the history of the NHS.

How many safety improvement programmes does NatPatSIP work on?

The NatPatSIP’s current work is focused across five safety improvement programmes, as shown in this ‘driver diagram’ ( click to download a PDF ):

Background

See more on psnet.ahrq.gov

Characteristics of Incident Reporting Systems

Limitations of Event Reporting

Using Event Reports to Improve Safety

Current Context