Learn: Learnhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/?d=1Learn: LearnenNHS Patient Safety Strategy: February 2021 updatehttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-patient-safety-strategy-february-2021-update-r4124/4124Tue, 02 Mar 2021 15:43:00 +0000Annual progress report for the NHS Patient Safety Strategy: year one (17 September 2020)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/annual-progress-report-for-the-nhs-patient-safety-strategy-year-one-17-september-2020-r3099/3099Wed, 23 Sep 2020 14:47:00 +0000The Patients Association's response to the consultation on the Patient Safety Specialist rolehttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/the-patients-associations-response-to-the-consultation-on-the-patient-safety-specialist-role-r2973/2973Mon, 07 Sep 2020 16:41:00 +0000NHS Improvement: Identifying Patient Safety Specialists (25 August 2020)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-improvement-identifying-patient-safety-specialists-25-august-2020-r2882/2882Thu, 27 Aug 2020 17:32:48 +0000NHS England Learning Handbook: After action reviewhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-england-learning-handbook-after-action-review-r3519/3519Mon, 10 Aug 2020 15:14:00 +0000Patient Safety Learning's response to the Patient Safety Specialist Consultation submissionhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/patient-safety-learnings-response-to-the-patient-safety-specialist-consultation-submission-r1798/ The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’.

A key action associated with this is a proposal to create Patient Safety Specialists within each NHS organisation in England. The strategy explains that ‘giving everyone in the NHS a foundation level understanding of patient safety is critical, but we also need experts to lead on safety in their own organisations’.NHS England and NHS Improvement have published draft Patient Safety Specialist requirements for public consultation.

Patient Safety Learning welcome any increase in patient safety capacity and expertise in the NHS and have provided specific feedback on the draft requirements for this role. In our response we identify several areas where we believe these can be improved, including the following points:

  • Patient Safety Specialists having a clear and direct reporting line to a named executive director on the Board with an assigned patient safety role and to a non-executive director with a similar role.
  • Ensuring that the requirements identify key relationships for the role holders not identified in the draft document: Medical Examiners, Coroners, Healthcare Safety Investigation Branch, Governors, Non-Executive Board Members, HR Directors and NHS Resolution.
  • Including a requirement that Patient Safety Specialists should demonstrate that they have the right skills and experience to work with patients, families and their carers on patient safety issues. They should also show that they can support their organisation to engage effectively in co-production with these groups.
  • The need to strengthen the requirements for the individuals holding these roles to have knowledge and experience of: Investigations, Complaints, Just Culture, Systems Thinking and Human Factors.
  • Giving consideration to how Patient Safety Specialists will engage with frontline staff, who are notable by their lack of reference in the draft requirements.
]]>1798Thu, 12 Mar 2020 16:00:00 +0000NHS Improvement: Patient Safety Specialisthttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-improvement-patient-safety-specialist-r1504/ NHS Improvement asked NHS organisations to identify, by June 2020, at least one person from their existing employees as their patient safety specialist. Training for these specialists will be based on the national patient safety syllabus being developed with Health Education England.

Working with representatives from a few NHS trusts, patient safety partners (patient and public voice representatives) and clinical commissioning groups, NHS Improvement have drafted the requirements for a patient safety specialist to help organisations identify the most appropriate person(s) for the role.

]]>1504Sat, 01 Feb 2020 13:48:00 +0000NHS Improvement: Patient safety review and response reportshttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-improvement-patient-safety-review-and-response-reports-r3637/3637Sat, 25 Jan 2020 17:20:00 +0000What is NHS Improvement?https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/what-is-nhs-improvement-r580/ This website give access to:

  • the Improvement hub
  • resources
  • events
  • news and alerts.
]]>580Fri, 20 Sep 2019 10:22:00 +0000NHS Improvement: Venous thromboembolism risk assessment (2019/20)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-improvement-venous-thromboembolism-risk-assessment-201920-r518/ Key results from the data collected:

  • England continues to achieve the 95% NHS Standard Contract threshold. Of the 3.8 million admitted inpatients aged 16 and over for whom data was reported in this collection, 3.7 million (96%) were risk assessed for VTE on admission.
  • From Q4 2015/16 to Q4 2016/17 the percentage of inpatients risk assessed for VTE was stable at 96%. The results for Q1 2017/18 showed a reduction of 1% with 95% of patients being risk assessed for VTE and this remained static until Q4 2017/18. In Q1 2018/19 the percentage of patients being risk assessed for VTE increased to 96% but decreased again in Q2 2018/19 to 95%. In Q3 2018/19 performance increased to 96% and remained at 96% in Q4 2018/19. From April 2019 the data collection changed to include inpatients aged 16 and over at the time of admission. In Q1 2019/20 the percentage of inpatients risk assessed was 96%.
  • In Q1 2019/20, the percentage of admitted inpatients aged 16 and over at the time of admission risk assessed for VTE was 96% for NHS acute care providers and 98% for independent sector providers. NHS acute care providers carried out about 97% of all VTE risk assessments.
  • Six regions (North East and Yorkshire, North West, Midlands, East of England, London and South East) achieved the 95% NHS Standard Contract operational standard in Q1 2019/20. The South West did not meet the operational standard and risk assessed 94.7% of inpatients.
  • In Q1 2019/20, 80% of providers (240 of the 299 providers) carried out a VTE risk assessment for 95% or more of their admissions (the NHS Standard Contract operational standard). This breaks down as 72% of NHS acute providers (106 of 147) and 88% of independent sector providers (134 of 152).
  • Of the 59 providers (20%) that did not achieve the 95% operational standard in Q1 2019/20, 76% (45 of 59) risk assessed between 90% and 95% of total admissions for VTE.
]]>518Thu, 12 Sep 2019 09:09:00 +0000Freedom to Speak Up: guidance for NHS trust and NHS foundation trust boards (updated 31 July 2019)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/freedom-to-speak-up-guidance-for-nhs-trust-and-nhs-foundation-trust-boards-updated-31-july-2019-r324/
  • Guidance for NHS trust and NHS foundation trust boards on Freedom to Speak Up
  • Freedom to Speak Up supplementary information
  • Freedom to Speak Up self-review tool
    • ]]>    324Wed, 31 Jul 2019 21:28:00 +0000    National guidance for ambulance trusts on learning from deaths (10 July 2019)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/national-guidance-for-ambulance-trusts-on-learning-from-deaths-10-july-2019-r170/ This guidance is to help NHS ambulance trusts in England to improve the way they review and learn from the deaths of patients who had been under their care. It builds on the work ambulance trusts already do on learning from incidents and on mortality reviews. It also sets out a standardised framework for ambulance trusts to use to develop and implement their local Learning from Deaths policies.

    ]]>    170Fri, 12 Jul 2019 14:14:00 +0000    NHS Improvement: Never Events (last updated 23 February 2021)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-improvement-never-events-last-updated-23-february-2021-r1725/1725Wed, 03 Jul 2019 13:23:00 +0000NHS Patient Safety Strategy (2 July 2019)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/nhs-patient-safety-strategy-2-july-2019-r59/ Patient safety is about maximising the things that go right and minimising the things that go wrong. It is integral to the NHS’ definition of quality in healthcare, alongside effectiveness and patient experience. This strategy describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems.

    ]]>    59Wed, 26 Jun 2019 13:02:07 +0000    Confirming removal or flushing of lines and cannulae after procedures (9 November 2017)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-improvement/confirming-removal-or-flushing-of-lines-and-cannulae-after-procedures-9-november-2017-r4168/4168Fri, 08 Mar 2019 17:19:00 +0000