Learn: Learnhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/page/2/?d=1Learn: LearnenExploring safety culture in Jordanian hospitals A baseline study (July 2017)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/exploring-safety-culture-in-jordanian-hospitals-a-baseline-study-july-2017-r6833/6833Thu, 20 May 2021 13:53:00 +0000Japan Health System Review (2018)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/japan-health-system-review-2018-r6315/6315Mon, 08 Mar 2021 16:06:00 +0000Center for Outcomes and Patient Safety in Surgery (COMPASS)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/center-for-outcomes-and-patient-safety-in-surgery-compass-r5586/5586Thu, 19 Nov 2020 16:57:00 +0000The Joint Commission: 2021 Hospital National Patient Safety Goalshttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/the-joint-commission-2021-hospital-national-patient-safety-goals-r3551/3551Thu, 12 Nov 2020 08:30:00 +0000Patient Safety Authority 2019 Annual Reporthttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/patient-safety-authority-2019-annual-report-r3670/ Read the Patient Safety Authority 2019 Annual Report

View previous Patient Safety Authority Annual Reports

]]>3670Sun, 01 Nov 2020 16:30:00 +0000Drafting Success: Creating a National Action Plan for Patient Safety (September 2020)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/drafting-success-creating-a-national-action-plan-for-patient-safety-september-2020-r3601/3601Tue, 20 Oct 2020 12:52:00 +0000The Safe Airway Society (Australia and New Zealand) videohttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/the-safe-airway-society-australia-and-new-zealand-video-r3126/3126Fri, 25 Sep 2020 15:18:17 +0000Vision Zerohttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/vision-zero-r3230/3230Wed, 12 Aug 2020 15:59:00 +0000Improving Oral Care Adherence for NV-HAP Prevention: The National VA HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses) Initiativehttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/improving-oral-care-adherence-for-nv-hap-prevention-the-national-va-happen-hospital-acquired-pneumonia-prevention-by-engaging-nurses-initiative-r2825/2825Tue, 04 Aug 2020 09:18:00 +0000Centre for Clinical Risk Management and Patient Safety (GRC) Department for Health of the Tuscany Regionhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/centre-for-clinical-risk-management-and-patient-safety-grc-department-for-health-of-the-tuscany-region-r4572/4572Mon, 11 May 2020 08:32:00 +0000Common Declaration. Patient Safety: Saving 200,000 lives a year in Europe (11 December 2019)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/common-declaration-patient-safety-saving-200000-lives-a-year-in-europe-11-december-2019-r3134/3134Sat, 28 Mar 2020 12:24:00 +0000Electronic Health Record (EHR): safety and usabilityhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/electronic-health-record-ehr-safety-and-usability-r1126/ This page links to videos explaining what types of errors and challenges there are when using EHR's. By highlighting these errors and challenges may help mitigate future harm for patients.

EHR.PNG.4e2c532737626c1bc9a59bfdef475a76.PNG

]]>1126Tue, 10 Dec 2019 10:05:30 +0000Blog: The American medical system is one giant workaroundhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/blog-the-american-medical-system-is-one-giant-workaround-r1131/1131Tue, 10 Dec 2019 15:27:04 +0000Hospital Watchdog: Patient bleeds to death after colonoscopy (February 2019)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/hospital-watchdog-patient-bleeds-to-death-after-colonoscopy-february-2019-r1214/ Dena’s vigilance and persistence as a whistleblower led to an investigation by The Centres for Medicare and Medicaid Services (CMS). Based on interviews and a review of hospital records, CMS found specific events contributing to her mother’s death and issued findings in a Summary Statement of Deficiencies.

Among the key problems, Martha had not been thoroughly assessed when changes in her condition occurred. In one instance, at 10:15pm, (14 hours after the procedure), the Registered Nurse failed to perform a thorough assessment, that included vital signs and notifying the doctor. The CMS report also showed how after Martha’s death the hospital tried to cover up what happened. 

]]>1214Tue, 19 Nov 2019 10:47:00 +0000Creating a safety culturehttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/creating-a-safety-culture-r1172/1172Sun, 17 Nov 2019 08:39:00 +0000Annie's story: How a system's approach can change safety culturehttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/annies-story-how-a-systems-approach-can-change-safety-culture-r1170/ In this five minute video, the authors chose to focus on the main theme – the human cost to healthcare workforce when there is a failure to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events.

]]>1170Sun, 17 Nov 2019 08:18:00 +0000The ‘C’ word (May 2017)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/the-%E2%80%98c%E2%80%99-word-may-2017-r1141/1141Tue, 12 Nov 2019 09:58:00 +0000Is your patient ready for transport? Developing an ICU patient transport decision scorecardhttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/is-your-patient-ready-for-transport-developing-an-icu-patient-transport-decision-scorecard-r1014/ The transport of the ICU patient is a complicated process and can lead to patient harm. In the Department of Critical Care Medicine, Calgary Health Region, staff underestimated the risks of intrahospital transport, which led to the two adverse events mentioned above. This article published in Healthcare Quarterly has describes the development of an ICU patient transport decision scorecard to support the safe transport of ICU patients for diagnostic testing.

The scorecard is a visual assessment tool. Each item on it is a decision point and a simple reminder to ensure that appropriate resources are available prior to transport. Outcome measures have been added to begin to measure the effectiveness of the tool.

Several lessons were learned from the development of this tool: the need to form a subgroup with team members from all sites and disciplines to ensure early buy-in; the involvement of a human factors expert to make the tool easier to use; and the need to continuously retest the tool using PDSA cycles.

]]>1014Mon, 28 Oct 2019 14:18:00 +0000The Joint Commission: Proactive prevention of maternal death from maternal haemorrhagehttps://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/the-joint-commission-proactive-prevention-of-maternal-death-from-maternal-haemorrhage-r873/873Sun, 06 Oct 2019 14:19:00 +0000How reporting hospital 'close calls' helps keep patients safe (March 2018)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/how-reporting-hospital-close-calls-helps-keep-patients-safe-march-2018-r1171/1171Sat, 17 Aug 2019 07:29:00 +0000Transforming patient safety: A sector-wide systems approach. Report of the WISH Patient Safety Forum 2015https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/transforming-patient-safety-a-sector-wide-systems-approach-report-of-the-wish-patient-safety-forum-2015-r726/726Thu, 08 Aug 2019 10:24:00 +0000Safety In Numbers: The Leapfrog Group’s Report on High-Risk Surgeries Performed at American Hospitals (2019)https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/international-patient-safety/other-countries-and-national-agencies/safety-in-numbers-the-leapfrog-group%E2%80%99s-report-on-high-risk-surgeries-performed-at-american-hospitals-2019-r240/ The Leapfrog Group is a US nonprofit organisation 'driving a movement for giant leaps forward in the quality and safety of American healthcare.' Their flagship Leapfrog Hospital Survey collects and transparently reports hospital performance to inform purchasers and giving consumers information to make informed decisions.

The Leapfrog Hospital Safety Grade, Leapfrog’s other main initiative, assigns letter grades to hospitals based on their record of patient safety.

Safety In Numbers summarises findings from the 2018 Leapfrog Hospital Survey, submitted by over 2,000 hospitals nationwide. This is the first year Leapfrog reported the new surgical standard by hospital, assessing whether both hospitals and surgeons met volume standards, and whether hospitals monitored for surgical necessity.

This Leapfrog report states that patients should be very careful before they choose a hospital for one of these high-risk procedures and should worry even more about hospitals that decline to report this information because 'candour and transparency is the necessary first step to improvement.'

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