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Patient Safety Learning

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  1. Event
    The Learning from Excellence (LfE) team bring you the 4th LfE Community Event. The theme for the event is “Being better, together”, reflecting on their aspiration to grow as individuals, and as part of a community, through focussing on what works. For this event, they are partnering with the Civility Saves Lives (CSL) team, who promote the importance of kindness and civility at work and seek to help us to address the times this is lacking in a thoughtful and compassionate way, through their Calling it out with Compassion programme. The 2021 event is planned to be on-line and will include
  2. Content Article
  3. Content Article
    Part 1 of the Digital Clinical Safety Strategy provides an introduction to patient safety and defines digital clinical safety. It summarises the evidence base behind this strategy and it explains the regulatory and policy context for the strategy. Part 2 sets out the Digital Clinical Safety Strategy. It directly links to the NHS Patient Safety Strategy, mirroring its structure, which highlights ‘Insight, Involvement and Improvement’, as three strategic priorities for safer systems and safer cultures. Actions are outlined for each of these three areas. The strategy specifies 23 actions, wh
  4. Content Article
    PReCePT (prevention of cerebral palsy in preterm labour) offers magnesium sulphate to eligible women during preterm labour, reducing the risk of a pre-term baby developing cerebral palsy by 50%. This HSJ Patient Safety Award-winning intervention led to 850 additional mothers in preterm labour receiving magnesium sulphate in 2019/20, avoiding an estimated 30 cases of cerebral palsy. The learning from the spread of PReCePT to all maternity units in the West of England was adopted as national safety improvement programme, leading to increased uptake across England. PERIPrem (Perinatal Excell
  5. Content Article
  6. Content Article
    Today marks the third annual World Patient Safety Day. Established by the World Health Organization (WHO) in 2019, this is intended as a day to help enhance understanding of patient safety and to engage the public in this, promoting actions to improve safety and reduce avoidable harm.[1] Patient safety and the impact of unsafe care The NHS describes patient safety as ‘the avoidance of unintended or unexpected harm to people during the provision of healthcare’.[2] The WHO in their definition expand on this, adding that it also involves ‘continuous improvement based on learning from err
  7. Content Article
  8. Event
    There is no “magic wand” for impacting patient experience in healthcare. Even the best tools and most proven strategies require coordination and commitment across the organization to succeed in delivering a better patient journey. Leading healthcare organizations understand that a great staff culture of service, robust process, and differentiated technology are all equally vital to creating an improved patient experience. Join Burl Stamp, FACHE, a national thought-leader on patient and employee engagement and a frequent author and speaker on contemporary leadership issues in health care,
  9. News Article
    A survey of almost 50,000 patients by the Care Quality Commission (CQC) found people’s experiences of emergency departments improved in 2020, compared to the last time the poll was conducted in 2018. On a scale of one to 10, the regulator found 33% of patients scored their overall experience as 10, compared to 29% in 2018. Eighty-eight per cent of patients scored their care at six or higher, compared to 85% three years ago. However, overall satisfaction levels declined at around 20 providers. Ted Baker, CQC’s chief inspector of hospitals, said: “This year’s survey shows some en
  10. News Article
    At a certain point, it was no longer a matter of if the United States would reach the gruesome milestone of 1 in 500 people dying of COVID-19, but a matter of when. A year? Maybe 15 months? The answer: 19 months. The burden of death in the prime of life has been disproportionately borne by Black, Latino, and American Indian and Alaska Native people in their 30s, 40s and 50s. “So often when we think about the majority of the country who have lost people to covid-19, we think about the elders that have been lost, not necessarily younger people,” said Abigail Echo-Hawk, executive vice p
  11. News Article
    76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). This figure represents an 11% increase on the total reported in 2019. HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020. Under the European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, HIQA is the competent authority for patient protection
  12. Content Article
    Further reading HIQA: Annual report of accidental or unintended exposures to ionising radiation in 2019 CQC reports on safe use of radiation in healthcare settings (19 December 2019)
  13. News Article
    Changes to periods and unexpected vaginal bleeding after having a Covid vaccine should be investigated to reassure women, says a leading immunologist specialising in fertility. Writing in the BMJ, Dr Victoria Male, from Imperial College London, said the body's immune response was the likely cause, not something in the vaccines. There is no evidence they have any impact on pregnancy or fertility. The UK's regulator has received more than 30,000 reports of period problems. These include heavier than usual periods, delayed periods and unexpected bleeding after all three Covid vaccines,
  14. News Article
    Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found. The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019. The HSIB launched a probe examining the care of 37 cases. Among its fi
  15. Content Article
    Safety recommendations HSIB made eight safety recommendations as a result of this investigation, five to NHS England and NHS Improvement, one to the Royal College of Obstetricians and Gynaecologists, one to NHSX, and one to DHSC. HSIB recommends that future iterations of the Royal College of Obstetricians and Gynaecologists’ guidance clarify the management of a reported change in fetal movements during the third trimester of pregnancy with due regard to national policy. HSIB recommends that NHS England and NHS Improvement leads work to develop a process to ensure consistency
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