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Content ArticleThe purpose of this Global Framework for National Occupational Health Programmes for Health Workers, as directed by the WHO Global Plan of Action (GPA) on Workers’ Health (2008–17) and consistent with the ILO Promotional Framework for Occupational Safety and Health Convention, 2006 (No. 187), is to strengthen health systems and the design of healthcare settings with the goal of improving health worker health and safety, patient safety and quality of patient care, and ultimately support a healthy and sustainable community with links to Greening Health Sector and Green Jobs initiatives.
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Content ArticleEditorial from Liam J Donaldson and Neelam Dhingra in the Journal of Patient Safety and Risk Management for World Patient Safety Day.
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Content ArticleToday, on World Patient Safety Day, we're delighted to release a short video, giving you a glimpse into an online workshop we held, in partnership with Nutshell Communications, on 7 September. The intimate, highly participative event, known as Whose Shoes?, was attended by staff in health and care and patients, as part of our work around World Patient Safety Day. During the event, different scenarios – crowdsourced by real people – were discussed. The purpose of the event was for attendees to get together and openly talk about their personal experiences around key issues in staff safety and how they impact patient safety. Patient Safety Learning Chief Executive Helen Hughes, commented: "We were delighted with our collaboration with Whose Shoes. It’s an impressive approach to provide the space and support to consider real-life scenarios and hear people’s responses and personal experiences. It’s the first time we’ve done this and we want to do more! We’ve captured insights and pledges for staff safety improvement that will inform our work and the change we all want to see for safer healthcare." Please enjoy this short video, giving you a glimpse into the event and an example of one of the scenarios we discussed.
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Content ArticlePatient Safety Learning held an online workshop, in partnership with Nutshell Communications, on 7 September. The intimate, highly participative event, known as Whose Shoes?, was attended by staff in health and care and patients, as part of our work around World Patient Safety Day. During the event, different scenarios – crowdsourced by real people – were discussed. The purpose of the event was for attendees to get together and openly talk about their personal experiences around key issues in staff safety and how they impact patient safety. New Possibilities graphic recorders, Anna Geyer and Carrie Lewis, have produced visual minutes of the event and a reflective summary after the event.
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Content ArticleThe World Health Organization (WHO) is calling on governments and healthcare leaders to address persistent threats to the health and safety of health workers and patients. “The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve suffering and save lives,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “No country, hospital or clinic can keep its patients safe unless it keeps its health workers safe. WHO’s Health Worker Safety Charter is a step towards ensuring that health workers have the safe working conditions, the training, the pay and the respect they deserve.” The pandemic has also highlighted the extent to which protecting health workers is key to ensuring a functioning health system and a functioning society. The WHO Charter, released for World Patient Safety Day 2020, calls on governments and those running health services at local levels to take five actions to better protect health workers. Sign up to the WHO Charter here
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Content ArticleThis year's World Patient Safety Day focuses on both patient and staff safety. Human Factors science keeps patients safe, but also helps keep staff safe, physically and psychologically. Martin Bromiley has written a a special one page opinion piece for the Clinical Human Factors Group about the behaviours that help create psychological safety.
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Content ArticleIn this latest report, the Healthcare Safety Investigation Branch (HSIB) has outlined their approach to working with patients and families with the aim of sharing that learning across the healthcare sector. They have set out their experiences so that other organisations can reflect on how it may be applicable to their work. The report not only covers HSIB's principles and process for effective family engagement, but also how they evaluated the approach using feedback from families involved in investigations. HSIB’s process for effective family engagement has been developed through close collaboration with families who have been involved in investigations. HSIB recognises that there is currently no national framework or process to assist those working with families during investigations. In the report foreword, HSIB’s Chief Investigator, Keith Conradi says: “in the past decade, the healthcare sector has recognised the need to ensure it works with patients and families…however it is also recognised that undertaking family engagement of a high quality can be challenging, particularly when the guidance on how to do it is limited.” The report also highlights some possible future developments, which includes a long-term aim of producing formal family engagement guidance which will be shared externally for organisations to access and use.
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Content ArticleA fundamental shift is underway in care provision for older populations, with long-term care (LTC) increasingly taking on care provision that was traditionally delivered in hospitals. As OECD populations are rapidly aging, there has been increasing demand on the LTC sector to provide care for more, and older people, with complex conditions and heightened needs for expert care. Currently, 58% of adults aged 65 or over report living with two or more chronic diseases, with this figure rising over 70% in many OECD countries. Simultaneously, trends in LTC focus on substitution of care settings from nursing homes and residential care towards home care and supporting older persons to live on their own or with family as long as possible. The total cost of avoidable admissions to hospitals from LTC facilities in 2016 was almost USD 18 Billion, equivalent to 2.5% of all spending on hospital inpatient care or 4.4% of all spending on LTC. Research shows that over half of the harm that occurs in LTC is preventable, and over 40% of admissions to hospitals from LTC are avoidable. The root causes of these events can be addressed through improved prevention and safety practices and workforce development—including skill-mix and education. Targeted investments in a number of key areas can have a significant impact by mitigating the main cost drivers of adverse events in LTC.
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Content ArticleRecognising the scale of avoidable harm linked with unsafe medication practices and medication errors, WHO launched its third Global Patient Safety Challenge: Medication Without Harm in March 2017, with the goal of reducing severe, avoidable medication-related harm by 50% over the next five years, globally. This report, 'Medication safety in high-risk situations', outlines the problem, current situation and key strategies to reduce medication-related harm in high-risk situation.
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Content ArticleMedication errors present a major public health burden and there is a need to optimise risk minimisation and prevention of medication errors through the existing regulatory framework. The European Medicines Agency (EMA) in collaboration with the EU regulatory network was mandated to develop regulatory guidance for medication errors, taking into account the recommendations of a stakeholder workshop held in London in 2013. This guidance is intended to support the implementation of the new legal provisions regarding the reporting, evaluation and prevention of medication errors and is intended mainly for the pharmaceutical industry and national competent authorities. Healthcare professionals (HCP) are expected to consult national clinical guidance on reducing the risk of medication errors.
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Content ArticleThe Piper Alpha exploded and sank on 6 July 1988, killing 165 of the men on board. Some of the lessons learned from the inquiry into the Piper Alpha Disaster could be applied to healthcare.
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Content ArticleIn the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.
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Content ArticleThis report from the Centre for Perioperative Care provides evidence to justify the case for perioperative care, the integrated multidisciplinary care of patients from the moment surgery is contemplated through to full recovery. This report has brought together a wide range of research about the effectiveness of perioperative care. It considered over 27,000 studies in preparing this review. The results show that perioperative care is associated with high quality clinical outcomes, reduced financial cost and better patient satisfaction. A perioperative approach can increase how prepared and empowered people feel before and after surgery. This can reduce complications and the amount of time that people stay in hospital after surgery, meaning that people feel better sooner and are able to resume their day-to-day life. The review highlights the effectiveness of clear perioperative pathways, with an average two-day reduction in hospital stay across multiple types of surgery. Different interventions, including prehabilitation, exercise and smoking cessation can significantly reduce complications by 30% to 80%. This scale of benefits is far greater than many new drugs or treatments launched.
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Content ArticleThe Health Service Executive (HSE) Dublin North East’s Patient Safety Tool Box Talks have been developed to assist with the delivery of key patient safety messages within the workplace. Patient Safety Tool Box Talks© are not a substitute for formal training but rather recognises the need to embed patient safety into the workplace and as such are a support to formal more detailed training programmes. This approach allows the delivery of consistent short customised patient safety messages to staff in a brief intervention as part of a team meeting or at a shift change. The talks are designed to take no more that 5-10 minutes to deliver are capable of being delivered by a non-specialist. If questions however arise beyond the scope of the talk these should be referred to a specialist for clarification. This Tool Box also contains Guidance on Delivering a Patient Safety Tool Box Talk© and a number of talks on a variety of safety topics.
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Content ArticleSir Robert Francis, Chair of Healthwatch England, reflects on the mid-Staffordshire inquiry 10 years on and explains why speaking up is so vital, particularly in the context of COVID19. He also shares his support for the new Complaint Standards Framework and tells us why it’s important to listen to, learn from and be honest with the people you serve. Listen to the podcast or download the transcript.
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Content ArticleDo patients’ and families’ experiences with communication-and-resolution programmes suggest aspects of institutional responses to injury that could better promote reconciliation after medical injuries? This interview study of 40 patients, family members, and hospital staff in Australia found that patients have a strong need to be heard after medical injury that is often unmet. Although 18 of 30 patient and family participants (60%) reported positive experiences with communication-and-resolution programmes overall and continued to receive care at the hospital, they reported that hospitals rarely communicated information about efforts to prevent recurrences. Opportunities are available to provide institutional responses to medical injuries that are more patient centred.
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Content ArticleThe aim of this study from Bismark et al. was to identify characteristics of doctors in Victoria, Australia, who are repeated subjects of complaints by patients.
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Content ArticleQuality improvement and patient safety have been important topics on the agenda in the Danish health care system for >20 years. Over the years, Denmark has developed an array of national quality and patient safety initiatives. This paper aims to describe how quality improvement and patient safety initiatives have been organised in the Danish health care system and highlight how accountability has been achieved.
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Content Article17 September 2020 marks the second annual World Patient Safety Day. The theme this year is 'Health Worker Safety: A Priority for Patient Safety'. In the run up to this special event, Patient Safety Learning are publishing a series of interviews with staff from across the health and care system to highlight key issues in staff safety and gain a clearer idea of the kind of change that needs to take place to keep staff, and ultimately patients, safe. In this video, Neal Jones, Director of Patient Safety at Liverpool University Hospitals, discusses the challenges staff are currently facing and the support that they need. A transcript of the video is also included below.
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Content ArticleAn educational session from The Association for Perioperative Practice (AfPP) dedicated to the dangers of noise and distraction in healthcare with a possible solution, Below Ten Thousand. Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions.
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Content ArticleIt is often the case that particular healthcare policies and practices change overnight from being discouraged or even forbidden to becoming more or less compulsory. An example of this is the change in how patients can access doctors during the coronavirus pandemic. At the end of July, Matt Hancock gave a speech on the future of healthcare in which he declared “… from now on, all consultations should be teleconsultations unless there is a compelling reason not to.” The following day, Sir Simon Stevens’ letter on the third phase of the NHS response to COVID-19 gave more nuanced messages and acknowledged the place of face to face consultations alongside digital and telephone consultations in some circumstances. Meanwhile, a recent RCGP survey reported that at the present time 61% of appointments are full telephone consultations and 16% are telephone triages. Many changes in how patients can access doctors have the potential to offer great benefits to patients and to ease pressures on health systems; however, what is right in some circumstances is not right for all as Ros Levenson, Chair of Academy Patient and Lay Committee, Academy of Medical Royal Colleges, discusses in her blog.
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Content ArticleThe NHS workforce has a remarkable record in providing safe, effective and equal care for everyone. But, like many healthcare systems around the world, the NHS is facing significant day-to-day challenges, made worse by the outbreak of COVID-19 and the resulting effects on health and social care. The NHS should only offer tests, treatments and procedures, often referred to as interventions, that the best available evidence shows is the most appropriate and clinically effective. Research evidence shows that some interventions are not clinically effective or only effective when they are performed in specific circumstances. And as medical science advances, some interventions are superseded by those that are less invasive or more effective. At both national and local levels, there is a general consensus that more needs to be done to ensure that the least effective interventions are not routinely performed, or only performed in more clearly defined circumstances. Earlier this year, NHS England and NHS Clinical Commissioners launched a new programme focusing on items that should not be routinely prescribed in primary care. 31 interventions were identified and the public invited to comment on them. The consultation period is complete and the responses that have been submitted will be considered and a final recommendation made later in the year.
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Content ArticleThe Institute for Healthcare Improvement (IHI)-convened National Steering Committee for Patient Safety (NSC) has released a National Action Plan intended to provide US health systems with renewed momentum and clearer direction for eliminating preventable medical harm. Safer Together: A National Action Plan to Advance Patient Safety draws from evidence-based practices, widely known and effective interventions, exemplar case examples and newer innovations. The plan is the work of 27 influential federal agencies, safety organisations and experts, and patient and family advocates. The plan provides clear direction that health care leaders, delivery organisations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care.
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Content ArticleThis survey, a collaboration between the International Society for Quality in Healthcare (ISQua) and the International Hospital Federation (IHF) was designed to frame the WHO Global Consultation on Patient Safety, which was held from 24-26 February 2020 to kick off the development of the Global Patient Safety Action Plan. Already then, the pandemic-to-be was affecting various regions, before striking health systems worldwide. The question of patient safety is a critical one in the discussion about COVID-19: hygiene and hospital-acquired infections, non-suitable hospital architecture, delayed surgeries and procedures, lack of personal protective equipment (PPE) and much more affected the safety of patients as well as of health workers, to whom the World Patient Safety Day 2020 is dedicated. In February 2020, the IHF disseminated a short survey on national safety plans to its Full Members, hospitals’ national/regional representatives. At the same time, ISQua disseminated their survey asking how well incident reporting is in place, and if the outcomes improve the 'no blame no shame' approach to their Individual and Institutional Members. The surveys were repeated in July 2020 to see if the onset of COVID-19 had made any positive or negative changes to the responses.
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Content ArticlePatient safety has gained less attention in primary care in comparison to specialised care. Kongsvik et al. explore how local medical centres (LMCs) can play a role in strengthening patient safety, both locally and in transitions between care levels. LMCs represent a form of intermediate care organisation in Norway that is increasingly used as a strategy for integrated care policies. The analysis is based on institutional theory and general safety theories.
