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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This World Health Organization (WHO) report highlights the public health impact of sepsis, with a particular focus on specific populations and those seeking healthcare, and we propose future directions and priorities in sepsis epidemiology research. Sepsis has many faces and can be a life-threatening condition, but it is potentially preventable and reversible. Research and policy-makers must be ready to forge partnerships to stimulate funding and help place sepsis more firmly on the list of critical health conditions to target in the pursuit of universal health coverage.
  2. Content Article
    Fifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
  3. Content Article
    Health is a universal human right and a main contributor to well-being, economic development, growth, wealth and prosperity for all. Health systems play a key role in protecting, restoring and maintaining the health of patients and populations. A well-trained, motivated and supported health workforce is the backbone of every health system and without them, there would be no healthcare. Health workers around the world are at the front line of the daily battle to contain diseases and to save lives while often risking their own health and lives. Poor and unsafe working conditions increase the risk of occupational diseases and injuries among health workers and jeopardize patient safety, quality of care and the overall resilience of health systems. The coronavirus disease (COVID-19) pandemic has drawn attention to significant gaps in the protection of health workers, emphasising the need to ensure that the occupational safety and health of health workers is a priority. This is fundamental if they are to be enabled to do their jobs and to protect the health of patients and populations. The development and implementation of national programmes for protecting the health and safety of all health workers is an effective way to ensure the application of national occupational safety and health legislation and policies tailored to the needs of the health sector. This World Health Organization (WHO) policy brief is intended to provide a short overview on the issues and recommendations for policy decision-makers in ministries of health and ministries of employment and labour; local authorities; managers of health facilities; professional associations of the various groups of health workers; and organizations of workers and employers in the health sector.
  4. Content Article
    17 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 interview, Patient Safety Learning's Content and Engagement Manager, Steph O'Donohue, speaks to Nick Kelly, Co-founder and CEO of the Axela Group, who specialise in health and social care services.
  5. Content Article
    In this BMJ perspective, David Oliver, a consultant in geriatrics and acute general medicine, discusses whether doctors should keep with tradition of using their professional titles amongst colleagues and patients, or whether, as in his own hospital, first names should be used as part of a wider focus on patient safety and a human factors culture. Of course, professional roles and hierarchies remain important in healthcare. Different people have different training or experience, and it’s important to have clear team leadership and responsibilities, especially in emergency care. But first names are part of a push to build strong team working, flatten hierarchies, and improve patient safety by making it easier for less senior team members or different clinical professionals to question senior doctors and “stop the line” before avoidable harm occurs.
  6. Content Article
    A framework has been developed by the Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives and the Society and College of Radiographers, in partnership with NHS England and NHS Improvement, to support maternity services with the local reintroduction of hospital visitors and individuals accompanying women to appointments. This framework has been designed to assist NHS trusts to reintroduce access for partners, visitors and other supporters of pregnant women in English maternity services. It applies to inpatient and outpatient settings. Reintroducing visits is challenging during a pandemic, and the priority must be the safety of all service users (including pregnant women), staff and visitors. 
  7. Content Article
    As highlighted by NHS England with the NHS People Plan[, healthcare organisations that prioritise workforce wellbeing will be better placed to put lessons learnt from the coronavirus pandemic into practice. Phil Taylor of RLDatix outlines the benefits of introducing a just culture not a blame culture and shares a methodology for positive change.
  8. Event
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    Institute for Healthcare Improvement (IHI) and BMJ International Forum: Copenhagen 2020 virtual event showcasing the latest innovations in quality improvement, hosting discussions on the key issues facing health and care systems, and empowering the healthcare community to move forward stronger and more connected than ever before. The event will explore how we can unite those across our health and care systems to reflect, recover, and reassess priorities in light of the changes brought by COVID-19. It will deliver: 35+ live lectures and interactive workshops 10+ hours of on-demand content, plus 30+ videos covering key improvement projects from across the globe Virtual poster displays and presentations Networking, huddles, and more! View programme Book now
  9. Community Post
    A recent thread on Twitter:
  10. Content Article
    17 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 joint interview, Patient Safety Learning speaks to Rob Tomlinson, a nurse in the operating theatres at East Lancashire Hospitals Trust, and Peter Smith, now retired after enjoying a thirty-year career in operating theatre nursing. Rob and Pete discuss why staff need to feel both physically and psychologically safe in the operating theatre and empowered to speak up, and  how the Below Ten Thousand language tool has made a huge difference in creating a safer operating environment.
  11. Content Article
    When you are receiving treatment, it is important to feel that you are in safe hands. The Private Healthcare Information Network (PHIN) website publishes information on a range of patient safety measures, including about serious safety incidents. One category of these are known as Never Events.  Here we explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.
  12. Content Article
    This document from the Department of Health and Social Care (DHSC) sets out how health and care systems can ensure that people: are discharged safely from hospital to the most appropriate place. continue to receive the care and support they need after they leave hospital. It replaces ‘Coronavirus (COVID-19) hospital discharge service requirements’ published on 19 March 2020.
  13. Content Article
    Since the Institute of Medicine’s 1999 report To Err is Human, it has been known that upwards of 100,000 deaths due to preventable medical errors occur each year. In the twenty years since then, little progress has been made in the way of reducing the number of these deaths and estimates now suggest between 200- 440,000 Americans are dying preventably each year. One major component many believe is lacking in the United States is a national agency that focuses on responsibility and accountability for patient safety. The Patient Safety Movement Foundation has published a white paper assessing the feasibility of creating a National Patient Safety Board to reduce preventable medical errors in facilities across the country.
  14. Content Article
    Mersey Care NHS Foundation Trust is committed to delivering perfect care but this depends on the development of a just and learning culture.
  15. Content Article
    As patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust.  We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts.  This interactive webinar was hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network. View the webinar on demand and download the slides.
  16. Content Article
    The rate at which nursing and ambulance staff are leaving the NHS is increasing. The number of nurse vacancies has risen to over 40,000 – a record high. The ambulance service has recorded an 80% per cent increase in staff leaving the profession since 2010. These rates are unequally distributed across professions, specialties and geographical regions, introducing inevitable inequalities in patient care. This Efficiency Research project aims to use this variation to detect underlying contributory factors for better or worse nurse and ambulance staff retention, and determine its effect on patient outcomes. A research team from Staffordshire University will use their experience of applying ‘big data’ analytics and unifying large datasets from three previous studies on the effect of nurse staffing on patient safety. Projects began in 2019 and will run until December 2023.
  17. Content Article
    The cost of providing care during a pandemic is seeing firsthand the evolution of medical knowledge, and wishing current data could have guided past decisions, says Eric Kutscher in this BMJ Opinion article.
  18. Content Article
    A National Patient Safety Alert has been issued on the risk of foreign body aspiration during intubation, advanced airway management or ventilation. Foreign body aspiration can occur if loose items are unintentionally introduced into the airway during intubation, ventilation or advanced airway management. This can lead to partial or complete airway blockage or obstruction, and if the cause is not suspected, can be fatal. The most common types of foreign bodies identified in incident reports were transparent backing plastic from electrocardiogram (ECG) electrodes and plastic caps of unclear origin. The alert asks providers to reduce this risk by purchasing safer alternative equipment without loose and transparent parts. Providers are also asked to develop or amend local protocols to ensure pre-prepared intubation and advanced airway management devices are covered or protected until use; and that the ends of reusable breathing system hoses are closed between patient cases.
  19. Content Article
    The Patients Association's response to the NHS consultation on draft requirements for Patient Safety Specialist roles. See also Patient Safety Learning's response to the consultation.
  20. Content Article
    The Patients Association was formed over fifty years ago. Since then, it has listened to patients concerns and spoken out on their behalf. Not long after the Patients Association took up its role, legislation was enacted by the government to establish the Parliamentary and Health Service Ombudsman (PHSO). Both organisations have similar values and agendas, intended to help and support the public, the difference being, one is an independent charity, the other a government body afforded all the power and legislation to act with credibility. However, sadly the Patients Association has no confidence that the PHSO will carry out an independent, fair, open, honest and robust investigation. The Ombudsman is frequently quoted as saying patients who suffer harm or poor care in hospitals are failed by a “toxic cocktail” within the health service, whereby complaints go unheard and lessons unlearned. The Ombudsman states: ”We are the last resort for complaints about the NHS. We listen to individual complaints and where things have gone wrong, help to get them put right.” The Patients Association, in partnership with the families of those who have contributed to this report, challenge that statement. Nearly 50 years after the PHSO was established, it is time for real and robust change, not just promises and more recommendations. The Patients Association have a clear request to the Government and Public Administration Select Committee-read our patients stories, listen to their concerns, consider our conclusions, recommendations and finally, hold the PHSO to account for its action.
  21. Event
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    This is a high-level, international virtual conference focused on patient safety and protecting health workers hosted jointly by Sovereign Sustainability & Development (SSD), RLDatix and the Saudi Patient Safety Center (SPSC). Registration
  22. News Article
    Around 250,000 clear face masks are set to be delivered to frontline NHS and social care workers to allow for better care to be provided to those who use lip-reading and facial expressions to communicate, whilst still ensuring staff and patients remain safe during coronavirus. The clear face masks will allow for improved communication with people with certain conditions like hearing loss, autism and dementia. Designed with an anti-fogging barrier to ensure the face and mouth are always visible, the see-through masks will help doctors, nurses and carers get important messages across to all patients clearly. An estimated 12 million people in the UK are thought to have hearing loss, while those who rely on facial expressions to support communication – such as people with learning disabilities, autism or dementia, or foreign language speakers and their interpreters – will also see benefit from the government deal. Minister for Care Helen Whately said: “Everyone using our remarkable health and care system deserves the best care possible and communication is a vital part of that." “This pandemic has posed numerous challenges to the sector, so we are always on the hunt for simple solutions to support those giving and receiving care." Read full story Source: National Health Executive, 7 September 2020
  23. Content Article
    Healthcare organisations are designed to achieve consistent and reproducible outcomes when faced with planned, predictable or ‘routine’ emergencies. Unfortunately, the more robust the system, the less agile it is when faced with a novel clinical crisis. This is not surprising, as it is impossible to create emergency operating procedures for every new or unforeseen catastrophe. Similarly, many surgeons in positions of leadership have limited exposure to executive decision-making or clinical expertise outside their area of specialist training. It is not unreasonable therefore for surgical leaders and their organisations to feel overwhelmed by complex and evolving crises, such as the recent COVID-19 pandemic. At such times, it is important to reflect on key strategies that can provide pragmatic, timely and cohesive means of restructuring the delivery of surgical care at an organisational level.
  24. Event
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    To commemorate World Patient Safety Day 2020, you are invited to join the WHO Global Virtual Event “One world: Global solidarity for health worker safety and patient safety” 17 September 2020. Registration
  25. Event
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    Patient Safety: Embracing technology in a rapidly evolving healthcare environment to reduce medication errors. In England 237 million mistakes occur at some point in the medication process. By embracing technology that already exists, we may actually hold the key to being able to significantly reduce this figure. Join Andrea Jenkyns MP, pharmacy and nursing thought leaders and patient safety representatives for an interactive discussion on embracing technology to reduce medication errors. The timing of this event is particularly significant as World Patient Safety Day takes place the following day and so these issues should be at the forefront of policy makers minds. Confirmed panelists include: Prof. Liz Kay, Former Director of Pharmacy at Leeds Teaching Hospitals NHS Trust Heather Randle, Lead for Medication Management at Royal College of Nursing Clive Flashman, Chief Digital Officer at Patient Safety Learning Ed Platt, Automation Director, Omnicell Registration
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