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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Beverley talks to us about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. -
Content ArticleSignificant Event Audit (SEA) ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided. This guidance from the Royal College of General Practitioners (RCGP) aims to enable primary care teams to conduct an effective SEA with the aim of improving care for all patients.
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Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content ArticleIn 2002, a dedicated group from Pennsylvania passed the Medical Care Availability and Reduction of Error (MCARE) Act, the most robust state-level legislation of its kind. Its legacy remains 21 years later. In this interview with the journal Patient Safety, Pennsylvania's Patient Safety Authority chair, Dr Nirmal Joshi, discusses ways care has improved, what challenges persist, and how to achieve the unachievable—true culture change.
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Content ArticleThis briefing by the NHS Confederation provides overview and analysis of the health and care bill.
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Content ArticleMedical equipment, supplies, and devices (ESD) serve a critical function in healthcare delivery and how they function can have an impact on patient safety. ESD-related safety issues include malfunctions, physically missing ESDs, sterilisation and usability. Describing ESD-related safety issues from a human factors perspective that focuses on user interactions with ESDs can provide additional insights to address these issues. This article in the journal Patient Safety reviewed ESD patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System to identify ESD-related safety issues.
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Content ArticleThis book published by the US Food and Drug Administration (FDA) looks at risk communication—the communication approach used for situations when people need good information to make sound choices. It is distinguished from public affairs (or public relations) communication by its commitment to accuracy and its avoidance of spin. Effective risk communication between healthcare professionals and patients is important to ensure patient safety, and in various chapters of the book, the authors look at how to maximise effective communication in healthcare scenarios.
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Content ArticleTargets have been applied to a wide range of public services over the past 40 years. This report analyses whether targets improve the performance of public services and the reasons for this, making recommendations on when and how government should set targets. It focuses on national targets and examines what evidence there is for how they have affected how efficiently public money is turned into outcomes for the public.
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Content ArticleThe CVDPREVENT Audit has published its third annual audit report covering the audit period up to March 2022. The report provides insight into the impact of the Covid-19 pandemic on primary care services, when diagnosis and management of hypertension were significantly disrupted. It also compares the national position against key ambitions identified as milestones for the prevention of cardiovascular disease (CVD) and the detection and management of atrial fibrillation, blood pressure and cholesterol. It also includes findings relating to diagnoses of chronic kidney disease and diabetes, lifestyle and health inequalities, as well as a number of recommendations to support the prevention of cardiovascular disease.
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Content ArticleChairs and non-executives are an important NHS leadership group. As independent board members, they hold the executive to account and in doing so build patient, public and stakeholder confidence in the NHS. This report by the Independent Taskforce on Improving Non-Executive Director Diversity in the NHS explores the steps needed to strengthen the diversity of NHS boards in England. Read a shorter summary of the report
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Content ArticleThis engagement document is focused on the role of integrated care partnerships (ICPs) within statutory arrangements for integrated care systems (ICSs). It has been jointly developed by the Department of Health and Social Care, NHS England and NHS Improvement and the Local Government Association (LGA). This document focuses on the role of ICPs within systems. ICPs are a critical part of ICSs and the journey towards better health and care outcomes for the people they serve. The ICP will provide a forum for NHS leaders and local authorities to come together, as equal partners, with important stakeholders from across the system and community. Together, the ICP will generate an integrated care strategy to improve health and care outcomes and experiences for their populations, for which all partners will be accountable.
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Content ArticleIn this article, Professor Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), outlines an NES research project which aimed to critically review the safety-related content, language and assumptions of a small but diverse range of health and care safety learning reports, policies, databases and curricula.
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Content ArticleIn this blog, interdisciplinary humanistic, systems and design practitioner Dr Stephen Shorrock explores the dangers of project leaders relying on assumptions about work-as-imagined, detached from the reality of contextualised work-as-done. He describes his experience working on a project in which he discovered that operational staff felt anxious and unprepared for the major changes to come. This was unacknowledged by management, and he ascribes their lack of awareness to a failure to physically and empathetically engage with the workers in the reality of the processes and systems management had designed. He highlights the importance of empathy and asks the question, "In your worlds, how connected are managers and other non-operational specialists with operational staff and the operational environment, where changes ultimately end up? Those who wish to support operational staff through change must take the role of pupil, or apprentice – not master."
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Content ArticleAlarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment or intervention. They play a critical safety role in high-risk industries such as healthcare, which relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. The automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. This study in the journal Patient Safety aimed to assess whether these guidelines may provide insights for advancing patient safety in healthcare.
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EventuntilThis online session will explore the purpose of clinical audit and then compare and contrast this with the key principles of a quality improvement approach. With this foundation we’ll then discuss how these approaches are complementary as part of a holistic approach to improving quality of health and care. Some NHS organisations are already on a journey to a more integrated approach to clinical audit and quality improvement, and we hear about the journey underway at Sherwood Forest Hospitals NHS Foundation Trust. It would be great to hear about your journeys with clinical audit and quality improvement too. This session will be presented by Nikki Davey, from Quality Improvement Clinic Ltd, and Craig Short, from Sherwood Forest Hospitals NHS Foundation Trust. Register for the webinar
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Content ArticleThis report by the National Paediatric Diabetes Audit (NPDA) is based on data from 33,251 children and young people receiving care from a paediatric diabetes unit (PDU) in 2021/22 in England and Wales. It found that the increase in incidence of Type 1 diabetes observed in the first year of the Covid-19 pandemic was followed by a continuing increase in the numbers of children newly diagnosed with the condition in 2021/22. Other key findings include: Almost all of those with Type 2 diabetes were overweight or obese, and almost half had a diastolic or systolic blood pressure in the hypertensive range. Despite reductions in the percentages recorded as requiring additional support between 2020/21 and 2021/22, over a third of children and young people were assessed as requiring additional psychological support outside of multidisciplinary meetings. Inequalities persist in terms of the use of diabetes related technologies in relation to ethnicity and deprivation.
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Content ArticleThis report is the Falls and Fragility Fractures Audit Programme's (FFFAP's) State of the Nation Report 2022 for Wales. It examines how the care of inpatient falls and fragility fractures has changed since 2020, highlighting what the audit reveals about the quality of patient care and the impact of the Covid-19 pandemic. The report used three sources of data and concludes with a number of recommendations around the care of people with hip fracture, preventing inpatient falls, and preventing future fractures.
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Content ArticleUnpaid carers play a substantial and vital role in meeting social care needs. The care they provide has enormous value, both for the people they care for and for wider society. Many carers experience great satisfaction from their role, and through the help and support they provide to friends and family members they may also reduce the costs of formal social care provision. At the same time, caring responsibilities can come at a high personal and financial cost, despite the 2014 Care Act giving carers the right to receive support. 1 in 5 carers report feeling socially isolated and 4 in 10 report financial difficulties because of their caring role. This report by The Health Foundation aims to explore national data on the number of unpaid carers and trends over time, as well as which groups are more likely to have caring responsibilities and who they provide care for. It gives an overview of the types of support available to carers, and what we know–and don’t know–about how many carers are accessing support.
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Content ArticleThis report is the National Confidential Inquiry into Suicide and Safety in Mental Health's (NCISH) annual report on UK patient and general population data for 2010-2020. It includes findings relating to people aged 10 and above who died by suicide between 2010 and 2020 across all UK countries as well as people under mental health care who have been convicted of homicide, and those in the general population.
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Content ArticleBased on data from January 2019 to December 2021, this report by the Paediatric Intensive Care Audit Network (PICANet) catalogues comprehensive information on referral, transport and admission events. This enables the monitoring of delivery and quality of care in relation to agreed standards, and the evaluation of clinical outcomes to inform national policy in paediatric critical care. It reports on five key metrics relevant to Paediatric Intensive Care services: case ascertainment including timeliness of data submission retrieval mobilisation times emergency readmissions within 48 hours of discharge unplanned extubation in PICU mortality in PICU
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Content ArticleThe Operating Room Black Box (OR Black Box) is a system that collects, stores and analyses a large amount of data from the operating room beyond just surgical video, such as video and audio of the operating room and patient physiology data. In this episode of the Behind the Knife podcast, Dr. Teodor Grantcharov, one of the creators of the OR Black Box, talks about how the technology can be used to enhance surgical training. Using the system for feedback through self-directed review, coaching and integrated AI analysis has changed the way we can learn and teach in surgery, and may have implications for the future of evaluation and assessing credentials.
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Content ArticleEach year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs.
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Content ArticleIn this webinar, Jane O'Hara, Professor of Healthcare Quality and Safety at the University of Leeds, outlines how understanding of the role of patients and families in supporting patient safety has developed over the past few years. She highlights the work of the Yorkshire Quality and Safety Research Group (YQSR) and looks at research demonstrating the role patients and families can play in improving the safety of healthcare systems.
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Content ArticleThe Global Taskforce on WASH in healthcare facilities aims to provide global strategic direction and coordination to the World Health Organization (WHO) and UNICEF and to allow for information exchange and dialogue. The latest World Health Organization (WHO) data show that there are major global gaps in water, sanitation and hygiene (WASH) services in health care facilities: half of health care facilities do not have basic hand hygiene services one in five facilities have no water services one in ten have no sanitation services. WHO and UNICEF convened a series of stakeholder ‘think-tanks’ to discuss barriers to progress, coinciding with the launch of the Global Report on WASH in health care facilities. The Global Taskforce on WASH evolved from these think-tanks, and this webpage includes a link to a synthesis of their work in 2022-23. The purpose of the task force is to: encourage and hold accountable national governments to achieve the objectives established by WHA 72/7 and SDG 3 and SDG 6 reinforce calls for strong health leadership (e.g. mobilising political leaders at global events including G7, G20, UNGA) work at country level to increase demand, financing and integration of WASH in health programming and reporting support greater collaboration with other initiatives (e.g. UHC, Child/maternal health, AMR, climate smart health systems, Hand Hygiene for All).
