Rhidian Bramley is a consultant radiologist and associate medical director at the Christie NHS FoundationTrust. In this blog he discusses how unintended consequences from implementation of digital solutions can have an impact on patient safety.
This blog by Adam Johns, Safety and Risk Manager for Cathay Pacific Airways, discusses the differences between complicated and complex systems and how this impacts on the way we manage safety and risk.
Epilepsy12 was announced as the winner of the 2018 Richard Driscoll Memorial Award for outstanding patient involvement in clinical audit at the annual Healthcare Quality Improvement Partnership (HQIP) AGM in London. The submission from the Royal College of Paediatrics and Child Health (RCPCH) demonstrated Epilepsy12’s overarching goal to improve NHS healthcare services for children and young people with seizures and epilepsy.
The PReCePT Programme is a quality improvement project designed to reduce the incidence of cerebral palsy through the administration of magnesium sulphate to eligible preterm mothers across England.
Early warning scores were developed to improve recognition of clinical deterioration in acute hospital settings. In 2015, the West of England Academic Health Science Network supported the roll-out of the National Early Warning Scores (NEWS) across a range of non-acute-hospital healthcare sectors. The objective of this study from Brangan et al., published in BMJ Open, was to explore staff experiences of using NEWS in these new settings. This study demonstrated that while NEWS can work for staff outside acute hospital settings, the potential for routine clinical practice to accommodate NEWS in such settings varied.
This toolkit has been designed for staff in care homes and carers in the community. It provides a readily accessible and practical guide to help them assist older people in their care to achieve optimum hydration.
It was developed through collaboration between Kent Surrey and Sussex Academic Health Science Network, Wessex Academic Health Science Network and NE Hants and Farnham CCG
Following the investigation into the Mid Staffordshire Hospital (United Kingdom) and the subsequent Francis reports (2013 and 2015), all healthcare staff, including students, are called upon to raise concerns if they are concerned about patient safety. Despite this advice, it is evident that some individuals are reluctant to do so and the reasons for this are not always well understood. This research study from Fisher and Kiernan, published in Nurse Education Today, provides an insight into the factors that influence student nurses to speak up or remain silent when witnessing sub-optimal care.
This toolkit supports the implementation of the Structured Judgement Review (SJR) process to effectively review the care received by patients who have died. This will allow learning and support the development of quality improvement initiatives when problems in care are identified. This toolkit also provides information and links to resources on change management and quality improvement methodologies.
Being called as a witness at an inquest is an infrequent event. It can however cause much anxiety and uncertainty. This guide is written to give advice to learners on how to prepare for an inquest and what support is available.
This document provides guidance for nurses, midwives and nursing associates on raising concerns (which includes ‘whistleblowing’). It explains the processes you should follow when raising a concern, provides information about the legislation in this area, and tells you where you can get confidential support and advice.
Of the nearly 237 million medication errors occurring in England each year, 28% have the potential to cause harm. This article published in The Pharmaceutical Journal outlines the immediate steps to be taken following identification of a medicines safety incident.
What patient safety beliefs get in the way of preventing harm? In this video, the Institute for Healthcare Improvement's (IHI) Frank Federico lists some common misunderstandings, including the tendency to think of the Institute of Medicine’s six quality aims for improvement in silos.
This is the first of a series of blogs on improvement of systems by Dr Rhidian Bramley. This introductory post looks at the drivers and some of the core concepts around designing clinical workflow in an electronic healthcare record (EHR) system. Dr Rhidian Bramley is a consultant radiologist and associate medical director at the Christie NHS Foundation Trust.
Adverse events in the nursing home setting are common and often preventable. This qualitative study, by Tong et al., of home care patients and their caregivers, published in the International Journal for Quality in Healthcare, revealed concerns about safe care space and ability to address physical needs. These results demonstrate the need for continued focus on safety in home care.
This short animation from the University of Western Australia highlights the importance of a multidisciplinary team briefing within the operating theatre environment.
This blog from Eli Quisenberry, Director of the Kaizen Promotion Office at the Virginia Mason Medical Centre, discusses what makes up 'standard work' and how this contributes to patient safety. Eli partners with leaders, staff and teams across the medical centre, applying the Virginia Mason Production System principles as they work to transform healthcare and achieve the organisation’s vision as the quality leader.