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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    If you're concerned about the quality of care, you can contact the Care Quality Commission (CQC). If someone is in danger you should contact the police immediately. You can call them on 03000 616161.
  2. Content Article
    This paper, published in BMJ Quality and Safety, investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm.
  3. Content Article
    Protect, formerly Public Concern at Work, aim to stop harm by encouraging safe whistleblowing. They advise people through their free, confidential advice line, train managers, senior managers and board members and support organisations to strengthen their internal whistleblowing or ‘speak up’ arrangements. They were closely involved in setting the scope and detail of the Public Interest Disclosure Act 20 years ago.
  4. Content Article
    Speaking up is the act of reporting concerns about malpractice, wrongdoing or fraud. Within the NHS and social care sector, these issues have the potential to undermine public confidence in these vital services and threaten patient safety. If you are working in this sector but don’t know what to do, or who to turn to about your concerns, Speak Up are the leading source of signposting, advice and guidance. Whether you are an employee, worker, employer or professional body/organisation, you can call their free speaking up helpline, send them an email or complete the online form safe in the knowledge everything you tell them is strictly confidential and anonymous. Speak Up offer legally compliant, unbiased support and guidance to ensure you can act in accordance with your values. This ensures you fully understand your options and legal rights specific to your employment situation. You can call the helpline on 08000 724 725.
  5. Content Article
    Practice staff should use the GP e-form to report all patient safety incidents and near misses whether they result in harm or not. These reports are used by to spot any emerging patterns of similar incidents or anything of particular concern. This will help protect patients by raising awareness of the risks through shared learning with general practices and other health providers across the country.
  6. Content Article
    About one in ten patients are harmed during health care. Published on the OECD Library website, this paper estimates the health, financial and economic costs of this harm. Results indicate that patient harm exerts a considerable global health burden. The financial cost on health systems is also considerable and if the flow-on economic consequences such as lost productivity and income are included the costs of harm run into trillions of dollars annually. Because many of the incidents that cause harm can be prevented, these failures represent a considerable waste of healthcare resources, and the cost of failure dwarfs the investment required to implement effective prevention.
  7. Content Article
    In his article for KevinMD.com, Ashish Jha looks at the metrics associated with hospital acquired conditions (HACs) in the US. He discusses the imperfections of HAC scored and argues that we need better measures in order to make further progress in the field of patient safety.
  8. Content Article
    Published by wbur, an American news station, this account from a doctor tells the story of his father's admission to hospital. Dr. Ashish Jha lists a catalogue of errors that took place over those few days, notes how common these mistakes are and argues we should be less tolerant of poor patient safety in healthcare.
  9. Content Article
    A written and audio commentary taken from the American news station, wbur. Dr. Ashish Jha discusses the emerging trend for hospitals to spend money opening hotel-like services and argues that too often patient safety takes a backseat to these marketing efforts.
  10. Content Article
    An extensive governance review of the events leading to the closure of Tawel Fan ward in December 2013 and a review of the current governance arrangements in older people’s mental health in Betsi Cadwaldr University Health Board.
  11. Content Article
    The Information Commissioner’s Office (ICO) has ruled the Royal Free NHS Foundation Trust failed to comply with the Data Protection Act when it provided patient details to Google DeepMind. The Trust provided personal data of around 1.6 million patients as part of a trial to test an alert, diagnosis and detection system for acute kidney injury. An ICO investigation found several shortcomings in how the data was handled, including that patients were not adequately informed that their data would be used as part of the test. The Trust has been asked to commit to changes ensuring it is acting in line with the law by signing an undertaking.
  12. Content Article
    Harold Fredrick Shipman was convicted at Preston Crown Court on 31 January 2000 of the murder of 15 of his patients while he was a General Practitioner at Market Street, Hyde, near Manchester and of one count of forging a will. He was sentenced to life imprisonment. On 1 February 2000, the Secretary of State for Health announced that an independent private inquiry would take place to establish what changes to current systems should be made in order to safeguard patients in the future. The Inquiry's First Report was published on 19 July 2002 and its Final Report on 27 January 2005.
  13. Content Article
    This investigation was prompted by evidence given to the Bristol Royal Infirmary Inquiry which spoke of the benefits of retaining hearts for the purpose of study and teaching and identified Alder Hey as holding the largest collection. Previously, the Director of the Association of Community Health Councils had expressed concerns about contraventions of the Human Tissue Act 1961 to the then Secretary of State for Health.
  14. Content Article
    NHS England published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust and highlighted a system-wide response. The report was commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust. Both Southern Health NHS Foundation Trust and the clinical commissioning groups (CCGs) that commission services from them have accepted the recommendations.
  15. Content Article
    Chaired by Robert Francis QC, this Inquiry was set up to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry looked at why the serious problems at the Trust were not identified and acted on sooner, to identify important lessons to be learnt for the future of patient care. 
  16. Content Article
    The Inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary.
  17. Content Article
    Health and social care providers internationally are heavily scrutinised by external regulators as part of accreditation, inspection and external review processes. The aims are generally to identify poor performance and/or to improve performance and in particular to ensure the delivery of good quality services. This can result in a complex, costly and overlapping network of oversight arrangements. In his editorial, published by the Journal of Health Services Research & Policy, Sheldon discusses this topic further.
  18. Content Article
    Mark Lomax, CEO at Patient Experience Platform, talks about the value of disruptive healthcare innovations and how to identify the 'disruption killers' and the champions within an organisation.
  19. Content Article
    This study, published in BMJ Quality and Safety seeks to determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.
  20. Content Article
    It is now accepted that healthy cultures in NHS organisations are crucial to ensuring the delivery of high-quality patient care. The Kings Fund developed a tool to help organisations assess their culture, identifying the ways in which it is working well, as well as the areas that need to change.
  21. Content Article
    Published in the BMJ journal Quality & Safety, the authors draw out high-level learning about culture and behaviour in NHS organisations; what influences culture and behaviour; and what needs to change to give effect to the vision of a safe, compassionate service in which patients and their families could have trust and confidence.
  22. Content Article
    Checklists have become the go-to solution for a vast range of patient safety and quality issues in healthcare. Some see them as a quick and obvious solution to a relatively straightforward problem. For others, they illustrate a failure to understand and address the complex challenges in patient safety and quality improvement.  ‘The problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.
  23. Content Article
    Published in Systematic Reviews, this paper looks at how organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting.
  24. Content Article
    High numbers of non-urgent attendances at paediatric emergency departments (i.e. attendances for illness that could have safely been treated elsewhere) increases waiting times, inconveniences families, incurs significant costs to the NHS, and reduces the time hospital staff can spend treating severely ill children. This report, produced by the Behavioural Insights Team (BIT) in collaboration with the Connecting Care for Children (CC4C) programme, addresses this issue.
  25. Content Article
    Getting to grips with human factors – strategic actions for safer care is a learning resource from the Clinical Human Factors Group (CHFG) that recognises the fundamental impact boards have on safety within their organisation. The aim of the resource is to encourage boards to invest time and resource in human factors, by raising awareness of human factors and demonstrating how human factors impact on quality, safety and productivity in healthcare. It is intended to be thought provoking, encouraging board members to think about themselves and their organisation whilst also providing practical actions that boards and individual members can and should be making in this area.
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