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Found 99 results
  1. Content Article
    In his book, Atul Gawande discusses how today we find ourselves in possession of stupendous know-how, which we willingly place in the hands of the most highly skilled people. However, he notes that avoidable failures are common and the reason is simple: the volume and complexity of our knowledge has exceeded our ability to consistently deliver it - correctly, safely or efficiently. The checklist manifesto shows how the simplest of ideas could transform how we operate in almost any field.
  2. Content Article
    The 4AT, developed in the UK, is now widely used internationally as a clinical tool for delirium detection in routine, non-specialist care, with increasing adoption for this specific use as well as in research studies. It has been validated in several published studies.
  3. Content Article
    Human factors expert Guy Hirst looks at checklist implementation in healthcare.
  4. Content Article
    I’d like to introduce my ‘Letter from America’, a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.
  5. Content Article
    Designed and tested by the Institute for Healthcare Improvement's (IHI) world-renowned safety experts, this toolkit includes documents on improving teamwork and communication, tools to help you understand the underlying issues that can cause errors, and valuable guidance about how to create and maintain reliable systems. Each of the nine tools includes a short description, instructions, an example and a blank template.
  6. Content Article
    This checklist was devised by the Intensive Care Society and the Faculty of Intensive care Medicine and is ready for you to download and use.
  7. Content Article
    The World Health Organization's surgical safety checklist to be used in all hospitals in the UK.
  8. Content Article
    These prompt cards were initiated in the Brighton and Sussex University Hospital Trust for the Emergency Department to ensure that safety measures are conducted everytime in high stress situations.
  9. Content Article
    This study from Petschonek et al. published in the Journal of Patient Safety sought to develop a survey that would measure individual perceptions of Just Culture in a hospital setting. The research team created a 27-item survey, which displayed adequate theoretical structure and internal reliability.
  10. Content Article
    Restorative Just Culture aims to repair trust and relationships damaged after an incident. It allows all parties to discuss how they have been affected, and collaboratively decide what should be done to repair the harm.
  11. Content Article
    Infographic picturing the guide to the Just Culture Algorithm.
  12. Content Article
    This info-graphic by the Faculty of Pain Medicine is a safety checklist for Interventional Pain Procedures under local anaesthesia or sedation. This has been adapted from the World Health Organization surgical checklist.
  13. Content Article
    This checklist from the Health and Safety Executive provides typical elements to score culture, particularly applicable for larger organisations.
  14. Content Article
    This checklist, recommended by the Association of Anaesthetists, with accompanying guidance is written to ensure the correct functioning of draw-over anaesthetic equipment and is important to patient safety.
  15. Content Article
    Kathy Nabbie reflects on the recent flights caught up in Storm Dennis and how 'routine' quickly became 'out of the ordinary'. As with aviation, in surgery we must always do the safety checks for each patient to ensure that every journey for the patient is a safe one.
  16. Content Article
    First, do no harm. Doctors, nurses, and clinicians swear by this code of conduct. Yet, medical errors are made every single day - avoidable mistakes that often cost lives. Inspired by two such mistakes, Dr. Peter Pronovost made it his personal mission to improve patient safety and make preventable deaths a thing of the past, one hospital at a time. Safe Patients, Smart Hospitals shows how Dr. Pronovost started a revolution by creating a simple checklist that standardised a common ICU procedure. His reforms are being implemented in all fifty states of the US and have saved hundreds of lives by cutting hospital-acquired infection rates by 70%. Atul Gawande profiled Dr. Pronovost's reforms in a New Yorker article and his bestselling book The Checklist Manifesto is based upon Dr. Pronovost's success in patient safety. But Safe Patients, Smart Hospitals is the real story: an inspiring, thought-provoking, accessible insider's narrative about how doctors and nurses are improving patient care.
  17. Content Article
    All patients should be risk assessed for venous thromboembolism (VTE) on admission to hospital. Patients should be reassessed within 24 hours of admission and whenever the clinical situation changes. This template checklist produced by the Department of Health and the National Institute for Heath and Clinical Excellence, is to aid the assessment in risk assessing patients for VTE.
  18. Content Article
    The purpose of this document, from the Chartered Institute of Ergonomics and Human Factors, is to provide health and social care teams with advice and guidance on the human-centred design of work procedures such as written instructions, checklists or flow charts during this period of 'crisis management' in response to COVID-19 and to support the design and re-design of care services and new ways of working. Implementation of the guidance will contribute to safer and easier to use procedures, which better support how people work and reduce risks to themselves, patients, carers and others.
  19. Content Article
    The Patient Safety Database (PSD), previously called Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. They have begun by developing an open and anonymous incident reporting system focused on non-technical skills. Each quarter they summarise in their newsletter cases reported on the platform. Read the latest newsletter.
  20. Content Article
    According to the World Health Organization, humanity faces its greatest ever threat: the climate and ecological crisis. Healthcare services globally have a large carbon footprint, accounting for 4-5% of total carbon emissions. Surgery is particularly carbon intensive, with a typical single operation estimated to generate between 150-170kgCO2e, equivalent to driving 450 miles in an average petrol car. The UK and Ireland surgical colleges have recognised that it is imperative for us to act collectively and urgently to address this issue. The Royal College of Surgeons of Edinburgh have collated a compendium of peer-reviewed evidence, guidelines and policies that inform the interventions included in the Intercollegiate Green Theatre Checklist. This compendium should support members of the surgical team to introduce changes in their own operating departments. The recommendations apply the principles of sustainable quality improvement in healthcare, which aim to achieve the “triple bottom line” of environmental, social and economic impacts. 
  21. Content Article
    This report from the AHSN Network shines light on ways we can do more to improve safety for residents of care homes. The publication showcases over 30 examples of projects delivered by England’s 15 Patient Safety Collaboratives (PSCs) and the Academic Health Science Networks (AHSNs) which host them. They include case studies in medicines safety, dementia, monitoring and screening, and workforce development.
  22. Content Article
    Urinary tract infection (UTI) was identified as the main reason to call a GP out-of-hours or to result in an unplanned admission to hospital from residential and nursing homes. Care home staff were using a urine dipstick to diagnose a urinary tract infection then calling a health care professional (HCP) for antibiotics, resulting in inappropriate use of antibiotics and over-treating what is perceived as a UTI in the absence of clinical symptoms.
  23. Content Article
    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.
  24. Content Article
    It is important that patients understand both verbal and written health information, including clinical explanations, recommendations, instructions and educational materials. However, health information and services often are unfamiliar and confusing, and many people struggle with health literacy and numeracy. Taking steps to help patients understand health information is therefore important to patient engagement and patient-centred care. This checklist is designed to help healthcare providers evaluate their current approaches to ensuring patient understanding and identify potential gaps and opportunities for improvement.
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