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Found 518 results
  1. Content Article
    An opportunity to connect virtually with health and care professionals from across the UK and Ireland on your shared interest in patient safety and quality improvement. An initiative from Supporting Q Connections programme.
  2. Content Article
    Hampshire and Isle of Wight Integrated Care System (ICS) has achieved great results in supporting access to the NHS Diabetes Prevention Programme. This case study outlines the approach taken by the ICS to improve access, what the outcomes were and key lessons learned.
  3. Content Article
    At the time of her death, Heather Findlay, aged 28 years, was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said “I’m sorry I have to do this to you” and ran away. ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park. At inquest, the jury came to a conclusion of death by suicide and giving a medical cause of death of: 1a hypoxic ischaemic encephalopathy 1b sodium nitrate toxicity.
  4. Content Article
    In this video, Chief Digital Officer Clive Flashman talks about the hub as a patient safety innovation as part of Patient Safety Learning's entry to the Digital Health Hub Foundation Digital Health Awards 2023.
  5. Community Post
    Hello everyone, We know there is much learning to be gained from listening to patient and families. This is particularly true when it comes to patient safety. Have you had an experience that you'd like to share with us? Maybe you identified a risk or shared a concern and were listened to and unsafe care was avoided? Maybe you weren't listenied to or you didn't realise what was going on and you or your family member were harmed? How did you find out about the patient safety incident? Was information shared with you that you needed to know? Were you supported? Was there an invetsigation into the incident and were you invited to contributed to it? Were lessona learned and acted upon? Have others learned from this experience, do you know?
  6. Community Post
    We know from academic research that patient engagement reduces the risk of unsafe care and harm, in patients own care and improving safety for all. Some organisations are investing time (if not money!) in recruiting, training and supporting patient leaders to work with Executives and senior staff, sharing their experience and as they engage with staff and patients, report back what they see. The model in Berkshire, as shared with me by Douglas Findlay, patient leader, is that they don’t make decisions on what needs to change and how, but report back what they see for others to learn and act. Do we know of other models of good practice? What can we learn and share from them?
  7. Content Article
    A casually centred proposal identifying how Fire and Rescue Services can improve pre-hospital care and quality of life outcomes for burn survivors.  David Wales and Kristina Stiles have released this report looking at the burn survivor experience in the pre-hospital environment. The work makes ten operational recommendations and also two 'lessons learned' recommendations exploring strategic partnership working and the resulting fragmented services.
  8. Content Article
    AHRQ's TeamSTEPPS - Team Strategies and Tools to Enhance Performance and Patient Safety - is an evidence-based set of teamwork tools, aimed at optimising patient outcomes by improving communication and teamwork skills among healthcare teams, including patients and family caregivers.
  9. Content Article
    The health needs of the population are changing, and many people need more co-ordinated care across primary, community, social and hospital services. More co-ordinated care requires organisations and staff to collaborate well across organisational and professional boundaries,
  10. Content Article
    There are an estimated 363,000 adults experiencing multiple disadvantage in England—they may be experiencing a combination of homelessness, substance misuse, mental health issues, domestic abuse and contact with the criminal justice system. The Changing Futures programme works in partnership in local areas and across government to test innovative approaches and drive lasting change across the whole system, in order to provide better outcomes for adults experiencing multiple disadvantage.  This prospectus provides information for partnerships interested in submitting an expressions of interest to be part of the Changing Futures programme.
  11. Content Article
    Patient engagement refers to “meaningful and active collaboration in governance, priority setting, conducting research and knowledge translation,” where patient partners are members of the teams, rather than participants in research or those seeking clinical care. It appears more has been written on the benefits rather than the risks of patient engagement and the authors in this study feel it is important to document and share what they call ‘patient engagement gone wrong.’ The authors anonymised these examples and sorted them into four statements: patient partners as a check mark, unconscious bias towards patient partners, lack of support to fully include patient partners, and lack of recognizing the vulnerability of patient partners. These statements and their examples are meant to show that patient engagement gone wrong is more common than discussed openly, and to simply bring this to light.
  12. Content Article
    This report summarises the key insights from the Birmingham ICS Delivery Forum event, held in Birmingham in April 2023. It places the discussions that took place into the broader context of health and care transformation, both at a local and national level, and uses wider sources and research to expand upon the key points.
  13. Content Article
    This is an overview of the role and responsibilities of the National Patient Safety Committee. This was established in 2021 to bring key national healthcare organisations together to address complex patient safety issues that require cross-organisation effort and input to make care safer within the NHS.
  14. Content Article
    This strategy sets out how the Care Quality Commission (CQC) will listen, inform and involve people and work in partnership with organisations that represent people. The new strategy will run to 2026 and has four objectives: Build a trusted feedback service where people’s experiences drive improvements in care Create a trusted, accessible public information service designed around people’s expectations and needs Develop an inclusive approach to proactively involving people who use services, their family, carers and organisations that represent or act on their behalf in shaping our plans, policies and products Work in partnership with organisations that represent or act on behalf of people who use services to improve care
  15. Content Article
    New research showed how a national quality improvement programme called PReCePT (Preventing Cerebral Palsy in Pre Term labour) accelerated maternity units’ use of Magnesium sulphate for pre-term labour. The programme could serve as a blueprint for future efforts to get clinical guidelines into practice in other areas of care. The quality improvement programme involved training staff on the benefits of magnesium sulphate, and having a local midwife dedicated to encouraging and monitoring use of the medicine at their maternity unit. The programme was supported by Academic Health Science Networks (a regional and national organisation that encourages improvement and innovation in healthcare).  This article from the National Institute for Health and Care Research provides a plain English summary and short film about the project.
  16. Content Article
    This is the government’s formal response to the recommendations made by the Health and Social Care Committee in its Seventh report - Integrated care systems: autonomy and accountability, published on 30 March 2023. This document also sets out its response to the recommendations made in the Hewitt Review, which was commissioned by the government in November 2022 and published shortly after the committee’s report on 4 April 2023.
  17. Content Article
    The Health and Social Care Committee carried out an inquiry to consider how Integrated Care Systems will deliver joined up health and care services to meet the needs of local populations. They have now published the report, together with formal minutes relating to the report.
  18. Content Article
    The National Institute for Health and Care Research (NIHR) Evidence Collections draw together evidence from important NIHR-funded and wider research. They aim to help people in policy and practice understand recent important research in a topic area. The most recent Collection is Maternity services: evidence for improvement. In this blog, one of the Collection's authors, Candace Imison, describes how it was framed by the findings from a recent investigation into failings in East Kent Hospitals’ maternity services. She focuses on some key messages from evidence on how to identify poor performance and provide effective board governance and oversight.
  19. 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. Maureen discusses the important role of professional standards in building a patient safety infrastructure, the need to reframe safety as a positive idea and her experience of implementing learning processes during her time as a GP.
  20. Content Article
    Hospital command and control centres (CCCs) are central locations within a hospital where staff can coordinate and manage the response to emergencies, disasters and other critical events. They are also often used to track and monitor the location and status of hospital staff and resources, such as beds, equipment and supplies, in order to ensure that they are used efficiently and effectively. This blog by Sukhmeet Panesar, Chief Health Officer at Monstar Labs, acts as an introduction to CCCs in healthcare. It includes information on the different types of CCC, the benefits of CCCs and the challenges they may face.
  21. Content Article
    The world is facing challenges emerging from multiple crises, including pandemics, wars and climate change. Against this backdrop, the Government of Japan will host the Group of Seven (G7) Summit in Hiroshima and the G7 Health Ministers' Meeting in Nagasaki, Japan, in May 2023. This article in The Lancet outlines key recommendations for G7 action to address these challenges through a human security approach and a transformation of global health architecture: Enhance resilience to public health emergencies by boosting country-led efforts to achieve universal healthcare Advance timely and equitable access to life-saving medical countermeasures as common goods Promote a multilayered approach to global health governance, including financing, that facilitates effective collaboration among state and non-state actors beyond the health sector at global and regional levels.
  22. Content Article
    In 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."
  23. News Article
    Patients will receive better, more joined-up care under new plans announced to improve the links between health and social care. The integration white paper sets out a vision for an integrated NHS and adult social care sector which will better serve patients and staff. Despite the best efforts of staff, the current system means that too often patients find themselves having to navigate complex and disjointed systems. Those with multiple conditions can be left feeling frustrated at having to repeatedly explain their needs to multiple people in different organisations, while others can end up facing delayed discharge because the NHS and local authorities are working to different priorities in a way that is not as joined up as it could be. The white paper sets out some of the ways health and care systems will draw on the resources and skills across the NHS and local government to better meet the needs of communities, reduce waiting lists and help level up healthcare across the country. Health and Social Care Secretary Sajid Javid said: "Better integration is vital to stop people falling into the gaps between health and social care. Ensuring our health and care systems work in unison will mean we can support hardworking staff, provide better care to patients and deliver value for the taxpayer." "Our Integration white paper is part of our wider plans to reform and recover the health and social care system, ensuring everyone gets the treatment and care they need, when and where they need it." The plans set out in the white paper will ensure care is more personalised and accessible and remove the burdens on patients. Better information sharing will mean people will no longer have to remember key facts such as dates of diagnosis or medicines prescribed, taking pressure off patients to coordinate their own care. Local health services will be tailored to the specific needs of the community to ensure the right services are available. This could mean for example more diabetes clinics in areas with higher obesity, or additional support for people to stop smoking in communities where there are higher numbers of smokers. The integration white paper is the next step in delivering the government’s promise of a health and social care system fit for the future. It builds on both the Health and Social Care Bill and the People at the Heart of Care white paper which set out a 10-year vision for social care funded through the Health and Care Levy, and follows the delivery plan for tackling the COVID-19 backlog of elective care. Dedicated plans to tackle health disparities are set to be published in due course. Read press release Source: Gov.uk, 9 February 2022
  24. News Article
    On Monday 22 November, the UK under its G7 Presidency convened a meeting on ‘Patient safety: from vision to reality’, co-sponsored with the World Health Organization (WHO). Patient safety is a critical global public health issue and is essential if health systems are to advance and achieve universal health coverage (UHC). This event provided an important opportunity to demonstrate the continued importance of patient safety as an urgent global endeavour, facilitate international collaboration, and support strategic initiatives designed to eliminate avoidable harm in healthcare globally. Since 2016, the UK has worked closely with international partners, including in the G7, to raise the profile of patient safety issues and work together to drive solutions. This engagement led to the establishment of the annual Global Ministerial Summit on Patient Safety and adoption by the 72nd World Health Assembly (2019) of a UK co-led Resolution on ‘Global Action on Patient Safety’ (creating an annual World Patient Safety Day on 17 September) and WHO’s ‘Global Patient Safety Action Plan 2021 to 2030’ by the 74th World Health Assembly (2021). The event on 22 November brought together G7 countries, UK devolved administrations, system partners and patient advocates to share learning and reaffirm the importance of this critical issue. With the unprecedented coronavirus (COVID-19) pandemic, patient safety has become an even more crucial area for international cooperation, and the event underlined the importance of countries continuing to work together to maintain momentum on improving patient safety worldwide. The event was chaired by Dr Aidan Fowler, National Director of Patient Safety for NHS England and NHS Improvement, and was very well attended by global experts. The importance of continued international work to improve patient safety was underlined in the keynote speeches from Dr Tedros Adhanom Ghebreyesus, Director General of WHO, as well as Sajid Javid, Secretary of State for Health and Social Care, and Jeremy Hunt, Chair of the Health and Social Care Committee. The event also provided an important opportunity for sharing learning from around the world; and highlighted the need for and value of continued collaboration between countries on health issues. Interventions from G7 countries and UK devolved administrations provided important insights into how different countries are tackling this shared aim of eliminating avoidable harm in healthcare. It was clear that although health systems differ from country to country, many threats to patient safety have similar causes and similar solutions. Read full story Source: Department of Health and Social Care, 23 November 2021
  25. News Article
    A ‘culture of distrust’ between consultants and the use of incident reporting as a tool of ‘reprisal’ impacted patient care at a trust’s cardiology department, a review has concluded. An external review undertaken for Hull University Teaching Hospitals Trust has made a series of recommendations after looking into allegations of bullying and several examples of poor care within its cardiology services. In a report published in the trust’s board papers, the Royal College of Physicians reported a “perceived tendency to downplay clinical incidents, and, to undermine those who wanted to raise patient safety issues”. It added: “We met a group of individual consultants who did not work well as a team. There is a culture of distrust, a lack of departmental cohesion and allegations of bullying in the department. All of which reinforce a clear divide between the interventional and non-interventional consultant cardiologists." “There have been a number of allegations of belittling, intimidation and undermining…The review team heard accounts of a culture where datix has been used as a tool for possible personal reprisal along with ignoring/downplaying incidents that have been raised.” The review concludes: “This behaviour is impacting on patient care and therefore, all medical staff should be reminded of good medical practice as the [General Medical Council] code of conduct of how doctors must work collaboratively with colleagues.” Read full story (paywalled) Source: HSJ, 16 November 2021
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