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Found 525 results
  1. Content Article
    Kenny Ajayi, Imperial College Health Partners - Patient Safety Programme Director, presented at the recent Bevan Brittan Patient Safety Seminar. Attached are his presentation slides.
  2. Content Article
    Asking a simple yet powerful question: ‘what matters to you?’ can give us, as healthcare professionals, vital insights into the lives of our patients, not always captured in routine assessments. If what matters to a patient is then shared with the whole multidisciplinary team (MDT) it can ensure that ongoing support and treatment is focused around the patients’ priorities, rather than what we think is important as healthcare professionals. It becomes truly patient focused. This blog was written by Ann Bryan, a physiotherapist, and Ines Brito, an occupational therapist, both part of the therapy team working at the Marie Curie hospice in Hampstead.
  3. Content Article
    A key part of the NHS long-term plan, primary care networks (PCNs) will bring general practices together to work at scale. But what are they? How are they funded and held accountable? And what difference will they make? The King's Fund explains the latest form of GP collaboration.
  4. Content Article
    The Medication Errors Group was established in 2017 under the leadership of Dr Brian Edwards and Professor Ian Wong.. Ensuring the safe and effective use of healthcare products is a key objective for those who work in pharmacovigilance, as well as all other stakeholders, including patients and caregivers. One key element of that is working to reduce and mitigate medication errors and other irrational use of drugs. The mission of the Medication Errors Group is To provide an opportunity for International Society of Pharmacovigilance (ISoP) members, and like-minded collaborators, to network globally in a professional and neutral environment, to share evidence and solutions that can ideally eliminate and/or at least reduce the number and severity of medication errors. This will enable continuous improvement in the use of medicines whilst supporting the interests of patients and their families, and healthcare professionals.
  5. Content Article
    Steve Turner's blog look at a workshop session delivered jointly by a facilitator and a user of mental health services. The aims of the session were to discuss adherence to medicines and treatments, relate this to practice through group work and discuss this with a user of mental health services
  6. Content Article
    The need for effective teamwork and improved communication amongst caregivers is increasingly recognised in healthcare policy worldwide. As healthcare organisations navigate in highly complex contexts, they are largely dependent on thorough collaboration and sharing of information between staff at all levels. Promoting high‐quality teamwork based on effective and frequent communication is therefore essential for developing well‐functioning healthcare organisations
  7. Content Article
     The Jeddah Declaration on Patient Safety is founded on the principles that guided the 4th Global Ministerial Patient Safety Summit 2019, Jeddah, Kingdom of Saudi Arabia. It is a call for action on many fronts, and for many actors, at all levels of healthcare provision and delivery – from frontline, to organisational and policy arenas. The Declaration is founded on the underlying spirit that it is imperative to reflect on the effectiveness of current practices in light of the now mature patient safety evidence base of 20 years and to collectively move forward with a vision to sustainable and scalable implementation of patient safety solutions known to improve care delivery systems, patient outcomes and safety culture. The Declaration signals a strong collective and global commitment to shape truly safer systems for generations to come.
  8. Content Article
    Football is a popular American pastime. Its focus on collaboration, individual skill reliance and teamwork serves as a touchpoint for the January 2020 Letter from America. Letter from America is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. 
  9. Content Article
    In The Silo Effect, the author uses an anthropological lens to explore how individuals, teams and whole organisations often work in silos of thought, process and product. With examples drawn from a range of fascinating areas - the New York Fire Department and Facebook to the Bank of England and Sony - these narratives illustrate not just how foolishly people can behave when they are mastered by silos but also how the brightest institutions and individuals can master them.
  10. Content Article
    This short video, by Understanding Patient Data,  shows people talking about why it's important to use patient data, and why we need to better explain the benefits and safeguards.
  11. Content Article
    Everyday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
  12. Content Article
    Patient and family advisory councils (PFAC) are groups of patients, family members, community members, and hospital staff who work together to bring the unique perspectives of patients and families to a hospital’s operations, especially its efforts to improve care. According to one estimate, more than 2,000 hospitals in the United States have PFACs. They are also slowly becoming more common in outpatient settings. Massachusetts is the only state that mandates all hospitals (acute care, rehabilitation, and long-term acute care) to have a PFAC. Five years on, this is a review of how the mandate came about, how the implementation process has gone, what PFACs in Massachusetts are doing now and what other states, healthcare organisations and consumer advocacy groups can learn from the Massachusetts experience.
  13. Content Article
    The pursuit of patient safety involves reducing the gap between best practice and the care actually delivered to patients. Understanding how to reliably deliver best practice care using established anaesthetic techniques may, today, be more important than seeking new ones. Advances in anaesthesia safety involve analysing failures and devising strategies to address these. However, anaesthetists do not work in isolation, and their contribution to the function of the multidisciplinary teams in which they work has far-reaching consequences for patient care.
  14. Content Article
    Many people with learning disabilities are not getting their annual health check, facing increased risk factors to a number of diseases as a result. This article, by Jim Blair and published by the British Journal of Family Medicine, considers what more can be done to help those most at risk
  15. Content Article
    The Institute for Healthcare Improvement ran a National Forum CEO and Leadership Summit in December 2019. This slide pack gives an overview of the summit, including speaker presentations and key objectives of the meeting.
  16. Content Article
    Earlier this year, the World Health Organization declared 17 September the first World Patient Day and presented it as an opportunity to speak up for patient safety. A week or so beforehand, health leaders from across the world had met in Salzburg, Austria, at the request of Salzburg Global Seminar and the Institute for Healthcare Improvement (IHI) to explore ways of improving the measurement of patient safety. The Lucian Leape Institute, an initiative of the IHI, led the convening and content curation. Participants of Moving measurement into action: designing global principles for measuring patient safety agreed that there is no single measure that allows all stakeholders in all settings to assess the past, current, and future safety of their system. Participants agreed a system of measures must be carefully designed to assess the safety of patients throughout their health journey. The conversations in Salzburg have helped establish eight global principles for the measurement of patient safety. They feature in this new document, Salzburg Statement on Moving Measurement into Action: Global Principles for Measuring Patient Safety.
  17. Content Article
    The Inaugural Australian Patients for Patient Safety Workshop, held over 3 days in Perth from July 7 ‐9, 2009, brought together a group of 40 health consumers, many of whom had experienced medical error or health system failure, health providers and health policy makers from around Australia.   Participants were selected for their efforts as change agents who have worked proactively to improve the safety of health care in Australia and their desire to further improve safety in health care, in partnership. Participants came together to build trust, functional working relationships grounded in mutual respect and appreciation of what each brought to the field of patient safety and to form strategies and action plans for improving patient safety in Australia. The core of those strategies and action plans is the Perth Declaration for Patient Safety.
  18. Content Article
    Using the data obtained from Fifth Sense’s ‘Quality of Life Impact of Olfactory Disorders’ survey amongst its members, a research paper was produced by Mr Carl Philpott and Duncan Boak to demonstrate the impact that olfactory disorders have on people’s lives. A summary of the findings can be read here. The study found it impacted on people's emotional wellbeing and their mental health, with many patients feeling their voice was unheard. There is a need for medical practitioners to take olfactory disorders more seriously.
  19. Content Article
    There has been an identified need for greater patient and family member involvement in healthcare. This is particularly relevant in an intensive care unit (ICU), as the family provides a key communicative and practical link between patient and clinician. Family members have been deemed a positive beneficial influence on ICU care and recovery processes, yet they themselves are often emotionally affected after discharge. There has been no standardised evidenced-based approach which explores research on family member involvement and the range and quality of contributions remain unclear. This study from Xyrichis et al. undertook a systematic review to assess the evidence base for interventions designed to promote patient and family member involvement in adult intensive care settings and develop a comprehensive typology of interventions for use by clinicians, patients and carers. The review provides valuable and rigorous insight into the range and quality of interventions available to promote patient and family member involvement in ICU. This is the first step towards addressing the absence of a synthesis of research for this context, and will, in addition, develop a typology of available interventions that will help service users and clinicians make informed decisions about the approaches to patient and family member involvement which they might want to adopt.
  20. Content Article
    Healthcare is in the midst of significant change, with substantial shifts in emphasis and priorities. Patient-centered care has become central to the core goals of better health, better quality, and lower costs while highlighting the necessity of incorporating patients’ efforts, needs, and perspectives into healthcare at all levels. Patient and family engagement (PFE) is critical to patient-centered care, and important theoretical and empirical work has identified key elements and implications of PFE, especially for management of chronic illnesses and preference-sensitive clinical decision making. Brown et al. believe that the ultimate goal of active, mutually respectful partnership among clinicians and patients/families is urgent and important. However, consistent terminology and definitions of PFE are still lacking. This deficit is particularly striking in intensive care units (ICUs), which pose special challenges to outpatient models of PFE: the emotional stakes are high, time is greatly compressed, surrogates play a central role, and the specter of death often dominates decision making.
  21. Content Article
    Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper from Holden et al. first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, ‘SEIPS 2.0’. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at ‘a moment in time’.  Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.
  22. 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?
  23. 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.
  24. Content Article
    Staff at C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, Michigan are adopting a new approach to safety. By picking up near misses, close calls, deviation off protocol and investigating each one via a daily huddle, they are able to enable change system wide.
  25. 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?
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