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Found 518 results
  1. 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. Rachel speaks to us about how patient partnership is key to tackling major issues facing the healthcare system and describes the central role of communication in improving patient safety.
  2. Content Article
    Ambulatory safety nets not only safeguard against diagnostic errors, they also encourage collaboration, support health care providers, and break down competitive barriers for the greater good of patient safety.
  3. Content Article
    This report, produced in collaboration with the Association of Ambulance Chief Executives and the NHS Confederation, highlights the pivotal role ambulance trusts play in delivering urgent and emergency care and sets out a long-term vision for an enhanced role they could take in co-designing this care. It sets out the case for change and includes several case studies that demonstrate the benefits of ambulance services taking this broader approach.
  4. Content Article
    Chris Elston, a patient safety education lead, shares how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from a patient safety incident at his Trust.
  5. Content Article
    SafetyNet brings together the collective efforts of the six NIHR Patient Safety Research Collaborations (NIHR PSRCs).across England in addressing patient safety challenges of strategic importance. The quarterly SafetyNet newsletter offers you the opportunity to find out about the exciting research and collaborations that are happening across the safety centres and wider organisations.
  6. Content Article
    NIHR Patient Safety Research Collaborations (PSRCs) are partnerships between universities and NHS trusts that support patient safety research. There are six PSRCs in England, aiming to bring patient safety discoveries to frontline NHS services.
  7. Event
    The overall objective of this masterclass is to build good governance commitment, capacity, and resilience in the face of severe resource constraints and complex staff, patient, political and regulatory expectations. The programme is interactive, developmental, based on best practice and focused on achievable improvement of practice, behaviours and outcomes. The course includes online access to the relevant CQG e-learning module for 12 months and a discount code to purchase additional modules. This masterclass is one of a series that will help enhance your understanding and application of governance in healthcare, this module is designed to help boards avoid silo thinking, over-complex agendas or multiple reports by exploring the three elements of Integrated Governance which are: Integrated thinking, systems, and reporting. At the completion of this module, the participant will be able to: Appreciate the value of integrated thinking Recognise the importance of building integrated systems Understand the importance of integrated reporting to inform management, the board, and stakeholders Apply the learning to the participant’s own organisation using the CQG Maturity Matrix. Register
  8. Content Article
    The Children and Young People’s Health Equity Collaborative (CHEC) is a partnership between the UCL Institute of Health Equity (IHE), Barnardo’s and three Integrated Care Systems (ICSs), Birmingham and Solihull, Cheshire and Merseyside, and South Yorkshire. The CHEC sees action on the social determinants of health as essential in improving health outcomes among children and young people and reducing inequalities in health. The CHEC recognises that social determinants of health are generally not sufficiently addressed in policies, services and interventions that aim to support better health among children and young people. This framework has been developed by the CHEC with direct input from children and young people local to the three ICSs. The CHEC Board were also involved in its development. The framework’s main purpose is to underpin action for achieving greater equity in children and young people’s health and wellbeing and will be used to support the development of pilot interventions in the three partner ICS areas. There is an ambition for the framework also to be used more widely, encouraging other ICSs to take action on the social determinants of health among children and young people.
  9. Content Article
    This article tells the story of how the This Is My Story (TIMS) initiative developed at John Hopkins Medicine, and how it is giving care teams a humanising window into the lives of patients who can’t speak for themselves. Initiated by Chaplain Elizabeth Tracey, who saw the toll not being able to communicate with intubated patients was having on healthcare workers during the first wave of the Covid-19 pandemic, TIMS provides healthcare teams with a short audio recording about each patient. The patient's family shares details about their loved one, such as information on hobbies, personal interests and the patient's career. Staff have reported the TIMS recordings having a big impact on how they view their patients, and the scheme has been rolled out across John Hopkins services.
  10. Content Article
    This article provides an overview of recent legislative developments intended to create a new independent board within the Department of Health and Human Services to improve patient safety in the United States of America.
  11. 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. Joy talks to us about why we need to reduce the use of restrictive practices in healthcare, the role of research in identifying unsafe practices and how the Restraint Reduction Network shares and helps organisations implement safer approaches to care.
  12. Content Article
    The Patient Safety Management Network (PSMN), created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. Claire Cox, Quality Patient Safety Lead, King's College Hospital NHS Foundation Trust, looks at how the Network has evolved over the last two years, its achievements and its aims going forward. 
  13. Content Article
    Martha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.
  14. Content Article
    This ethnographic study looked at five local Healthwatch organisations to determine the extent to which they have fulfilled their intended role of fostering co-creation in health and social care in England. The study results demonstrate clear activity and some tangible impacts that have been achieved towards the aim of cocreation. However, the authors also highlight that the positioning of these organisations as 'collaborative insiders' in local governance systems has limited the issues that have been prioritised in co-creative activities. This analysis suggests that the increasing promotion of ideas of co-production in English health and social care has resulted in fertile grounds for localised co-creation. However, the authors highlight that the areas Healthwatch focused on were ones where other agencies in the system recognised their limitations, and where they knew they needed help to avoid socially undesirable outcomes. As a result, the approaches taken to co-creation by Healthwatch were largely conservative and constrained. The authors state that, "Even though they were not explicitly ruled out-of-bounds, Healthwatch officers knew that to be considered legitimate and serious players in the governance of health and social care, they needed to be selective about which issues they brought to the table."
  15. Content Article
    This month marks two years of the hub's Patient Safety Spotlight interview series. Patient Safety Learning's Content and Engagement Manager Lotty Tizzard reflects on the value of sharing personal insights and identifies the key patient safety themes that interviewees have highlighted over the past two years.
  16. Content Article
    This animation aims to help staff and employers across health and social care understand Oliver's Training and why it is so vitally important. It was co-designed and co-produced with autistic people and people with a learning disability. Oliver McGowan died aged 18 in 2017 after being given antipsychotic medication to which he had a fatal reaction. He was given the medication despite his own and his family's assertions that he could not be given antipsychotics, and the fact that this was recorded in his medical records. The animation tells his story and highlights the increased risks facing people with learning disabilities and autism when accessing healthcare.
  17. Content Article
    As the Cumberlege Review and Paterson Inquiry made clear, having accurate and timely data on treatments and outcomes is critical to patient safety. NHS England is working to strengthen this data by implementing a central database to collect key details of implantable devices at the time of operation. The new Outcomes and Registry Platform will bring existing registries together for the first time and introduce new registries. In a blog for the Patient Safety Commissioner website, Scott Pryde, Programme Director for NHS England’s Outcomes and Registries Programme, and Katherine Wilson, Clinical Steering Group Chair of the programme, discuss the new National Registry of Hearing Implants, a registry specifically for cochlear implants. They highlight the importance of collaboration between patients, clinicians, regulators and medical device manufacturers.
  18. Content Article
    Effective teamwork is critical to the provision of safe, effective healthcare. High functioning teams adapt to rapidly changing patient and environmental factors, preventing diagnostic and treatment errors. While the emphasis on teamwork and patient safety is relatively new, significant team-related foundational and implementation research exists in disciplines outside of healthcare. Social scientists, including, organizational psychologists, have expertise in the study of teams, multi-team units, and organizations. This article highlights guiding team science principles from the organisational psychology literature that can be applied to the study of teams in healthcare. The authorsʼ goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations.
  19. Content Article
    This study examines the prevalence of advanced care planning (ACP) for patients undergoing endoscopic, fluoroscopic, laparoscopic or open surgical gastrostomy tube procedures at an academic hospital in the USA. The authors found that only 10.6% of included patients had accessible ACP documents available within their electronic medical record (EMR) and that Black patients had lower rates of ACP documentation. They also highlight an association between ACP documentation and decreased hospital length of stay, with no difference in mortality. The authors recommend the expansion of ACP in perioperative settings.
  20. Content Article
    Coloplast UK is a manufacturer of ostomy, continence, urology and wound care products. They commissioned the Patients Association to conduct a project to explore and recommend ways to better engage patients and carers in policymaking and the assessment of medical technologies for intimate healthcare. The Patients Association held a roundtable meeting and case study interviews with patients with intimate healthcare conditions and other stakeholders. They also conducted a survey of third-sector organisations who represent those patients and carried out desk-based research. This report summarises the findings of the project, which include that the existing mechanisms of engagement typically adopt a “patient involvement” approach where patients and carers do not have equal status as partners in the decision-making process. The report makes a number of recommendations to improve the way in which patients and their carers are engaged.
  21. Content Article
    It’s long been recognised that cross-functional collaboration is essential. Still, stubborn silos that bog down execution, hamper innovation, and slow decision-making are still a common and persistent challenge.  This article highlights three traits that high-performing leaders have in common and strategies for leaders to increase their own lateral agility.
  22. Content Article
    The research focuses on the application of user-centred design approaches and co-design principles in improving usability and acceptability of clinical tools (e.g. medicine reconciliation charts, diagnosis support tools and track-and-trigger charts). It highlights that limited practical guidance is currently available.
  23. Content Article
    This training tracker from the Patient Experience Library helps you find courses on patient experience and patient/public involvement hosted by a range of external organisations. Each listing contains details on how to book places and contact the course providers.
  24. News Article
    The Department of Education has recently provided an update to the national framework for Children’s Social Care. The key point to be aware of is the increased focus on sharing responsibility and strengthening multi-agency working to safeguard children. This change is likely to impact a wide variety of stakeholders involved in children’s care, including NHS Trusts, ICBs, education partners, local authorities, voluntary, charitable and community sectors and the police. The focus continues to be on a child-centred approach with the intention of keeping children within the care of their families wherever possible; this collaborative working may include working with parents, carers or other family but the wishes and feelings of the child alongside what is in the child’s best interests remain paramount. Joined up working is to be viewed as the norm. For health professionals, you will be expected to have lead roles for children with health needs, such as children who are identified as having special educational needs or disabilities. Read full story Source: Bevan Brittan, 23 January 2024
  25. Content Article
    Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.
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