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Found 518 results
  1. Content Article
    Patient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
  2. Content Article
    This article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
  3. Content Article
    The Health Equity Network will launch in January 2023 and aims to build momentum for health equity across the UK. It will provide an opportunity for public and private sector organisations, community and voluntary groups and individuals to share their work on health equity and to engage across the country with others with the same interests. This article describes how the Network will work and offers the opportunity to register interest in joining.
  4. Content Article
    Sarah Kay and Jaydee Swarbrick are involved in the Patient Safety in Primary Care Project in Dorset. In this blog, they summarise a recent event they held to share learning from medicines incidents.
  5. Content Article
    The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, talks about her experience as an early adopter of PSIRF. She describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. She talks about the open way in which investigation reports are compiled and reviewed to ensure everyone involved is happy with the way events are presented.
  6. Content Article
    The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk NHS Foundation Trust, reflects on her trust's experience of being a PSIRF early adopter. Lucy talks about the benefits of PSIRF and how to make it work in practice. She highlights the need for effective collaboration between teams and the importance of engaging with patients, families and staff in new ways.
  7. News Article
    NHS England has launched the first substantive consultation on changes to the NHS provider licence since 2013. Licences set out the requirements providers must meet and are the legal mechanism NHS England can use to take enforcement action. Having a licence has long been mandatory for foundation trusts and independent providers, and will become so for trusts. The intention is for the proposals to take effect from next year. Most of the changes to the licence regime have been made to bring it into line with this year’s Health and Care Act and accompanying policy changes. For example, trusts will be required to collaborate with other providers and work effectively as part of their integrated care system. This extends to trusts delivering agreed financial plans decided at a system level. The aim is to provide “mutual accountability” and ensure each provider does not use “more than their fair share of NHS resources”.' Read full story (paywalled) Source: HSJ, 28 October 2022
  8. News Article
    University College London Hospitals (UCLH) is to host to a new collaboration researching patient safety, after being awarded £3 million in funding from the National Institute for Health and Care Research. The NIHR Central London Patient Safety Research Collaboration (PSRC) aims to improve safety in Surgical, Perioperative, Acute and Critical care (SPACE) services, which treat more than 25 million NHS patients annually. Perioperative care is care given at and around the time of surgery. Amongst the highest risk clinical settings are SPACE services because of the seriousness of the patients’ conditions and the complex nature of clinical decision making. Further risks arise at the transitions of care between SPACE services and other parts of the health and social care system. The research team led by UCLH and UCL will develop and evaluate new treatments and care pathways for SPACE services. This will include new interventions such as surgical and anaesthetic techniques, and new approaches to predicting and detecting patient deterioration. They will also help the NHS become safer for patients through the development of innovative approaches to organisational learning, and to how clinical evidence is generated. The PSRC’s learning academy will support the next generation of patient safety researchers through a comprehensive programme of funding, mentoring and peer support. The team includes frontline clinicians, policy makers and world-leading academics across a range of scientific disciplines including social and data science, mechanical and software engineering. Patients and the public representing diverse backgrounds are key partners in the collaboration. Professor Moonesinghe said: “We have a great multidisciplinary, multiprofessional team ready to deliver a truly innovative programme to improve patient safety in these high-risk clinical areas. As a uniquely rich research environment, UCLH and UCL are well placed to lead this work, and we are looking forward to collaborating with clinicians and patients across the country to ensure impact for the whole population which the NHS serves.”
  9. Content Article
    This engagement document is focused on the role of integrated care partnerships (ICPs) within statutory arrangements for integrated care systems (ICSs). It has been jointly developed by the Department of Health and Social Care, NHS England and NHS Improvement and the Local Government Association (LGA). This document focuses on the role of ICPs within systems. ICPs are a critical part of ICSs and the journey towards better health and care outcomes for the people they serve. The ICP will provide a forum for NHS leaders and local authorities to come together, as equal partners, with important stakeholders from across the system and community. Together, the ICP will generate an integrated care strategy to improve health and care outcomes and experiences for their populations, for which all partners will be accountable.
  10. Content Article
    With record-long waits for treatment, it has never been so important for NHS trusts to understand the level of risk to patients on the waiting lists. But while it’s one thing to assess and categorise the patients and their risks while waiting, it’s quite another to then subsequently intervene to effectively care for patients during that wait. With the use of technology, there are potentially enormous gains to be made on waiting list management, and one integrated care system is forging ahead on this front. The ICS in question is Cheshire and Merseyside. HSJ takes a look at the progress Cheshire and Merseyside are making.
  11. Content Article
    The Global Taskforce on WASH in healthcare facilities aims to provide global strategic direction and coordination to the World Health Organization (WHO) and UNICEF and to allow for information exchange and dialogue. The latest World Health Organization (WHO) data show that there are major global gaps in water, sanitation and hygiene (WASH) services in health care facilities: half of health care facilities do not have basic hand hygiene services one in five facilities have no water services one in ten have no sanitation services. WHO and UNICEF convened a series of stakeholder ‘think-tanks’ to discuss barriers to progress, coinciding with the launch of the Global Report on WASH in health care facilities. The Global Taskforce on WASH evolved from these think-tanks, and this webpage includes a link to a synthesis of their work in 2022-23. The purpose of the task force is to: encourage and hold accountable national governments to achieve the objectives established by WHA 72/7 and SDG 3 and SDG 6 reinforce calls for strong health leadership (e.g. mobilising political leaders at global events including G7, G20, UNGA) work at country level to increase demand, financing and integration of WASH in health programming and reporting support greater collaboration with other initiatives (e.g. UHC, Child/maternal health, AMR, climate smart health systems, Hand Hygiene for All).
  12. Content Article
    How can improvement-led delivery enhance the quality of outcomes for our patients, communities and our health and care workforce? In April 2022, Amanda Pritchard requested a review of the way in which the NHS, working in partnership, delivers effectively on its current priorities while developing the culture and capability for continuous improvement. Led by Anne Eden, NHS Regional Director South East, with a steering group chaired by Sir David Sloman, Chief Operating Officer, NHS England, the review team co-developed 10 recommendations with health and care leaders that have been consolidated into three actions.
  13. Content Article
    Social movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organisations that, as voluntary and intrinsically motivated change agents, mobilise around a common cause to improve outcomes through knowledge uptake and sustainability. This article in the International Journal of Nursing Sciences shares a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in healthcare. The authors concluded that social movement action can provide a lens through which to view implementation science. Collective action and collective identity–concepts less frequently canvassed in implementation science literature–can lend insight into grassroots approaches to uptake and sustainability. The concept analysis resulted in the development of the Social Movement Action Framework.
  14. Content Article
    This article describes a patient led a quality improvement (QI) project, working with a multidisciplinary team including pharmacists at East London Foundation Trust (ELFT). Their goal is to develop a better process so that he – and other patients – can get the medications they need in a timely manner. Katherine Brittin, MPH, Associate Director at ELFT says, “All of our work is about how we support service users to get involved to get the best from our services and for us to respond to what matters to them.” In the article, Brittin offers tips to health systems that may be inspired by ELFT’s example.
  15. 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. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety.
  16. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, chaired by Professor Ted Baker, to consider ‘what does safety look like at a system level?’ and discuss the key issues and help support the development of Integrated Care Systems. This report captures the key themes covered in this discussion.
  17. Content Article
    Sam Freeman Carney, Health Policy and Improvement Lead at Parkinson's UK, explains how critical it is that people with Parkinson’s get their medication on time and how, on World Parkinson’s Day last year, a group of healthcare professionals who live with Parkinson’s themselves decided to take action.
  18. Content Article
    On 1 July 2022, Integrated care systems (ICSs) were placed on a statutory footing. ICSs are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. Following their introduction, on the 18 November 2022, the Government announced that it would commission an independent review into the oversight of ICSs, considering how to best enable them to succeed, balancing greater autonomy and robust accountability, to be led by former Secretary of State for Health, the Rt Hon Patricia Hewitt. This report sets out the findings of this review.
  19. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, considering ‘What does safety look like at a system level?’. The round table was chaired by Professor Ted Baker, who led the discussion around the key issues facing Integrated Care Systems and how we can help support their development.
  20. 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. Lesley talks to us about how personal stories enrich our understanding of data, drive real quality improvement and remind us that healthcare is all about people. She also explains how her own personal experience drives her work to improve healthcare experiences for patients and their families.
  21. Content Article
    How one Devon ICS has worked with local trusts to cut deliver extra capacity at a former Nightingale hospital, now converted into an elective centre.
  22. Content Article
    Research on maternity care often focuses on factors that prevent good communication and collaboration and rarely includes important stakeholders – parents – as co-researchers. To understand how professionals and parents in Dutch maternity care accomplish constructive communication and collaboration, Korstjens et al. examined their interactions in the clinic, looking for “good practice”.
  23. Content Article
    Within the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey’s pragmatism, in this study Kirstine Z. Pedersen and Jessica Mesman propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey’s understanding of transaction as the inseparability between human and environment, they develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. They further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.
  24. Content Article
    Medical errors, especially those resulting in patient harm, have a negative psychological impact on patients and healthcare workers. Healing may be promoted if both parties are able to work together and explore the effect and outcome of the event from each of their perspectives. There is little existing research in this area, even though this has the potential to improve patient safety and wellness for both healthcare workers and patients. Using a patient-oriented research approach, this study in BMJ Open Quality examined the potential for patients and healthcare workers to heal together after harm from a medical error. The study's findings suggest that, after a medical error causing harm, both patients and healthcare workers have feelings of empathy and respect towards each other that often goes unrecognised. Barriers to communication for patients were related to their perception that healthcare workers did not care about them, showed no remorse or did not admit to the error. For healthcare workers, communication barriers were related to feelings of blame or shame, and fear of professional and legal consequences. Patients reported needing open and transparent communications to help them heal, and healthcare workers required leadership and peer support, including training and space to talk about the event.
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