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Found 1,211 results
  1. Content Article
    In this video, clinicians from Great Ormond Street Children's Hospital who are involved in the SAFE project talk about how the ‘huddle’ technique – a ten minute free, frank exchange of information between clinical and non-clinical professionals involved in a patient’s care every few hours – is helping them to improve their situation awareness, resolve risks to patient safety more quickly and reduce harm.
  2. Content Article
    This leaflet by NHS Employers (Wales) explains what bullying in the workplace is, how it can affect people and what to do about it.
  3. Content Article
    Last year, the Canadian Patient Safety Institute (CPSI) launched a safety improvement project focused on the Measurement and Monitoring of Safety. The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety and helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.
  4. Content Article
    This 15 minute video from the Brighton and Sussex University Hospitals NHS Trust gives an introduction to what human factors is within healthcare.
  5. Content Article
    Interesting article, by the Patient Safety Network, around how patients can be involved in the solution and the cause of some patient safety incidents.
  6. Content Article
    Involving patients in improving safety is a Health Foundation publication also known as an evidence scan. It is designed to help those involved in improving the quality of healthcare understand what research is available on a particular topic. This publication describes research into how patients have been involved in improving safety.  It addresses two questions: How have patients and carers been involved in improving safety in healthcare?  Is there any evidence that patient involvement leads to improved safety? 
  7. Content Article
    In this thought paper published by The Health Foundation, Dr Rebecca Lawton and Dr Gerry Armitage look at ways to involve patients in clinical safety and the readiness of patients and health professionals to adopt new roles. They discuss the importance of involving patients in the development of patient engagement and involvement strategies. Genuine patient involvement in their own care requires a fundamental cultural shift in the relationship between patients and clinicians. 
  8. Content Article
    This discussion paper published in Patient Safety & Quality Healthcare (PSQH) examines the possible barriers and facilitators to patient engagement drawn from a literature search. It proposes a framework with recommendations to address these barriers and promote patient-provider engagement.
  9. Content Article
    A report of the National Patient Safety Foundation’s Lucian Leape Institute's roundtable on consumer engagement in patient safety.  This US based report looks at how increasing engagement between those who provide care and those who receive it at every level can result in improved health care outcomes for individuals and safer and more productive work environments for healthcare professionals. 
  10. Content Article
    The involvement of patients in their care is a top priority for the NHS, highlighted in the NHS Constitution and the NHS Five Year Forward View. Healthcare providers are encouraged to develop different relationships with patients and communities to help empower them and engage them in their care. This same approach applies to patient safety in healthcare, where greater engagement of patients is seen as one of the building blocks for improvement. .
  11. Content Article
    In 2017, The Point of Care Foundation made a film of a Schwartz round at Ashford and St Peter’s Hospitals NHS Trust. The full session lasted one hour – this is an edited version which aims to show what happens in a round. Schwartz rounds often tackle difficult emotional situations. This film deals with a particular case about a sick baby, which some viewers may find upsetting.
  12. Content Article
    An adverse clinical event, patient safety incident or medical error can have a far-reaching impact not only for the patient and their families, the 'first victims', but also the healthcare professionals involved. These are sometimes referred to as ‘second victims’. Often there are few opportunities for second victim healthcare professionals to discuss the details of incidents or events and share how this has affected them personally. The East Midlands Patient Safety Collaborative (EMPSC) funded the University of Leicester as part of their National Safety Culture workstream to develop a Second Victim Support Unit within the Children’s Hospital at University Hospitals Leicester to test whether models of support established in the US could be successfully transferred to UK health settings.
  13. Content Article
    A case study on how Healthier Lancashire and Cumbria have been driving forward their digital strategy. This strategy includes how they are standardising and redesigning digital systems to improve patient safety (see Theme 4 - Manage the system more effectively).
  14. Content Article
    The NHS Long Term Plan highlighted several safety issues that need to be addressed: the fear of blame and retribution which curtails reporting and learning, lack of staff understanding of patient safety matters and workforce issues. This short article summarises what I have learnt about how After Action Review (AAR) can directly address the first two of these and indirectly impact on the third. 
  15. Content Article
    PatientSafe Network in Australia has been promoting the theatre cap challenge across the world. By wearing your name on your theatre cap it can improve team work and patient safety. The PatientSafe Network is a registered non for profit charity. It has been developed by front line healthcare staff and is for anyone to use – patients, relatives, doctors, nurses, pharmacists, healthcare managers, equipment and system developers, insurers – who wants to improve patient safety.
  16. Content Article
    How can leaders ― with or without formal authority ― create psychological safety in healthcare? In this short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes three key actions to foster a psychologically safe work environment.
  17. Content Article
    Near misses or good catches present organisations with learning opportunities. Using data comparisons run by the Pennsylvania Patient Safety Authority, this article by Wallace et al. highlights how good catch programmes can contribute to significant reductions in harmful events and offers insights from risk managers and patient safety officers regarding elements that are necessary to establish successful good catch initiatives and the culture to support them.
  18. Content Article
    Epilepsy12 was announced as the winner of the 2018 Richard Driscoll Memorial Award for outstanding patient involvement in clinical audit at the annual Healthcare Quality Improvement Partnership (HQIP) AGM in London. The submission from the Royal College of Paediatrics and Child Health (RCPCH) demonstrated Epilepsy12’s overarching goal to improve NHS healthcare services for children and young people with seizures and epilepsy.
  19. Content Article
    Following the investigation into the Mid Staffordshire Hospital (United Kingdom) and the subsequent Francis reports (2013 and 2015), all healthcare staff, including students, are called upon to raise concerns if they are concerned about patient safety. Despite this advice, it is evident that some individuals are reluctant to do so and the reasons for this are not always well understood. This research study from Fisher and Kiernan, published in Nurse Education Today,  provides an insight into the factors that influence student nurses to speak up or remain silent when witnessing sub-optimal care.
  20. Content Article
    This toolkit supports the implementation of the Structured Judgement Review (SJR) process to effectively review the care received by patients who have died. This will allow learning and support the development of quality improvement initiatives when problems in care are identified. This toolkit also provides information and links to resources on change management and quality improvement methodologies.
  21. Content Article
    This document provides guidance for nurses, midwives and nursing associates on raising concerns (which includes ‘whistleblowing’). It explains the processes you should follow when raising a concern, provides information about the legislation in this area, and tells you where you can get confidential support and advice.
  22. Content Article
    Policy to date has mostly focused on the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), Tarrant et al., in a paper published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice.
  23. Content Article
    This short animation from the University of Western Australia highlights the importance of a multidisciplinary team briefing within the operating theatre environment.
  24. Content Article
    Designed and tested by the Institute of Healthcare Improvement (IHI)’s world-renowned safety experts, the Patient Safety Essentials Toolkit can help you improve teamwork and communication, understand the underlying issues that can cause errors, and create and maintain reliable systems. IHI's Vice President, Frank Federico, helped develop the contents of the new toolkit. In the following interview, he provides an overview of how to put the toolkit to good use.
  25. Content Article
    Lewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Lewis' mother Helen Haskell, President of Mothers Against Medical Error and member of the Institute for Healthcare Improvement (IHI) Board of Directors, explains why communication isn’t always the norm after adverse events and why this dynamic is changing.
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