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Found 80 results
  1. Content Article
    Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.
  2. Content Article
    In 2020, over 2,000 people over the age of 60 fell and fractured their hip while staying in hospital in England and Wales. This graphic has been produced by the National Audit of Inpatient Falls (NAIF), which audits the delivery and quality of care for patients over 60 who fall and fracture their hip or thigh bone across England and Wales. It features the three most important findings of the 2021 NAIF Report, chosen by the patient and carer panel. The infographic covers the following questions: How can falls be prevented? What should happen after a fall? How can I help to improve care in hospital?
  3. Content Article
    This guide by the Royal College of Physicians explains what a hip fracture is and answers questions about how patients will be cared for before and after a hip operation. It is written for patients and their families and carers. The guide covers aspects of hip fracture care such as: pain relief memory problems who should be involved in your care how soon an operation should take place eating and drinking bladder problems rehabilitation and physiotherapy following surgery when you will be able to go home future falls prevention bone strengthening medication
  4. 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. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care.
  5. Content Article
    Fracture liaison services (FLSs) check if people who have recently broken a bone after falling from a standing height or less (a fragility fracture) might also have osteoporosis – a disease that weakens bones. They then advise on treatments to reduce the risk of another fracture, helping to improve patient outcomes. The Royal College of Physicians (RCP) estimates that at least 90,000 patients in England and Wales who should have anti-osteoporosis therapy are not receiving it. This guide by the RCP's Fracture Liaison Service Database (FLS-DB) aims to help patients and their families and carers understand what to expect following a fragility fracture. It outlines three key findings and the actions that individuals can take to ensure they receive the care and treatment they need from health services.
  6. Content Article
    The National Audit of Inpatient Falls (NAIF) has published its latest report into the care given to patients who fell while they were in hospital and sustained a hip fracture. Based on data from 1,394 patients in 2021, the report presents information on post-fall management and tracks performance against National Institute for Health and Care Excellence (NICE) Quality Standard 86, which includes checking the patient for injury before moving, using safe lifting equipment and prompt medical assessment after the fall.
  7. Content Article
    When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.
  8. Content Article
    The National Institute for Health and Care Excellence (NICE) is developing an update to the guideline on assessment and prevention of falls in older people and people 50 and over at higher risk. It has published the final scope for the update alongside consultation comments and responses, an equality impact assessment and the stakeholder list. The final guidance is expected to be published on 13 June 2024.
  9. Content Article
    A broken hip or ‘hip fracture’ is a serious injury, which each year in the UK leads to around 75,000 people needing hospital admission, surgery and anaesthesia, followed by weeks of rehabilitation in hospital and the community. The National Hip Fracture Database (NHFD) is an online platform that uses real-time data to drive Quality Improvement (QI) across all 163 hospitals that look after patients with hip fractures in England and Wales. This report highlights key research carried out using data from the NHFD in 2021, and makes a number of recommendations to improve treatment and outcomes for patients with hip fractures.
  10. Content Article
    In this short video, Associate Professor, Paediatric Podiatrist and Research Lead, Cylie Williams shares practical tips to help people wear their masks safely. Cylie talks about how to shape the mask effectively to different face shapes and how to prevent glasses from steaming up which can cause people to fall.
  11. Content Article
    Falls and fractures in older people are often preventable. Reducing falls and fractures is important for maintaining the health, wellbeing and independence of older people. A fall is defined as an event which causes a person to, unintentionally, rest on the ground or lower level, and is not a result of a major intrinsic event (such as a stroke) or overwhelming hazard. Having a fall can happen to anyone; it is an unfortunate but normal result of human anatomy. However, as people get older, they are more likely to fall over. Falls can become recurrent and result in injuries including head injuries and hip fractures.
  12. Content Article
    The Falls and Fragility Fractures Pathway defines the core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures.The Falls and Fragility Fractures Pathway has been developed in collaboration with the National Clinical Director for Musculoskeletal Services, Peter Kay, Public Health England (PHE), the National Osteoporosis Society (NOS) and a range of other stakeholders from across the health and care system. The pathway defines the key interlocking components for an optimal system for prevention and management and the priority higher value interventions that systems should focus on to address variation, improve outcomes, reduce cost and contribute toward a sustainable NHS.
  13. Content Article
    The objective of this study was to to report the frequency of adverse events (AEs) that occurred during the months when SARS-CoV-2 spreading rate was at its highest in the Italian nursing homes, and to identify which conditions and attributes were most associated with the occurrence of AEs. Authors note that future recommendations for the management and care of residents in nursing homes during the COVID-19 pandemic should include specific statements for the most vulnerable populations, such as people with dementia. This research paper can be viewed in full via the link below to the Frontiers in Psychiatry website.
  14. Content Article
    In the past, healthcare workers considered bed rails a useful device to prevent patient falls from bed. While bed rails have their benefits, their use or misuse may also place patients at significant risk, resulting in death or serious injury. Entrapment is an occurrence involving a patient who is caught, trapped, or entangled in the hospital bed system, which includes the spaces in or around the bed rail, hospital bed mattress, or hospital bed frame. Entrapped body parts associated with risk for severe injury include the head, neck, and chest. Awareness of this risk must be heightened across the healthcare continuum. The Patient Safety Authority has collated guidelines, resources and educational tools on bed safety.
  15. Content Article
    Falls represent a leading cause of preventable injury in hospitals and a frequently reported serious adverse event. Hospitalisation is associated with an increased risk for falls and serious injuries including hip fractures, subdural hematomas, or even death. Multifactorial strategies have been shown to reduce falls in acute care hospitals, but evidence for fall-related injury prevention in hospitals is lacking. Dykes et al. assessed whether a fall-prevention tool kit that engages patients and families in the fall-prevention process throughout hospitalisation is associated with reduced falls and injurious falls. The study found that implementation of a fall-prevention tool kit was associated with a significant reduction in falls and related injuries. A patient–care team partnership appears to be beneficial for prevention of falls and fall-related injuries.
  16. Content Article
    Falls in Pennsylvania continue to be one of the biggest contributors to patient harm and the fourth most frequently reported adverse event. Looking more broadly, falls are also a frequent cause of patient harm across the United States and globally. Allen and Wallace conducted a review of the literature to identify international strategies and novel approaches to reduce falls and falls from injury, mainly in healthcare facilities, published in the last decade. The review revealed that while no single country has been able to eradicate patient falls, several had implemented measures showing moderate levels of success. Those struggling with a high incidence of falls may benefit from reviewing and adopting one or more of these innovative techniques.
  17. Content Article
    Tens of thousands of patients fall in health care facilities every year and many of these falls result in moderate to severe injuries. Find out how the participants in the Center for Transforming Healthcare’s seventh project are working to keep patients safe from falls.  
  18. Content Article
    This web page includes the four work streams that Health Improvement Scotland are undertaking. These include: Falls Deteriorating patient Catheter induced infections Pressure ulcers.
  19. 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. 
  20. Content Article
    This infographic was produced by Sonia Sparkles, a Transformation Manager in the NHS. It highlights how to prevent falls in hospital.
  21. Content Article
    This guideline by the National Institute for Health and Care Excellence (NICE) covers assessment of fall risk and interventions to prevent falls in people aged 65 years and over. It aims to reduce the risk and incidence of falls and the associated distress, pain, injury, loss of confidence, loss of independence and mortality.
  22. Content Article
    Which? magazine explores ways to keep people safe in their homes and outside by using electronic devices to alert others for assistance. Personal alarms allow people to call for assistance if they have an accident or a fall at home. They can help older and less abled people to feel safer at home, and to remain independent for longer. They can also offer peace of mind to family and friends.
  23. Content Article
    React To is a series of training resources developed by healthcare professionals. Although aimed at care home staff these resources are also relevant to other carers and healthcare professionals.
  24. Content Article
    This coroner's case, by coroner Emma Serrano, describes the events that led up to Maureen Brown's death at University Hospital of Derby and Burton NHS Trust. Maureen had an inpatient fall and died from her injuries. Could this death been prevented? How can we ensure the voice of the carer/family is heard, documented and acted upon in clinical practice?
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