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Found 291 results
  1. Content Article
    It has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub.
  2. Content Article
    Over the past 10 years, it has often been stated that the NHS treats more than a million people every 36 hours, but is that still true? Here, the King's Fund analyse NHS activity (eg, calls, appointments, attendances and admissions) and explore some of the underlying trends that lie behind these headline statistics. Following the disruption caused by the Covid-19 pandemic, NHS activity has almost returned to pre-pandemic levels.
  3. Content Article
    The Regional Patient Safety Observatory of the Community of Madrid is an initiative aimed at increasing the quality of healthcare and the safety of professionals and patients in the healthcare environment. The Observatory is a consultative and advisory body of the Ministry of Health in matters of health risks and is functional in nature.  Its objectives are: Promote and spread the culture of health risk management in the Community of Madrid. Obtain, analyse and disseminate regular and systematic information on health risks. Propose measures to prevent, eliminate or reduce health risks. It hosts the Patient Safety Brief Library, a tool for disseminating scientific knowledge developed by a group of experts within the framework of the Patient Safety Strategy 2027 of the Ministry of Health.
  4. Content Article
    Poorly designed electronic health records (EHRs) are common, and research shows poor design consequences include clinician burnout, diagnostic error, and even patient harm. One of the major difficulties of EHR design is the visual display of information, which aims to present information in an easily digestible form for the user. High-risk industries like aviation, automotive, and nuclear have guidelines for visual displays based on human factors principles for optimised design. In this study, Pruitt et al. reviewed the visual display guidelines from three high-risk industries—automotive, aviation, nuclear—for their applicability to EHR design and safety.
  5. Content Article
    All Systems Ergo, invites Human Factors specialists from around the world to share their experience of incorporating Human Factors into their field of work and the impact it has had to support patient outcomes and improve care within healthcare. Hosted by Fran Ives, Chartered Human Factors Specialist, the bi-weekly podcast discusses a number of key human factors topics including transportation, patient safety and product design, as well as personal stories of industry professionals’ inspiring career journeys.
  6. Content Article
    As the NHS is approaching its 75th birthday, this report from the Tony Blair Institute for Global Change proposes how the NHS needs to transform if it is to survive.
  7. Content Article
    Report, together with formal minutes relating to the report.
  8. Content Article
    In this blog, Dr Ahmed Khalafalla looks at the war in Sudan and its disastrous consequences for the health system. He outlines his observations about the impacts of war and conflict on patient safety, from shortages of medical equipment to disruptions to vital primary care services.
  9. News Article
    As the NHS turns 75, it is under unprecedented pressure: record waiting lists, demand for care and delays in discharging patients who are well enough to go home are putting all parts of the health service under immense strain. Sickness absence is at record levels, while nearly 170,000 NHS workers in England quit their jobs last year. Recent strikes by nurses, ambulance staff and junior doctors, coupled with the historic decision by consultants and radiographers to strike, too, show the depth of anger. Five experts spell out what’s needed to make the health service thrive again. Read full story Source: The Guardian, 3 July 2023
  10. Content Article
    Our heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it.
  11. Content Article
    "I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails . . . ’ So begins this pioneering book by Niall Downey – a cardio-thoracic surgeon who retrained to become a commercial airline pilot – where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring.
  12. News Article
    What would the NHS see if it looked in a mirror, asks Siva Anandaciva, author of the King’s Fund’s study comparing the health service with those of 18 other rich countries, in the introduction to his timely and sobering 118-page report. The answer, he says, is “a service that has seen better days”. Britons die sooner from cancer and heart disease than people in many other rich countries, partly because of the NHS’s lack of beds, staff and scanners, a study has found. The UK “underperforms significantly” on tackling its biggest killer diseases, in part because the NHS has been weakened by years of underinvestment, according to the report from the King’s Fund health thinktank. It “performs poorly” as judged by the number of avoidable deaths resulting from disease and injury and also by fatalities that could have been prevented had patients received better or quicker treatment. The comparative study of 19 well-off nations concluded that Britain achieves only “below average” health outcomes because it spends a “below average” amount for every person on healthcare. Read full story Source: The Guardian, 26 June 2023
  13. Content Article
    The King's Fund compared the healthcare systems in different countries by doing three things: Reviewed the research literature and assessed previous attempts to rank and compare health care systems. Interviewed academic experts in international health care policy and experts who had extensive knowledge of the UK, German and Singaporean healthcare systems. Analysed the latest quantitative performance data for the UK health care system and the health systems of 18 higher-income peer countries.  They analysed data in three main domains:  the context the health system operates in (eg, the health status and behaviours of the population)  the resources a health system has (eg, levels of staffing, equipment and health care spending)  how well the health care systems uses its resources and what it achieves as a result (eg, measures of efficiency in delivering services, quality of care, financial protection from the costs of ill health, and health care outcomes). 
  14. News Article
    Litigation costs for specialties including intensive care, oncology and emergency medicine have rocketed by up to five times as much as they were before the pandemic, internal data obtained by HSJ reveals. HSJ's data reveal costs for claims relating to intensive care, oncology, neurology, ambulances, ophthalmology and emergency care have increased – both for damages and legal costs – by significantly more than average. The steepest cost rise was in intensive care, which saw the bill increase fivefold from £4.3m in 2019-20 to £23.7m in 2021-22. Other specialisms which reported higher than average percentage increases were oncology, a 159% increase from £15m to £38.9m, and neurology, a 95% uplift from £18.4m to £36m. Key findings from these reports included missed or delayed diagnosis, missing signs of deterioration, failure to recognise the significance of patients re-attending accident and emergency multiple times with the same problem, and communication issues. Adrian Boyle, president of the Royal College of Emergency Medicine, said: “I’m extremely worried about the amount of money we’re spending on litigation… There’s a good reason we must not normalise an abnormal situation and we need to invest in an emergency care system which avoids these huge costs.” Read full story (paywalled) Source: HSJ, 23 June 2023
  15. Content Article
    Patient Safety Learning has developed a unique set of patient safety standards, resources and tools to help organisations not only establish clearly defined patient safety aims and goals, but also support their delivery and demonstrate achievement. This page provides an overview of our Standards with links to further information.
  16. Event
    until
    As the adoption of artificial intelligence (AI) in health and care continues to progress rapidly, it's essential that clinicians ensure this technology is used for the benefit of patients and to assist us in providing equitable and high-quality care both now and in the future. However, it's also crucial that we are aware of the potential risks and unintended consequences of using AI. This month, the RSM will delve into the development of machine learning (ML) and AI and their applications to healthcare. It will also debate the need for ethical guidelines and regulation in this field. By attending this event, you will understand: What is machine learning and artificial intelligence. How AI is being currently applied to healthcare and the potential future uses. How data drives AI and the potential bias within the data. The way ML and AI can lead to errors and harm. The ethical issues surrounding the use of AI in healthcare. The need for regulations and governance, both in healthcare and the broader society. Register
  17. Content Article
    The UK Covid-19 Inquiry has been set up to examine the UK’s response to and impact of the Covid-19 pandemic, and learn lessons for the future. The Inquiry’s work is guided by its Terms of Reference.
  18. News Article
    The government has downgraded the importance of improving public health in its annual ‘mandate’ to the NHS. ‘The government’s 2023 mandate to NHS England’ is noticeably shorter at 18 pages than the previous document from March 2022. Speaking at the NHS ConfedExpo conference, health secretary Steve Barclay said: “For over a decade, governments have used the mandate to make asks of the system. Sometimes these asks have been excessive, with long documents with many pages full of tests and targets… But what we’ve done this year is make it short and clear… setting out our priorities: Cutting waiting lists; the three recovery plans; tech; and workforce". All the keystone targets for recovering the elective backlog, emergency care waits and cancer care remain in place. However, the latest mandate places significantly less emphasis on public health. For example, one of the five objectives in the 2022 mandate called for the service to “embed a population health management approach within local systems, stepping up action to prevent ill health and tackle health disparities”. It also makes no mention of any vaccination programme. Read full story (paywalled) Source: HSJ, 15 June 2023
  19. News Article
    These are challenging times for hospitals. Covid-19 put unprecedented stress on health systems, as have inflation and global financial uncertainty. In the USA and around the world, leading hospitals are dealing with rising costs, aging populations and a medical workforce exhausted from battling a global pandemic. Among the hallmarks of great hospitals, however, are not just first-class care, first-class research and first-class innovation. The very best institutions also share another quality: consistency. The world's best hospitals consistently attract the best people and provide the best outcomes for patients as well as the most important new therapies and research. Of all the hospitals in the world, relatively few can do all those things year in and year out. To recognise them, Newsweek and global data firm Statista have put together their fifth annual listing of the World's Best Hospitals 2023. This year, they have ranked over 2,300 hospitals in 28 countries, including one that is new to the list, Taiwan. For the first time, they have ranked all top 250 global hospitals. They have listed the best hospitals by country; each country list also includes a listing of top specialty hospitals. Read full story Source: News Week
  20. Content Article
    Analysis, commentary and insight on patient flow from leaders across the healthcare sector. Please note you will need to submit your details to be able to download the report.
  21. Event
    until
    This unique series of online events will provide Healthcare Financial Management Association (HFMA) members with a variety of engaging sessions over three days. The programme will be centred around several key themes: Career development – including resilience training, progression within the NHS, qualifications mapping and developing your personal brand. The bigger picture – technologies of the future, system working, diversity and inclusion. Thought leadership – case studies from across the four nations of the NHS, with real-life examples. At the halfway point of the year, the event will reflect on what’s gone on in the past six months and considering the learnings to take forward and how to make improvements. By the end of the three days, you’ll be well equipped to take on the second half of the year both on a personal, and professional level. Best of all, this event is free to HFMA members. All registered delegates will have access to all the session on demand for 3 month after the event. Speakers will include: Jo Howarth, CEO of The Happiness Club Max Siegel, LGBTQ+ content creator, activist, educator and speaker. Jennifer Holloway, personal brand specialist and author Helen Hughes, CEO Patient Safety Learning. Download programme Register
  22. News Article
    People concerned about the safety of patients often compare health care to aviation. Why, they ask, can’t hospitals learn from medical errors the way airlines learn from plane crashes? That’s the rationale behind calls to create a 'National Patient Safety Board,' an independent federal agency that would be loosely modelled after the US National Transportation Safety Board (NTSB), which is credited with increasing the safety of skies, railways, and highways by investigating why accidents occur and recommending steps to avoid future mishaps. But as worker shortages strain the US healthcare system, heightening concerns about unsafe care, one proposal to create such a board has some patient safety advocates fearing that it wouldn’t provide the transparency and accountability they believe is necessary to drive improvement. One major reason: the power of the hospital industry. The board would need permission from health care organisations to probe safety events and could not identify any healthcare provider or setting in its reports. That differs from the NTSB, which can subpoena both witnesses and evidence, and publish detailed accident reports that list locations and companies. A related measure under review by a presidential advisory council would create such a board by executive order. Its details have not been made public. Learning about safety concerns at specific facilities remains difficult. While transportation crashes are public spectacles that make news, creating demand for public accountability, medical errors often remain confidential, sometimes even ordered into silence by court settlements. Meaningful and timely information for consumers can be challenging to find. However, patient advocates said, unsafe providers should not be shielded from reputational consequences. Read full story Source: CNN, 30 May 2023 Related reading on the hub: Blog - It is time for a National Patient Safety Board: Pittsburgh Regional Health Initiative
  23. Event
    ANNOUNCEMENT: Due to the upcoming junior doctors industrial action, this event was originally 14 July but has been postponed to 10 October. Meeting the NHS' net zero emission targets requires carbon reductions across patient pathways. Achieving this means delivering high quality, evidence based, low carbon care to our patients. Clinicians are a vital part of the innovation, adoption, and embedding of low carbon practices which prioritise high quality patient care. The BMJ and the UK Health Alliance on Climate Change are hosting a new one-day conference which will focus on reducing the carbon impact of services across the health and care system, and the role that every healthcare professional can play in delivering a net zero NHS. Due to popular demand the event will be both an in-person and virtual event. You can attend virtually, via a live feed, or add your name to the waiting list to attend in-person on 14 July at BMA House, London. Register
  24. Content Article
    Webinar with Dr Chris Sirrs, Research Fellow at the Centre for the History of Medicine, University of Warwick, on the histories of patient safety in the NHS.
  25. Content Article
    Multisectoral efforts to influence behaviours around healthy diet and exercise, while essential, have been insufficient to halt the rising prevalence of obesity. While these efforts must continue and escalate, it is now imperative to also deliver a corresponding health system response which ensures that services to prevent, treat and manage the disease are universally available, accessible, affordable, and sustainable. WHO “Health service delivery framework for prevention and management of obesity” offers a way forward.
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