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Found 183 results
  1. News Article
    Ministers have been accused of trying to cover up the findings from investigations into hundreds of health and social care worker deaths linked to coronavirus after it emerged the results will not be made public. The Independent revealed on Tuesday that medical examiners across England and Wales have been asked by ministers to investigate more than 620 deaths of frontline staff that occurred during the pandemic. The senior doctors will review the circumstances and medical cause of death in each case and attempt to determine whether the worker may have caught the virus during the course of their duties. But now the Department of Health and Social Care (DHSC) said the results will be kept secret with the aim of helping local hospitals to learn and improve protection for staff. Separately, trade unions and NHS Providers, which represents hospital trusts, have urged the government to ensure full investigations into every death and to be transparent about findings to reassure health and social care staff ahead of any second wave. Sir Ed Davey, acting leader of the Liberal Democrats, said: “We currently have one of the highest number of deaths of health and care workers in Europe. The government has utterly failed to protect staff in both hospitals and care homes. The fact that now they are trying to cover up how and why each tragic death occurs is a disgrace." Read full story Source: The Independent, 15 August 2020
  2. News Article
    MPs are to launch a new system for evaluating whether key health targets are being met in England. A panel of experts reporting to the Commons health committee will assess progress made on policy commitments, starting with maternity services. They will rate performance from "outstanding" to "inadequate" and seek to drive improvements where needed. Panel chair Dame Jane Dacre said it would be "fair and impartial" in its findings. She said she was keen to ask recent patients and users of NHS services to contribute to the panel's work as well as specialists in chosen fields, all of whom would have no political affiliation. "It will be challenging, but I am committed to using available evidence to evaluate pledges, with the aim of improving patient care," she added. The panel will scrutinise, on behalf of the health committee, major commitments made by the Department of Health, NHS England, NHS Improvement and other public bodies. It will base its approach on the Care Quality Commission, which evaluates care homes, hospitals, GP practices and other health services. Read full story Source: BBC News, 5 August 2020
  3. News Article
    The list is a dismal and shameful one - Mid-Staffordshire, Morecambe Bay, the rogue surgeon Ian Paterson, maternity care at the Shrewsbury and Telford. All are patient safety scandals involving tragic stories of life-changing mistreatment of patients and, in some cases, the loss of loved ones. Pledges have been made that patient safety will be put front and centre of health policy. New regulators have been put in place. But now yet another review has found the health system in England to be "disjointed, siloised and defensive" and that the culture needs a shake-up. It has called for a new patient safety champion with legal powers to be put in place. The plan is to have an individual with "real standing" outside and independent of the system, accountable to the parliamentary Health and Social Care Select Committee. The Commissioner would be expected to take up and investigate patient complaints where appropriate, and hold organisations to account - the review had stated that the failure of health authorities to respond to concerns was a recurrent theme. Read full story Source: BBC News, 8 July 2020
  4. News Article
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
  5. News Article
    In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived." “Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections. Read full story Source: AvMA, 28 January 2020
  6. Content Article
    Patient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert. Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’. The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement. The key elements from the review are highlighted. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
  7. Content Article
    In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report. This article contains a summary of the report, which can be read in full here.
  8. Content Article
    Between 2006 and 2009, WHO elaborated and issued the concept of ‘My Five Moments for Hand Hygiene’ in healthcare in collaboration with the pioneering infection prevention and control (IPC) research group at the University of Geneva. The primary objective of this approach is to facilitate behavioural change and prioritise hand hygiene action at the exact times needed to prevent the transmission of pathogens and avoid harm to patients and health workers during care delivery. Importantly, the Five Moments approach overcomes some relevant barriers to hand hygiene practices identified before its launch, such as long lists for hand hygiene action without any consideration of the dynamics of patient, health worker and environmental interactions The Five Moments approach is being constantly tailored to meet the challenges of care locations outside the traditional hospital setting, as well as across all countries and resource levels. The main thrust of the approach remains targeted at patient and health worker safety at the point of care where the risk of acquiring infection can be at its highest. Further work to help meet the Five Moments objectives through its adaptation and adoption worldwide is to be welcomed. WHO committed to further action and research on lessons learnt from field implementation, as well as the active dissemination of available tools to support countries to further understand and accept this proven approach.
  9. Content Article
    This webpage provides links to all recent NHS England national Patient Safety Alerts and sets out the criteria for issuing a Patient Safety Alert.
  10. Content Article
    In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, highlights a recent discussion at a meeting of the Patient Safety Management Network about how After Action Reviews (AARs) can help promote learning and patient safety improvement.
  11. Content Article
    This report provides an overview of the work of Healthcare Inspectorate Wales (the independent inspectorate and regulator of healthcare in Wales) during 2020-21. It discusses National Reviews undertaken in this period and trends emerging from its quality checks of health services. It also highlights areas of innovation, new methods of public and staff engagement and the delivery of care in new settings as a result of the COVID-19 pandemic.
  12. Content Article
    This guide by the University Hospitals Bristol clinical audit team provides a brief summary of what clinical audit is, and what it isn't. It outlines the main stages of clinical audit and describes how it can be used, how to engage patients in the process and which staff members should be involved.
  13. Content Article
    Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and head of patient safety insight at NHS Improvement.  
  14. Content Article
    NICE guidance on the management of chronic pain no longer recommends the initiation of many medications (e.g. NSAID’s, gabapentinoids etc) for primary chronic pain. However, there are many patients in the community who are already using these medications and it is important that when implementing this guideline, the recommendations are not used out of context.  This joint statement aims to provide information that will help doctors and patients when reviewing medications.
  15. Content Article
    Read how Mersey Care NHS Foundation Trust has adopted and embedded its just and learning culture and its training package.  The trust estimates that the just and learning culture has provided economic benefits of roughly £2.5million since 2016. A just and learning culture is one focused on fairness and learning, and absent of blame when things go wrong. It aims to encourage staff to feel able to speak up.  
  16. Content Article
    In this article for NHSManagers.Net, Peter Carter, former General Secretary and chief executive of the Royal College of Nursing, questions why the First Do No Harm report didn't attract the publicity it warranted and urges the Government to address the issues raised in it as a matter of some urgency.
  17. Content Article
    Better Births set out a compelling view of what maternity services should look like in the future. The vision is clear: we should work together across organisational boundaries in larger place-based systems to provide a service that is kind, professional and safe, offering women informed choice and a better experience by personalising their care. Whilst Better Births described the vision, this resource pack sets out in detail what needs to be done and how it can be accomplished across the whole of England. It is designed to provide tools to help Local Maternity Systems turn the vision into reality and the practical advice needed to plan, commission and operate maternity services in their localities.  
  18. Content Article
    This is a study evaluating the implementation of a patient safety programme across a paediatric department at the largest public hospital in Guatemala. In their conclusion, the authors note that implementing such programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives.
  19. Content Article
    Safety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
  20. Content Article
    Poster from the Princess Alexandra Hospital on their Learning from deaths project.
  21. Content Article
    In this opinion piece for the BMJ, David Oliver, a consultant in geriatrics and acute general medicine, draws lessons from the Grenfell Tower disaster and subsequent public inquiry. 72 people lost their lives in the fire that destroyed Grenfell Tower in 2017. Evidence to the public inquiry has shown that several residents had raised concerns about the building's safety over many years, and that architects, building contractors, and providers and fitters of cladding material had also expressed concerns about the safety of the exterior cladding used on Grenfell Tower. David Oliver highlights that had these concerns been listened to and acted on, the disaster could have been avoided and many lives saved. He draws parallels with concerns being raised by patients about the safety of the healthcare system and highlights the role of staff in repeatedly raising and keeping a record of concerns. He states that NHS leaders must create a culture where no one is afraid to speak out and act to mitigate safety issues. Leaders must expect to be held accountable for their response - or lack of response - to safety issues raised.
  22. Event
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    The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Compassionate engagement and involvement of those affected by patient safety incidents is central to the PSIRF approach. This webinar will provide guidance, practical insight and ideas on how to implement PSIRF principles within the independent provider sector (where contracted under the NHS standard contract). Audience: PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. This webinar will specifically be useful for those working in/ with the independent provider sector. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England Patient safety leads, Integrated Care Boards (TBC). Register
  23. Event
    until
    Digital technologies have transformed how health and care services are offered and used, and the better and more widespread use of these technologies bring further opportunities to improve people’s health and experiences of services. Through the lens of both the workforce and people who draw on health and care services, this event will explore how to successfully adopt digital solutions in health and care and the practical realities of implementation. At this event, you’ll have the opportunity to discuss different digital technologies, and hear how they can be used innovatively to improve service design and delivery and user experience, as well as help tackle the current pressures facing the NHS and the wider system. Join experts from The King’s Fund and across the health and care system to share best practice and consider how we can ensure the system has the skills, leadership and culture to harness digital transformation. Register
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