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Found 262 results
  1. Content Article
    The Care Quality Commission (CQC) has published the second report of Professor Glynis Murphy’s independent review of its regulation of Whorlton Hall between 2015 and 2019. CQC commissioned Professor Murphy to conduct an independent review to look at whether the abuse of patients at Whorlton Hall could have been recognised earlier by the regulatory process and to make recommendations for how CQC can improve its regulation of similar services in the future. In addition, CQC asked Professor Murphy to conduct a review of international research evidence to look at how abuse is detected within services for adults with a learning disability and autistic people and how such detection can be improved. The first report of Professor Murphy’s review made a number of recommendations for CQC to strengthen its inspection and regulatory approach for mental health, learning disability and/or autism services. This second report outlines the progress that CQC has made to implement the recommendations. This includes publication of the final report of its review of restraint, seclusion and segregation; work on closed cultures and the development of a tool for rating support plans.
  2. Content Article
    Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish. Clinical governance encompasses quality assurance, quality improvement and risk and incident management. These guidelines cover responsibilities, programme standards and performance monitoring, quality assurance, quality improvement, and risk and incident management.
  3. Content Article
    Patients, clinicians and managers all want to be reassured that their healthcare organisation is safe. But there is no consensus about what we mean when we ask whether a healthcare organisation is safe or how this is achieved. In the UK, the measurement of harm, so important in the evolution of patient safety, has been neglected in favour of incident reporting. The use of softer intelligence for monitoring and anticipation of problems receives little mention in official policy. This paper from Vincent et al. proposes a framework which can guide clinical teams and healthcare organisations in the measurement and monitoring of safety and in reviewing progress against safety objectives. The framework has been used so far to promote self-reflection at both board and clinical team level, to stimulate an organisational check or analysis in the gaps of information and to promote discussion of ‘what could we do differently’.
  4. Content Article
    In her latest Letter from America, Lorri Zipperer explores the lack of coordination that is undermining the current US response to the COVID-19 crisis and preparation for the next phase. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments and patient safety challenges in the United States.
  5. Content Article
    The highly publicised crashes of two Boeing 737 Max aircraft quickly triggered pointed questions about the company’s commitment to safety versus profits. As we near the twentieth anniversary of the landmark Institute of Medicine (IOM) report on medical error, To Err is Human, that same level of scrutiny should apply to hospitals.  Cost-benefit analysis is both a legitimate and crucial management function. But the criteria used in those calculations can range from appropriate to appalling. It’s long past time to examine how the “business case for safety” can sometimes represent a serious threat to patients’ lives. Michael L. Millenson discusses the dangers in the "business case" for patient safety in his blog in Health Affairs.
  6. Content Article
    Connection, inclusion and compassion are certain, unchanging, and provide a safe refuge to deal with what feels frightening and isolating for so many. The challenge set by the Francis Inquiry Report – to create a compassionate, inclusive organisational culture – is now amplified in the COVID-19 era, which the NHS entered with pre-existing record levels of staff stress and chronic excessive workloads. This workshop from the University of Manchester, explores the problems and opportunities associated with changing healthcare organisation cultures.
  7. Content Article
    The Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.
  8. Content Article
    This study, published in BMJ Open, aimed to review the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care.
  9. Content Article
    Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. We tend to regard excellence as something to gratefully accept, rather than something to study and understand. Our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation.
  10. Content Article
    In this study published in the Quality Management in Healthcare journal, a community health organisation’s successful method of frontline staff committee engagement  generated process changes that culminated in reduced medication errors and increased near misses. Continuous quality improvement initiatives supported by these committees included technical handling and administration of medication, medication reconciliation, and enhancements to standardised treatment protocols.
  11. Content Article
    When you are ready to implement measures to improve patient safety, this is the book to consult. Charles Vincent, one of the world's pioneers in patient safety, discusses each and every aspect clearly and compellingly. He reviews the evidence of risks and harms to patients, and he provides practical guidance on implementing safer practices in healthcare. The second edition puts greater emphasis on this practical side. Examples of team based initiatives show how patient safety can be improved by changing practices, both cultural and technological, throughout whole organisations. Not only does this benefit patients, it also impacts positively on healthcare delivery, with consequent savings in the economy. Patient Safety has been praised as a gateway to understanding the subject. This second edition is more than that it is a revelation of the pervading influence of healthcare errors and a guide to how these can be overcome.
  12. Content Article
    Sally Howard, topic leader for the hub, shares her insight on the imminent NHS Improvement Framework after she attended a webinar with National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey.
  13. Content Article
    A US based study to determine whether medical errors, family experience and communication processes improved after implementation of an intervention to standardise the structure of healthcare provider-family communication on family centered rounds.
  14. Content Article
    It is now accepted that healthy cultures in NHS organisations are crucial to ensuring the delivery of high-quality patient care. The Kings Fund developed a tool to help organisations assess their culture, identifying the ways in which it is working well, as well as the areas that need to change.
  15. Content Article
    Spreading successful improvement work across the NHS is an essential part of improving health care quality and efficiency. Yet all too often an idea that has been shown to work well in one place is not adopted by others who could benefit from it. This guide from the Health Foundation, intended for those actively engaged in health care improvement, draws on this experience and empirical evidence, to provide practical information about how communications approaches can be used to spread improvement ideas. 
  16. Content Article
    A Quality Account is a report about the quality of services offered by an NHS healthcare provider.The reports are published annually by each provider, including the independent sector, and are available to the public. Quality Accounts are an important way for local NHS services to report on quality and show improvements in the services they deliver to local communities and stakeholders. The quality of the services is measured by looking at patient safety, the effectiveness of treatments patients receive, and patient feedback about the care provided.
  17. Content Article
    Winter 2017/18 saw an unprecedented demand for health and care support services. Emergency departments bore the brunt of this demand. This report from the Care Quality Commission (CQC) calls for wider action for health and social care services to work together. A joint approach will help the whole health and care system to manage capacity as demand grows. The same approach can encourage early and effective planning - for all periods of peak demand.
  18. Content Article
    This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts.
  19. Content Article
    What links the Mercedes Formula One team with Google? What links Team Sky and the aviation industry? What connects James Dyson and David Beckham? According to this book, they are all Black Box Thinkers. Written by Matthew Syed, Black Box Thinking is a new approach to high performance, a means of finding an edge in a complex and fast-changing world. 
  20. Content Article
    This guide aims to support NHS organisations to apply a framework for measuring and monitoring safety. It describes some broad principles to bear in mind when using the framework and provides some prompts for each of the framework’s dimensions to help people focus on some of the main challenges to understanding safety. The guide also provides a brief summary of the research underpinning the framework and details of further resources available to find out more.
  21. Content Article
    The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded. 
  22. Content Article
    "Looking back down the path of another person’s journey is not the same thing as making the trip yourself." What a great quote! It is so true. Henriksen and Kaplan discuss hindsight bias, outcome knowledge and adaptive learning in this paper published in BMJ Quality & Safety in 2003.
  23. Content Article
    This guidance by NHS Resolution, aims to provide advice for commissioners seeking to ensure that providers with which they are proposing to contract have in place adequate indemnity arrangements. Commissioners need to understand and take account of the differences in cover for clinical negligence risks purchased by healthcare organisations. Commissioners have an important role to play in ensuring that providers possess adequate indemnity. Crucially, they need to understand that in certain circumstances they will have to take over directly the liabilities of providers.
  24. Content Article
    The US Agency for Healthcare Research (AHRQ): invests in research on the US's health delivery system that goes beyond the "what" of healthcare to understand "how" to make healthcare safer and improve quality creates materials to teach and train health care systems and professionals to put the results of research into practice generates measures and data used by providers and policymakers.
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