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Found 542 results
  1. Content Article
    Presentation from Dr Helen Highham at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
  2. Content Article
    Published in Systematic Reviews, this paper looks at how organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting.
  3. Content Article
    Effective communication is critical to successful large-scale change. Yet, in our experience, communications strategies are not formally incorporated into quality improvement frameworks. The 1000 Lives Campaign was a large-scale national quality improvement collaborative that aimed to save an additional 1000 lives and prevent 50 000 episodes of harm in Welsh health care over a two year period. This research, published in the Journal of Communication in Healthcare, used the campaign as a case study to describe the development, application, and impact of a communications strategy embedded in a large-scale quality improvement initiative.
  4. 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. 
  5. Content Article
    In this briefing, the Improvement Analytics Unit (a partnership between the Health Foundation and NHS England) identifies some early signals of changes in hospital use by vanguard care home residents in Wakefield, in order to inform local learning and improvement.
  6. Content Article
    This report is a practical guide to developing an organisation-wide approach to improvement. It summarises the benefits of such an approach and outlines the key elements and steps that NHS trust leaders should adopt when pursuing this agenda.
  7. Content Article
    The Radio Ombudsman features full and frank conversations with special guests on a range of topics such as NHS investigations, good complaint handling and improving public services. Hosted by Parliamentary and Health Service Ombudsman Rob Behrens, it generates lively discussion and interesting ideas. The Ombudsman makes final decisions on complaints about government departments, other public organisations and the NHS in England.
  8. 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.
  9. Content Article
    Report of handling of complaints by NHS hospitals in England by Ann Clwyd MP and Professor Tricia Hart.
  10. Content Article
    This independent review looked into the way NHS Wales handled concerns. The review was led by Keith Evans, the former chief executive and managing director of Panasonic UK and Ireland, and supported by Dr Andrew Goodall, Chief Executive, Aneurin Bevan University Health Board. A report was compiled making 109 recommendations.
  11. Content Article
    Healthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper published in BMJ Quality & Safety, Amalberti and Vincent discuss the strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.
  12. Content Article
    Maintaining momentum highlights failings in specialist mental health services in England, and the devastating toll this takes on patients and their families.  The report's findings provide fresh impetus to deliver on the recommendations set out in the NHS Five Year Forward View for Mental Health.
  13. Content Article
    In this interview with Nick Robinson from the BBC, Jeremy Hunt (then Foreign Secretary) speaks passionately about patient safety and the statistics surrounding avoidable patient deaths. Listen from 9:30 for this section. They veer away from the topic but return to it at 12:20 where he speaks about the importance of learning from mistakes in healthcare.
  14. Content Article
    As improvement practice and research begin to come of age, Mary Dixon-Woods in this BMJ feature considers the key areas that need attention if we are to reap their benefits. Mary Dixon-Woods is the Health Foundation Professor of Healthcare Improvement Studies and Director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety, she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians.
  15. Content Article
    ‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.
  16. Content Article
    This case story is based on real events and NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. Although the case occurred in the emergency department there is learning for other departments. As you read about this incident, please ask yourself: Could this happen in my organisation? Who could I share this with? What can we learn from this?
  17. Content Article
    The World Health Organization (WHO) began when the Constitution came into force on 7 April 1948 – a date that is now celebrated every year as World Health Day. The WHO are now more than 7000 people from more than 150 countries working in 150 country offices, in six regional offices and at headquarters in Geneva.
  18. Content Article
    Healthcare provision in the NHS is very safe but, on rare occasions when things go wrong, it is important that those involved are properly informed and supported, compensation is paid fairly, unnecessary costs are contained and that we learn in order to improve.
  19. Content Article
    NHS Improvement supports foundation trusts and NHS trusts to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. From 1 April 2019, NHS England and NHS Improvement came together to act as a single organisation.
  20. Content Article
    The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care.
  21. Content Article
    The Healthcare Safety Investigation Branch (HSIB) became operational on 1 April 2017. Their purpose is to improve safety through effective and independent investigations that don't apportion blame or liability. Although funded by the Department of Health & Social Care and hosted by NHS England and NHS Improvement, HSIB operates independently. It is also independent from regulatory bodies like the Care Quality Commission (CQC). By offering a new perspective and developing meaningful and influential recommendations, they aim to drive positive change at a wider level.
  22. Content Article
    The Canadian Incident Analysis Framework is a resource to support those responsible for, or involved in, managing, analysing and/or learning from patient safety incidents in any healthcare setting. The aim is to increase the effectiveness of analysis in enhancing the safety and quality of patient care.
  23. Content Article
    A guide supporting clinical, patient experience and quality teams to draw on patient experience data to improve quality in healthcare.
  24. Content Article
    This report by The Point of Care Foundation, looks at staff engagement in three NHS hospital trusts and provides insights into the views of staff and managers.
  25. Content Article
    Serious Incidents in healthcare are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. This procedure describes the circumstances in which such a response may be required and the process and procedures for achieving it This policy provides managers with the process and procedures into the management and investigation of a Serious Incident, including guidance, templates and information.
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