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Found 224 results
  1. Content Article
    The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of healthcare.
  2. Content Article
    Key points: Building an organisation-wide approach to improvement is a journey that can take several years. It requires corporate investment in infrastructure, staff capability and culture over the long-term. An essential early step is securing the support and commitment of the board for a long-term programme, including their willingness to finance the skills and infrastructure development needed to implement it. The report includes case studies of three English NHS trusts with an outstanding CQC rating that have implemented an organisational approach to improvement.
  3. Content Article
    NICE's role is to improve outcomes for people using the NHS and other public health and social care services. They do this by: Producing evidence-based guidance and advice for health, public health and social care practitioners. Developing quality standards and performance metrics for those providing and commissioning health, public health and social care services. Providing a range of information services for commissioners, practitioners and managers across the spectrum of health and social care. This website will link into all NICE Guidelines.
  4. Content Article
    Practical guidance on the application of human factors in the investigation process is presented. Nine principles for incorporating human factors into learning investigations are identified: 1. Be prepared to accept a broad range of types and standards of evidence. 2. Seek opportunities for learning beyond actual loss events. 3. Avoid searching for blame. 4. Adopt a systems approach. 5. Identify and understand both the situational and contextual factors associated with the event. 6. Recognise the potential for difference between the way work is imagined and t
  5. Content Article
    Healthcare safety is complex every day – yet the emergence of the novel coronavirus has made holes in the Swiss cheese of the system more apparent. UK psychologist James Reason’s now famous “Swiss Cheese Model” serves as a metaphor for this month’s Letter from America. As more details on the coronavirus emerge, and time enables reflection on what has transpired, deeper analyses will no doubt materialise. Knowledge is developing in real time, helping us see gaps in our safety barriers and providing valuable insight to the challenge of reducing harm. The Swiss Cheese model illustrates how l
  6. Content Article
    I am an avid fan of the show, Silent Witness; pathologists trying to find out how someone was killed just from the body. The deceased is the only witness to what actually happened. So, by looking at the surroundings is the only way of determining what might have happened. I also love watching 24 Hours in Police Custody. This is where they interview the person directly involved in the incident, the people around the time of the incident and the person who potentially did the crime: questioning, piecing together exactly what happened using statements, CCTV footage, verbal accounts of everyo
  7. Content Article
    Watch Professor John Radford's interview with Sky News, explaining the importance of research at The Christie:
  8. Community Post
    It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are
  9. Community Post
    Stephen Moss, Patient Safety Learning Trustee, suggests four practical tips to help staff keep patients safe: With your colleagues ask a random selection of patients if they have felt unsafe in the last 24 hours (you might want to select a different form of words). If the answer is yes, get under the skin of why they have felt unsafe, pool the knowledge and agree what action you are going to take, or what might need escalating to your line manager. Have a discussion with your colleagues about how you can support each other to uphold your values and professionalism when the going ge
  10. Content Article
    Allow me to start this essay with a real personal story: more than a decade ago, while I was doing my Transplant & Hepato-Biliary Surgery fellowship in the USA, I had to have elective orthopaedic surgery. The good news was the hospital where I was about to have the surgery was the number one in the US News Ranking for Orthopedics that year. The bad news was that I was literally ‘terrified’ while I was in the pre-op holding area, just before I was wheeled into the operating room! How could that be? Me: the surgeon, terrified of having a straightforward orthopaedic procedure in the numb
  11. Content Article
    In this study from Timmel et al., CUSP was implemented beginning in February 2008 on an 18-bed surgical floor at an academic medical center to improve patient safety, nurse/physician collaboration, and safety on the unit. This unit admits three to six patients per day from up to eight clinical services. Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on a surgical inpatient unit after implementing a safety programme. As part of the CUSP process, staff described safety hazards and then as a team designed and implemented several interventions. C
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