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Found 224 results
  1. Content Article
    Often, there are many perspectives that we need to consider before we have a complete picture. 'The Blind Men and the Elephant', and earlier versions of this parable, show us the limits of perception and the importance of complete context. This also applies when we are facing a difficult or complex issue in relation to patient safety. As part of the Patient First programme at Brighton and Sussex University Hospitals NHS Trust, we used A3 problem solving. Many others do too. It’s a structured problem-solving tool, first employed at Toyota and typically used by 'lean' manufacturing p
  2. Content Article
    Here you can find patient safety resources including: Mortality reports Quality reports National Patient Safety Strategy Blogs.
  3. Content Article
    Five opportunities for learning: Serious incidents that require full investigation should be prioritised and alternative methods for managing and learning from other types of incident should be developed. Patients and families should be routinely involved in investigations. Staff involved in the incident and investigation process should be engaged and supported. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident. Using human factors principles to develop solutions that
  4. Content Article
    This guidance is to help NHS ambulance trusts in England to improve the way they review and learn from the deaths of patients who had been under their care. It builds on the work ambulance trusts already do on learning from incidents and on mortality reviews. It also sets out a standardised framework for ambulance trusts to use to develop and implement their local Learning from Deaths policies.
  5. Content Article
    The report documents concerns about the lack of a properly independent investigation system, unlike deaths in prison and police custody which are independently investigated pre-inquest, and the consistent failure by most NHS Trusts to ensure the meaningful involvement of families in investigations. Ultimately, it highlights the lack of effective public scrutiny of deaths in mental health detention that frustrates the ability of NHS organisations to learn and make fundamental changes to policy and practice to protect mental health in-patients and prevent further fatalities and argues for u
  6. Content Article
    The report argues for a fundamental rethink about the use of prison and calls for a political boldness to implement evidence-based change. The vulnerabilities of young prisoners have been well documented by countless research, investigations and inquest findings, yet they continue to be sent to unsafe environments, with scarce resources and staff untrained to deal with their needs. Based on INQUEST's specialist casework with the families of the prisoners who died, the report found that: 83% were classified as “self-inflicted”. The highest number of deaths occurred in HMYOI Glen
  7. News Article
    Health chiefs are designing an “early warning” system to detect and prevent future maternity care scandals before they happen, a health minister has said. Patient safety minister Nadine Dorries said she hoped the system would highlight hospitals and maternity units where mistakes were being made earlier. The former nurse also revealed the Department of Health and Social Care was drawing up a plan for a joint national curriculum for both midwives and obstetricians to make sure they had the skills to look after women safely. During a Parliamentary debate following the publication
  8. Content Article
    The toolkit explores the three phases of how we normally respond to a crisis; Emergency – at the beginning of a crisis there is high energy. A sense of urgency and a common goal brings teams together and things get done. Regression – our sense of purpose becomes less clear, energy levels drop, people get frustrated and are less productive. Recovery – new goals emerge, and we begin to focus on rebuilding rather than simply surviving. An end, or at least a new sense of normality, is in sight. The aim of this framework is to help people begin to think about how they might mo
  9. Content Article
    The National Action Plan centres on four foundational and interdependent areas, prioritised as essential to create total systems safety, with 17 recommendations to advance patient safety. Culture, Leadership, and Governance 1. Ensure safety is a demonstrated core value. 2. Assess capabilities and commit resources to advance safety. 3. Widely share information about safety to promote transparency. 4. Implement competency-based governance and leadership. Patient and family engagement 5. Establish competencies for all healthcare professionals for the engagement
  10. Content Article
    Immediate and essential actions 1) Enhanced safety Essential action - Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks. Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents (SIs) have regional and Local Maternity System (LMS) oversight. 2) Listening to women and families Essential action - Maternity services must ensure that women and their families are listened to with their voices heard. 3) Staff training and working together Essent
  11. Content Article
    Questions healthcare leaders should consider as they work to innovate, design, and implement action toward improvement: How are you resourcing your organization to learn from failure? How do you ensure learning happens and is applied widely from the board room to the frontline? How are you partnering within your organisation and the broader healthcare community to empower in-house leaders to achieve improvements? How are you engaging decision-makers to commit to sustained improvement? How do you demonstrate your responsibility and accountability to engage with fro
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