It is recommended that the Royal College of Ophthalmologists, working with relevant stakeholders, develop models and review workforce required for the optimal delivery of glaucoma care. The models should be tested and evaluated.
It is recommended that NHS England/Improvement require commissioners to agree, under their service contracts, the action that providers will take to ensure compliance with the Portfolio of Indicators for Eye Health and Care follow-up performance standard. Where the standard has not been met, there should be a requirement for providers to
This document is accompanied by:
general advice and advice for hospital inpatients
supporting information for healthcare staff including background and findings
posters in English and Welsh
Health and Safety Laboratory report FS/06/12 ‘Fire hazards associated with contamination of dressings and clothing by paraffin based ointments’
examples of products containing paraffin
warning / hazard stickers for products
a patient safety video
leaflets in English and Welsh.
Although the deadline for actions has passed, this guidance remains best practic
The full report provides several tools to assist with implementation of the recommendations, including a checklist of safe practices for improving drug allergy CDS and an educational PowerPoint file describing the workgroup’s findings and recommendations, which can be used to garner support for the organisation’s effort.
The transport of the ICU patient is a complicated process and can lead to patient harm. In the Department of Critical Care Medicine, Calgary Health Region, staff underestimated the risks of intrahospital transport, which led to the two adverse events mentioned above. This article published in Healthcare Quarterly has describes the development of an ICU patient transport decision scorecard to support the safe transport of ICU patients for diagnostic testing.
The scorecard is a visual assessment tool. Each item on it is a decision point and a simple reminder to ensure that appropriate resou
This guidance for medical doctors explains how to apply the principles of good medical practice. It is separated into two parts:
Part 1: Raising a concern - gives advice on raising a concern that patients might be at risk of serious harm, and on the help and support available to you.
Part 2: Acting on a concern - explains your responsibilities when colleagues or others raise concerns with you and how those concerns should be handled.
Key learning points
Richard Thomson: Evidence based patient involvement in improving patient safety
Understanding the key drivers and barriers for involving patients in improving patient safety.
Identifying the key elements of an implementation plan for patient involvement.
Erica van der Schriek-de Loos: Patients as consultants in care processes: improving safety or not?
Optimising patient safety is only possible when patients are engaged as consultants of their own healthcare processes. Implementation of initiatives needs to be based on the relationship between pati
The authors examine how patient harm can be minimised effectively and efficiently. This is informed by a snapshot survey of a panel of eminent academic and policy experts in patient safety. System-level and organisational-level initiatives were seen as vital to provide a foundation for the more local interventions targeting specific types of harm. The overarching requirement was a culture conducive to safety.
Our recent observational study, published in the Health Informatics Journal, focussed on staff safety in the mental healthcare setting. We worked with a mental healthcare provider to extract and analyse incidents of adverse events.
In one aspect of the work, we looked specifically at the incidents that were reported that had recorded a member of staff as a ‘victim’ of the adverse event. From the 1 September 2014 to the 31 March 2017, 19,693 members of staff were reported as victims across 10,119 adverse events. For context, this was the equivalent of around 25 incidents per week, but it i
Reduce incidence of falls and harm.
Embed falls prevention into everyday practice.
Engage clinical staff to identify patients at risk and implement harm prevention strategies.
Process for target wards:
Present data for the past 12 months for falls by severity, as baseline metric.
Present serious falls and actions undertaken.
Falls Risk Assessment audit as baseline metric.
Falls Link Worker ensures a display board is refreshed with falls prevention displays and audit result.
Ward team set own targets for improvement weekly.