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Showing results for tags 'Patient safety strategy'.
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Content ArticleQuality improvement initiatives take many forms, from the creation of standards for health professionals, health technologies and health facilities, to audit and feedback, and from fostering a patient safety culture to public reporting and paying for quality. For policymakers who struggle to decide which initiatives to prioritise for investment, understanding the potential of different quality strategies in their unique settings is key. This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarises available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.
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Content ArticleErrors associated with healthcare and their effects are prevented and mitigated through patient safety interventions. There is wider evidence that substantial public health harm is caused due to poor patient safety in both developed and developing nations. In the past, research in patient safety has largely been associated with developed nations. However, there has been a shift of focus to developing countries in recent years due to the global awareness of the need to enhance patient safety standards for all patients. This article, published in the Journal of The Royal Society of Medicine, aims to discuss the contextual factors associated with patient safety through focusing on developing a systems approach to enhance the quality and safety of care in developing countries.
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2020: The conversation changed but our goals did not
HelenH posted an article in Patient Safety Learning
2020 has been a strange year, and a very difficult one for many around the world. Along with organisations everywhere, we at Patient Safety Learning have had to adapt how we work due to the COVID-19 pandemic. Though our working environments and areas of focus have changed, our goals as a charity have not. We continue to be an independent voice, committed to working in partnership to improve patient safety. -
Content ArticleIt was little noticed but the Chancellor in his Spending review on 25 November announced revisions to the Green Book, the Treasury rules for evaluating the costs and benefits of public investments. In this article, Roger Steer takes a look at this re-write of the Treasury rules. The Treasury highlight a string of the common failings in business cases, which those that examine NHS business cases will long recognise. However, this is yet another example of where patient safety doesn't appear in business cases...
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NICE Patient Safety Update (November 2020)
Patient Safety Learning posted an article in NICE
This report provides an update on patient safety matters at the National Institute for Health and Care Excellence (NICE) for the period of September 2019 to September 2020. The board paper proposes NICE develops a unified approach to patient safety, integrating the work already occurring in different parts of the organisation. It will build on existing structures and draw on the expertise of the Science, Evidence and Analytics Directorate to consider how new technology such as artificial intelligence could help detect patient safety signals more quickly in the future. The work will also explore how patient safety at NICE can evolve and integrate with NICE Connect, their multiyear project which will transform the way they produce and present their guidance and the lives of people receiving care. -
Community Post
Ward-patient eQMS with error recovery protocols saves many thousands of lives globally
Derek Malyon posted a topic in Improving patient safety
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Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf- Posted
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Content ArticlePatient safety is one of the five priorities of the G20 Health Ministers' Declaration. Read the patient safety section of the Declaration below.
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Content ArticleFalls in Pennsylvania continue to be one of the biggest contributors to patient harm and the fourth most frequently reported adverse event. Looking more broadly, falls are also a frequent cause of patient harm across the United States and globally. Allen and Wallace conducted a review of the literature to identify international strategies and novel approaches to reduce falls and falls from injury, mainly in healthcare facilities, published in the last decade. The review revealed that while no single country has been able to eradicate patient falls, several had implemented measures showing moderate levels of success. Those struggling with a high incidence of falls may benefit from reviewing and adopting one or more of these innovative techniques.
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Content ArticleThe collapse of healthcare services round the world, the behaviour of some of the “agencies” enforcing quarantining, and high levels of patient harm during the COVID-19 pandemic, undoubtedly warrant a strong response. We need a new agenda for change if we are to address the current threat to patient centred healthcare and patient safety globally. Kawaldip Sehmi, CEO International Alliance of Patient Organizations, summarises the key messages and actions from the 9th biennial Global Patients Congress 2020,
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Content ArticleRecording for the Session on Patient Safety held on 31 October as a part of the Global Indian Physician COVID-19 Collaborative.
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Content ArticleThe purpose of the US Joint Commission's National Patient Safety Goals is to improve patient safety. The goals focus on problems in healthcare safety in the USA and how to solve them. They include identifying patients correctly, improving staff communication, use medicine safely, use alarms safely, prevent infection, identify patient safety risks and prevent mistakes in surgery.
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Content ArticleMany risks faced by patients in acute mental health settings are similar to those that occur in other areas of healthcare, for example medication errors and cross-infection. In addition, however, there are unsafe behaviours associated with serious mental health problems, including violence and self-harm; the measures taken to address these, such as restraint or seclusion, may result in further risks to patient safety. This article by Catherine Gilliver in the Nursing Times discusses the need for a physical and psychosocial environment in which staff, patients and visitors feel recognised and valued.
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Content ArticleThe Patient Safety Authority is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires healthcare facilities to report all incidents of harm (serious events) or potential harm (incidents).
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Content ArticleIn this podcast from The Health Foundation, Chief Executive Dr Jennifer Dixon talks to Jeremy Hunt about his tenure as the longest-serving health secretary. Jeremy speaks about his passion for patient safety, a topic which became his professional focus following the Mid-Staffs investigations. He highlights the importance of the patient safety agenda and the need to learn from past experiences. With the challenges of the COVID-19 pandemic holding the world’s attention, what would Hunt have done differently? And what are the key lessons for government as we enter a new phase of the pandemic?
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News ArticleThe first wave of COVID-19 may gave subsided in some areas of the United States, but in others it is growing and hospitals everywhere are continuing to face significant challenges. The American Hospital Association recently estimated that hospitals will incur at least $323.1 billion in losses through the end of this year due to COVID-19. Key contributors include postponed and cancelled elective procedures, lower patient volumes across all departments, and higher costs for supplies and devices. Other factors compound the financial challenges, including pressure for hospitals to implement new initiatives that foster a safer care environment for COVID-19 patients, non-COVID-19 patients, and healthcare providers. This pressure is mounting, as spikes in cases continue to appear in various regions, and as concerns grow about the flu season. The good news is that improving patient, staff, and visitor safety can actually help hospitals recover from the financial losses they are experiencing due to the pandemic. For example, enhanced patient safety leads to: Fewer costly events, such as hospital-acquired infections or conditions, acute kidney injuries, adverse drug events, readmissions, and return visits to the emergency department. Faster and more proactive identification of cost-saving opportunities, such as IV to PO conversions and more optimal management of high-cost drugs. Higher patient volumes due to a stronger quality and safety reputation. Hospitals face significant financial challenges, but they must also act quickly to ensure patient, staff, and visitor safety. Luckily, improving margins and enhancing patient safety don’t need to be competing priorities. When hospitals implement effective safety improvement approaches, margin improvements naturally follow. Read full story Source: MedCity News, 25 October 2020
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Content ArticleOn 17 November, there will be a Parliamentary launch event of the Surgical Fires Expert Working Group’s report 'A case for the prevention and management of surgical fires in the UK, which focuses on the prevention of surgical fires in the NHS'. Unfortunately surgical fires are still a patient safety issue. Each year patients needlessly suffer burns during surgical procedures which leave them with long-lasting, life-changing injuries and burdens the NHS with millions of pounds of avoidable costs and liabilities. Despite this, there is not a consistent, standardised approach across the NHS to prevent them. Kathy Nabbie, a theatre scrub nurse practitioner, shares how she implemented Fire Risk Assessment Score (FRAS) into her department.
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Content ArticleIn this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production.
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Content ArticleThe work presented here was undertaken by the OECD to provide a strategic background report for the Patient Safety Priority within the G20 Health Working Group (HWG) 2020. It was commissioned by the Saudi Government. ‘"Acting on patient safety requires leadership and communication, political will, and investment. Transparency across a health system is also integral to begin improving safety and reducing harm. This can only be achieved through investing in a modern information infrastructure, but also relies on sound governance, accountability and proactive leadership. The analysis is clear: unsafe care kills millions, and harms tens of millions of people each year. It also exerts a great economic cost on health systems and society, consuming valuable resources that could be put to productive uses elsewhere. Much of this can be prevented through concerted action and adequate investment. The time for action is now."
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Content ArticleAn informal conversation with Dr Tejal Gandhi and Dr Jeffrey Brady about their work as co-chairs of the National Steering Committee for Patient Safety and how the committee’s new action plan, Safer Together: A National Action Plan to Advance Patient Safety, aims to change the patient safety landscape. The plan, released September 14, focuses on four foundational areas: culture, leadership, and governance; patient and family engagement; workforce safety; and learning systems.
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Content ArticleCreating a foundation for safe and reliable care requires more than just a small team in an organisation. This short video captures what the Patient Safety Movement Foundation has to offer healthcare organisations hoping to make their care better and safer from the ground up.
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News Article
WHO Quality of Health Care and Patient Safety Offices to be Located in Athens
Patient Safety Learning posted a news article in News
The offices of the World Health Organisation (WHO) for the Quality of Health Care and Patient Safety will be located in Athens, Health Minister Vassilis Kikilias and the WHO Regional Director for Europe, Hans Kluge, announced on Friday after their meeting in Copenhagen. "The choice of Greece is a recognition of the work by Prime Minister Kyriakos Mitsotakis, the Greek Ministry of Health and the Greek government in managing the pandemic and implementing public health policies, such as the successful implementation of the anti-smoking law, and promoting important reforms, such as passing the law for the establishment of the National Organisation for Quality Assurance in Health," the health ministry said in a statement. "Greece has recently led important developments in the field of health, such as legislation banning smoking in public places, the launch of the National Anti-Smoking Action Plan and reforms in the field of primary health care." "All the above, in combination with the excellence of the Greek health institutions and the leading researchers in the field of health and wellness, indicate a strong leadership within the European Region and beyond. In addition, they create an ideal framework for the creation of a much-needed centre of excellence in the field of quality healthcare and patient safety." Read full story Source: The National Herald, 16 October 2020 -
Content ArticleIn this blog, Patient Safety Learning considers the need for global action to improve patient safety and sets out its response to the WHO’s consultation on the draft Global Patient Safety Action Plan 2021-2030.
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Content ArticleThe Patient Association's response to the PHSO: Complaint Standards Framework. Summary of core expectations for NHS organisations and staff. See also Patient Safety Learning's response to the framework.
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Content ArticleThis report tracks the progress made against the NHS Patient Safety Strategy objectives.
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Content ArticleThe African Partnerships for Patient Safety (APPS) is a WHO Patient Safety Programme concerned with building sustainable hospital to hospital patient safety partnerships. The programme is focused on countries of the WHO African Region but has also opened the network and programme resources to all hospitals in all regions of the world. It sits within the programmatic area of Global Partnerships for Patient Safety. APPS is concerned with advocating for patient safety as a precondition of health care and catalyzing a range of actions that will strengthen health systems, assist in building local capacity and help reduce medical error and patient harm. The programme acts as a channel for patient safety improvements that can spread across countries, uniting patient safety efforts. APPS has taken place in a dynamic context in which insights are emerging on multiple dimensions of patient safety in African settings and political changes have seen shifts in approaches to patient safety in the United Kingdom. What is clear however is that the published literature on evidence-based patient safety interventions in the African context still lags behind high-income countries. This report highlights that issues and solutions from high income settings cannot simply be applied to African countries, and there is a need to understand the insights presented here from front-line partners to ensure that culture and context are addressed and the necessary adaptation made to existing approaches moving forward.
