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Showing results for tags 'Patient safety strategy'.
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Content ArticleHealthcare worldwide is faced with a crisis of patient safety: every day, everywhere, patients are injured during the course of their care. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. Mary Dixon-Woods and Peter J Pronovost propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors – organisations, individuals, groups – each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. Efforts by individual actors, including local quality improvement projects, may have the paradoxical effect of undermining system safety. Many challenges cannot be resolved by individual organisations, since they require whole-sector coordination and action. The authors call for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.
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Content ArticleIn this Virtual Event held by the Patient Safety Movement for World Patient Safety Day 2020, over 50 speakers share their heart-wrenching and heroic stories of survival and loss as well as their professional and personal experiences that will help educate and inspire you to unite for safe care. If you missed the event you can now view the recording of it.
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Content ArticleThe purpose of this Global Framework for National Occupational Health Programmes for Health Workers, as directed by the WHO Global Plan of Action (GPA) on Workers’ Health (2008–17) and consistent with the ILO Promotional Framework for Occupational Safety and Health Convention, 2006 (No. 187), is to strengthen health systems and the design of healthcare settings with the goal of improving health worker health and safety, patient safety and quality of patient care, and ultimately support a healthy and sustainable community with links to Greening Health Sector and Green Jobs initiatives.
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Content ArticleThe World Health Organization (WHO) is calling on governments and healthcare leaders to address persistent threats to the health and safety of health workers and patients. “The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve suffering and save lives,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “No country, hospital or clinic can keep its patients safe unless it keeps its health workers safe. WHO’s Health Worker Safety Charter is a step towards ensuring that health workers have the safe working conditions, the training, the pay and the respect they deserve.” The pandemic has also highlighted the extent to which protecting health workers is key to ensuring a functioning health system and a functioning society. The WHO Charter, released for World Patient Safety Day 2020, calls on governments and those running health services at local levels to take five actions to better protect health workers. Sign up to the WHO Charter here
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Content ArticleThe Institute for Healthcare Improvement (IHI)-convened National Steering Committee for Patient Safety (NSC) has released a National Action Plan intended to provide US health systems with renewed momentum and clearer direction for eliminating preventable medical harm. Safer Together: A National Action Plan to Advance Patient Safety draws from evidence-based practices, widely known and effective interventions, exemplar case examples and newer innovations. The plan is the work of 27 influential federal agencies, safety organisations and experts, and patient and family advocates. The plan provides clear direction that health care leaders, delivery organisations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care.
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News ArticleThursday 17 September is WHO’s World Patient Safety Day. There’s no better moment in history to call for new legislation that finally ensures health worker and patient safety. Today, the Patient Safety Movement Foundation released a detailed white paper urging the creation of a National Patient Safety Board. In a statement, the Patient Safety Movement said COVID-19 has exposed the safety gaps in our healthcare system that already cause 200,000 deaths a year and that we must put health workers, and thus patients, first by finally establishing a National Patient Safety Board (NPSB). This would solve the problem in three key ways: Data-driven insight and standards: An NPSB would create and maintain a National Patient Safety Database to receive non-identifiable patient safety work product. The Board would facilitate the reporting, collection, and analysis of patient safety data and the development and dissemination of training guidelines and other recommendations to reduce medical errors and improve patient safety and quality of care. Transparency and accountability: The NPSB would also require an on-going analysis of the patient safety data in the Database and other available data to determine performance and systems standards, tools, and best practices (including peer review) for doctors and other health care providers necessary to prevent medical errors, improve patient safety, and increase accountability within the health care system. Align incentives: An NPSB would save lives and taxpayer dollars by aligning incentives, especially Medicare reimbursements, with proven patient safety protocols. "COVID-19 shouldn’t be the breaking point for our health workers, but it should be the breaking point for our tolerance of the lack of patient safety. Congress must act today on this bipartisan issue.” Read full story Source: The Patient Safety Movement, 8 September 2020
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Content ArticleSince the Institute of Medicine’s 1999 report To Err is Human, it has been known that upwards of 100,000 deaths due to preventable medical errors occur each year. In the twenty years since then, little progress has been made in the way of reducing the number of these deaths and estimates now suggest between 200- 440,000 Americans are dying preventably each year. One major component many believe is lacking in the United States is a national agency that focuses on responsibility and accountability for patient safety. The Patient Safety Movement Foundation has published a white paper assessing the feasibility of creating a National Patient Safety Board to reduce preventable medical errors in facilities across the country.
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EventuntilThis is a high-level, international virtual conference focused on patient safety and protecting health workers hosted jointly by Sovereign Sustainability & Development (SSD), RLDatix and the Saudi Patient Safety Center (SPSC). Registration
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Content ArticleIn advance of the second annual World Patient Safety Day on 17 September 2020, the theme of which is Health Worker Safety: A Priority for Patient Safety’, this blog from Patient Safety Learning looks at how staff safety relates to patient safety.
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content ArticleMaking Healthcare Safer III report is the third in a series of reports from the Agency for Healthcare Research and Quality (AHRQ), which reviews research supporting patient safety practices in place to reduce patient harms. This supplement from Shoemaker-Hunt et al. presents the reviews for eight of the patient safety practices from the Making Healthcare Safer III report: The use of rapid response teams to reduce failure-to-rescue events. The use of patient monitoring systems to improve sepsis recognition and outcomes. Environmental cleaning and decontamination to prevent Clostridioides difficile infection in healthcare settings. Chlorhexidine bathing strategies for multidrug-resistant organisms Using deprescribing practices and STOPP criteria to reduce harm and preventable adverse drug events in older adults The effect of opioid stewardship interventions on key outcomes System-level patient safety practices that aim to reduce medication errors associated with infusion pumps Improving team performance and patient safety on the job through team training and performance support tools.
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News Article
CQC chief sceptical about need for ‘patient safety commissioner’
Patient Safety Learning posted a news article in News
The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review. In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England. Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value. He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be. “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.” Read full story (paywalled) Source: HSJ, 24 August 2020 -
Content ArticleThe highly publicised crashes of two Boeing 737 Max aircraft quickly triggered pointed questions about the company’s commitment to safety versus profits. As we near the twentieth anniversary of the landmark Institute of Medicine (IOM) report on medical error, To Err is Human, that same level of scrutiny should apply to hospitals. Cost-benefit analysis is both a legitimate and crucial management function. But the criteria used in those calculations can range from appropriate to appalling. It’s long past time to examine how the “business case for safety” can sometimes represent a serious threat to patients’ lives. Michael L. Millenson discusses the dangers in the "business case" for patient safety in his blog in Health Affairs.
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Content ArticleThe dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. This short paper from Susan Burnett and Charles Vincent, outlines the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalised health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
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Content ArticleThis month, the Institute of Public Policy Research (IPPR) published their new Injury Prevention Policy, Better Than Cure.[1] In this report they call on the Government to make injury prevention a public health priority and to take further action to prevent the transmission of Covid-19 in the workplace. Patient Safety Learning welcomes the publication of this report and its recognition of the importance of improving patient safety. We concur with its identification of unsafe care as being driven by a range of underlying systems issues, such as the culture of fear, barriers to resource sharing and insufficient focus on patient safety training and skills. These closely relate to the six foundations of safer care we have set out in A Blueprint for Action.[2] We also agree about the importance of two core areas which they highlight for action in this respect: 1) The Government should commit to long-term safe staffing This is particularly an important issue as we return to more normal levels of care following the peak of the Covid-19 pandemic, with the need to ensure that organisations and staff transition to this safely.[3] We consider that system wide (health and social care) workforce modelling is needed to inform resourcing and ensuring safe staffing. 2) The NHS should use patient safety networks to share best practice We strongly agree about the importance of sharing learning for patient safety. We need people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. This is why we have created the hub, a patient safety learning platform. Designed with input from patient safety professionals, clinicians and patients, the hub provides a community for people to share learning about patient safety problems, experiences, and solutions. References 1. IPPR. Better Than Cure: Injury Prevention Policy, August 2020. 2. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 3. Patient Safety Learning. Patient Safety Learning’s response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, June 2020.
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Content Article
CPSI: Safer Healthcare Now!
Patient Safety Learning posted an article in Healthcare Excellence Canada
The Safer Healthcare Now! campaign was launched in 2005 and provides interventions to raise awareness and facilitate implementation of best practices to support patient safety improvement in Canada. The interventions serve as a resource for frontline healthcare providers, healthcare organisations, and health quality committees and councils. This Canadian Patient Safety Institute (CPSI) web page provides information, resources, and tools you can put into practice to identify, prevent, and learn from patient safety incidents. -
Content ArticleConcerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analysing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and the therapies often have narrow therapeutic windows. Thus, many of the processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviours that can result in substantial patient harm. To improve safety at the University of North Carolina, Chera et al. have applied the concepts of NAT to their practice to better understand their systems’ behaviour and adopted strategies to reduce complexity and coupling. Furthermore, recognising that you cannot eliminate all risks, they have stressed safety mindfulness among their staff to further promote safety. Many specific examples are provided herein. The lessons from NAT are translatable to clinical oncology and may help to promote safety.
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Content ArticleHealthcare Quarterly is a Canadian publication and this issue, supported by the Canadian Patient Safety Institute (CPSI), focuses on patient safety.
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Content ArticleFounded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organisations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission evaluates and accredits more than 22,000 health care organisations and programs in the United States. The below link takes you to the 2020 National Patient Safety Goals (NPSGs) for the Ambulatory Health Care program. The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them.
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Content ArticleNational Healthcare Safety Network (NHSN) subject matter experts provide updates on NHSN Analysis for 2020. Topics include: Changes to NHSN Dataset Generation (DSG) Adjusted Ranking Metric (ARM) & the Reliability-Adjusted Rankings Dashboard MDRO/CDI Module analysis updates, 2020 CLABSI analysis changes and introduction to SIR/SUR percentile distribution 2020 changes to the HAI-AR analysis reports Recently published NHSN surveillance reports Patient Safety Portal.
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Content ArticleFounded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating healthcare organisations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission evaluates and accredits more than 22,000 healthcare organisations and programmes in the United States. The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. The goals are to: Identify individuals served correctly Use medicines safely Prevent infection Identify individuals served safety risks.
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Content ArticleThis report details the experiences of the Scan4Safety demonstrator sites. Six trusts implemented scanning of people, products and places over the two-year initiative, which was funded by the Department of Health and made extensive use of unique identifiers from GS1, a not-for-profit organisation that develops and maintains global standards for business communication. At these organisations, all patients have a barcode on their wristband which is scanned before a procedure. All equipment used for that procedure is also scanned – including implantable medical devices – and recorded against the patient and the location. At some trusts, staff even have barcoded badges which are scanned before a procedure so making it possible to identify which teams were identified in which procedures. The result is complete traceability alongside a full understanding of costs, at patient and clinical team level.
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Content ArticleThis paper, from THIS Institute, aims to describe exactly what needs to happen for maternity care to be safe by examining how interventions and context work together to nurture and sustain safe practice.
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Content ArticleTHIS Institute at the University of Cambridge has undertaken a rapid response project to develop an ethical framework for COVID-19 testing for NHS workers. It sought to identify and characterise the ethical considerations likely to be important to the testing programme, while recognising the tension between different values and goals. The project was guided by an expert group and by an online consultation exercise held between 27 May and 8 June 2020 to characterise the range and diversity of views on this topic. The 93 participants in the consultation included NHS workers in clinical and non-clinical roles, NHS senior leaders, policy-makers, and relevant experts. The project report emphasises that getting the COVID-19 swab testing programme for NHS workers right is crucial to support staff and patient safety and broader public health. It also recognises that COVID-19 does not affect all population groups equally. People who are socio-economically disadvantaged or members of Black, Asian and Minority Ethnic (BAME) groups may face distinctive issues in relation to testing.
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Content ArticleThe shared commitment and responsibility uniting everyone within and outside of healthcare during the COVID-19 has been unparalleled. Prior to the pandemic, this type of shared commitment has been discouragingly lacking for other major healthcare concerns such as patient safety. Reasons for this include organisational leaders who are incentivised to focus on activities essential for reimbursement and quality measurement rather than those involving the promotion of safety culture and implementation of systems-based approaches to improve safety, compounded by lack of clear ownership and accountability to solve long-standing safety challenges. The COVID-19 pandemic is leading to several ongoing impacts on the healthcare delivery system, many of which have patient safety implications. We are witnessing negative effects from delays in care from patients not seeking (or unable to seek) healthcare, patients with complex chronic conditions not having ongoing ambulatory care and new types of diagnostic errors. However, we are also witnessing some early short-term positive effects in selected safety areas where the COVID-19 pandemic has provided a new glimmer of hope. Singh et al. explore this further in their article in BMJ Quality & Safety.
