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Found 543 results
  1. Content Article
    I'm Martin. In this blog I want to talk about my role as a Macmillan acute oncology clinical nurse specialist (CNS) and what our team has done to improve patient safety within the acute ward of our hospitals. Coming from a non-oncology background there was a lot to learn when I moved into acute oncology. My background was mainly acute cardiac and respiratory, but this allowed me to notice how powerful and time effective the presence of an acute oncology CNS could be in improving cancer patient safety within the emergency department.
  2. Content Article
    Suicide is a major public health issue with more than 800,000 people taking their own lives worldwide per year. This loss of life has devastating effects on families and friends and the person’s wider network. Patients in contact with mental health services and those who present to hospital following self-harm are identified by national suicide prevention strategies as key target groups for reducing suicide rates. Despite decades of research into self-harm and suicide prevention, there are significant gaps between research, policy, and clinical practice. In this editorial in the Journal of Mental Health, Quinlivan et al. discuss how adopting a patient safety paradigm can provide additional insights into suicidal behaviour in mental health services and generate new opportunities for suicide prevention.
  3. Content Article
    Typically issued in response to a new or under-recognised patient safety issue with the potential to cause death or severe harm. NHS Improvement aim to issue warning alerts as soon as possible after becoming aware of an issue and identifying that healthcare providers could take constructive action to reduce the risk of harm. Warning alerts ask healthcare providers to agree and coordinate an action plan, rather than to simply distribute the alert to frontline staff.
  4. Content Article
    Sidney Dekker says when there has been an incident of harm, we need to know "who is hurt, what do they need, and whose obligation is it to meet that need?" In this blog, commissioned by Patient Safety Learning, Joanne Hughes, hub topic lead, develops our understanding of the needs of patients, families and staff when things go wrong.  Using Joanne's expertise and informed by her personal experience and engagement with many others who have suffered second harm, this blog discusses the care needs for harmed patients, their families and for staff when things go wrong. It aims to highlight the chasm between what is needed and what is currently delivered.
  5. Content Article
    The safe management of a patient’s airway is one of the most challenging and complex tasks undertaken by a health professional - complications can result in devastating outcomes. How can anaesthetists improve safety, prevent complications, and be prepared to manage difficulties when they arise? How, in a crisis, can we ensure that human and technical resources are best utilised? This free course from Future Learn, endorsed by the Difficult Airway Society, will provide answers to these key questions and help you develop strategies to improve patient safety in your area of practice, discussing safe airway management in patient groups and multidisciplinary clinical settings.
  6. Content Article
    The findings in this report followed a 14-year inquiry into hyponatraemia-related deaths in five children in Northern Ireland. The inquiry was set up in 2004 to investigate the deaths of Adam Strain, Claire Roberts, Raychel Ferguson, Lucy Crawford and Conor Mitchell. The chairman said that the deaths of Adam Strain, Claire Roberts and Raychel Ferguson were the result of "negligent care".
  7. Content Article
    In the worst moment of your life, what would you need? In 2017, Jen Gilroy-Cheetham’s life changed forever. Just six months after having her second child, she was diagnosed with a rare neuroendocrine tumour and was advised that she would need to undergo open surgery to have half of her stomach removed. Complications led to one of the darkest and scariest times of Jen’s life, as she was put into a hospital ward feeling unwell, vulnerable and unsafe. Now recovered, Jen shares her experiences as a patient from a hospital bed - or audience member - watching all of the healthcare staff around her - actors on a stage - doing everything they could to make her feel safe. In reliving her journey to recovery, Jen highlights what’s needed within a healthcare setting to make patients feel safe. Jen feels that highlighting what’s worked well to help her to feel safe and what needs to change is valuable and may help others in the future.
  8. Content Article
    Several organisations, researchers and clinicians have discussed the need for a patient safety culture in dentistry. Strategies are available to help improve patient safety in healthcare and deserve further consideration in dentistry. Published by the British Dentistry Journal, this article: discusses the history of patient safety initiatives in healthcare and dentistry describes strategies that can be applied to identify patient safety issues in dentistry emphasises the importance of both process and cultural factors in developing a safer healthcare environment.
  9. Content Article
    In this presentation on improving patient safety and reducing alarm fatigue, the panellists discuss the right and wrong way to use continuous surveillance monitoring. 
  10. Content Article
    This diagram, published by the Institute for Healthcare Improvement (IHI), is titled A driver diagram to systematically and proactively identify and eliminate non-value-added waste in the US health care system by 2025. Produced by the IHI's Leadership Alliance's Waste Working Group, it sets out a number of drivers for reducing waste in the healthcare system in America. The top driver listed focuses on safety and reducing harm.
  11. Content Article
    South Australia Health's patient-centred involves engaging with the consumer and the consumer to make sure they are responsive to their needs, values and preferences. One way South Australia Health gathers feedback is to survey people who have spent time in a country or metropolitan public hospital. In 2017, 2228 people were interviewed and their responses were analysed. This report summarises the results of the survey.
  12. Content Article
    Communication failures in healthcare teams are associated with medical errors and negative health outcomes. These findings have increased emphasis on training future health professionals to work effectively within teams. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) communication training model, widely employed to train healthcare teams, has been less commonly used to train student interprofessional teams. This study, published in BMJ Quality and Safety, reports the effectiveness of a simulation-based interprofessional TeamSTEPPS training in impacting student attitudes, knowledge and skills around interprofessional communication.
  13. Content Article
    Regardless of a patient's health literacy level, it is important that staff ensure that patients understand the information they have been given. The teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way for clinicians to confirm they have explained things in a manner their patients understand. The related show-me method allows staff to confirm that patients are able to follow specific instructions (e.g., how to use an inhaler).
  14. Content Article
    This is a patient safety solution document from the World Health Organization, focusing on communication during handover. It includes suggested actions, potential barriers and also ways to engage patients and families.
  15. Content Article
    The Clinical Excellence Commission in New South Wales, Australia, is driving person-centred care by stimulating districts to compete to provide it. Karen Luxford and Stephanie Newell describe the integrated approach, its uptake, and encouraging early evidence of change.
  16. Content Article
    The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: increase time nurses spend in direct patient care improve safety and reliability of care improve experience for staff and patients make changes to physical environments to improve efficiency. The objective of this paper, published in BMJ Quality & Safety, was to explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale quality improvement intervention.
  17. Content Article
    The framework for safe, reliable, and effective care, set out by the Institute for Healthcare Improvement, provides clarity and direction to health care organisations on the key strategic, clinical, and operational components involved in achieving safe and reliable operational excellence, a 'system of safety', not just a collection of stand-alone safety improvement projects.
  18. Content Article
    Presentation from Jo Hughes at the Patient Safety Learning Annual Conference 2019 on engaging patients and families in patient safety. Joanne’s daughter Jasmine died in 2011 following failures in her care. Soon after Joanne set up Mother’s Instinct with the ambition to provide a source of support specifically for families whose children die following medical error, and a platform to share their stories and experiences for learning to improve patient safety for children, patient engagement in patient safety, and care of avoidably bereaved parents.
  19. Content Article
    Presentation from Linda Kenward at the Patient Safety Learning Annual Conference 2019 on engaging patients and service users. Linda is Principal Lecturer in Nursing at the University of Cumbria.
  20. Content Article
    In recent years, there has been an increasing focus on the role of safety culture in preventing incidents such as medication errors and falls. However, research and developments in safety culture has predominantly taken place in hospital settings, with relatively less attention given to establishing a safety culture in care homes. Despite safety culture being accepted as an important quality indicator across all health and social care settings, the understanding of culture within social care settings remains far less developed than within hospitals. It is therefore important that the existing evidence base is gathered and reviewed in order to understand safety culture in care homes.
  21. Content Article
    Since the emergence of the opioid epidemic in the United States at the beginning of the 21st century, more than 400,000 Americans have died as the result of an opioid overdose. As of 2018, the Substance Abuse and Mental Health Services Administration estimates that more two million people have an opioid use disorder. With the rate of opioid-related inpatient stays and the number of opioid-related emergency department visits continuing to rise dramatically in the US, hospitals have the opportunity to make a major impact in reducing morbidity and mortality related to opioid use. This document, produced by the Institute for Healthcare Improvement, provides system-level strategies that hospitals can implement immediately to address the challenges of preventing, identifying, and treating opioid use disorder.
  22. Content Article
    Paul Batalden has defined quality improvement as: “the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”. Quality improvement (QI) goes beyond traditional management, target setting and policy making. QI methodology is best applied when tackling complex adaptive problems – where the problem isn’t completely understood and where the answer isn’t known – for example, how to reduce frequency of violence on inpatient mental health wards. QI utilises the subject matter expertise of people closest to the issue – staff and service users – to identify potential solutions and test them. East London NHS Foundation Trust (ELFT) is a provider of mental health and community services, to a population of approximately 1.5 million people, mainly across East London, Bedfordshire and Luton.
  23. Content Article
    Earlier this year, the World Health Organization declared 17 September the first World Patient Day and presented it as an opportunity to speak up for patient safety. A week or so beforehand, health leaders from across the world had met in Salzburg, Austria, at the request of Salzburg Global Seminar and the Institute for Healthcare Improvement (IHI) to explore ways of improving the measurement of patient safety. The Lucian Leape Institute, an initiative of the IHI, led the convening and content curation. Participants of Moving measurement into action: designing global principles for measuring patient safety agreed that there is no single measure that allows all stakeholders in all settings to assess the past, current, and future safety of their system. Participants agreed a system of measures must be carefully designed to assess the safety of patients throughout their health journey. The conversations in Salzburg have helped establish eight global principles for the measurement of patient safety. They feature in this new document, Salzburg Statement on Moving Measurement into Action: Global Principles for Measuring Patient Safety.
  24. Content Article
    What is the Autism Act? The Autism Act 2009 was the result of two years of active campaigning, with thousands of National Autistic Society members and supporters persuading their MPs to back Cheryl Gillan MP’s Private Members Bill. It is the only act dedicated to improving support and services for one disability.
  25. Content Article
    Sally Howard, topic leader for the hub, shares her insight on the imminent NHS Improvement Framework after she attended a webinar with National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey.
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