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Found 544 results
  1. Content Article
    Reducing the burden of harm and instilling better practice requires both systems thinking and committed local ownership. Comparisons of health systems across the world can help visualise best practice, opportunities for learning and potential for diffusion of innovations. Most importantly, depicting the global state of patient safety showcases exemplar safety systems and facilitates exploration of their characteristics and enablers.   This report seeks to stimulate ambitious visions and bold action to significantly reduce harm and improve the lives of millions of patients and their families. 
  2. Content Article
    This is the first in a series of blog posts by Suzette Woodward around implementing patient safety. Part one describes the growing sense of unease about the way we do safety in healthcare and how we can do it differently. It describes the dominant approach to patient safety in healthcare we use today – which has been coined by some as Safety I.
  3. 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.
  4. 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).
  5. 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.
  6. 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.
  7. 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.
  8. Content Article
    East Kent Hospitals University NHS Foundation Trust is delighted to have been the recipients of the Patient Safety Learning Award 2019 for ‘Professionalising Patient Safety’ for our FallStop programme.
  9. News Article
    It’s been 20 years since the Institute of Medicine — known now as the National Academy of Medicine — published the groundbreaking report, To Err is Human. And in that time, the healthcare industry has seen vast changes, bringing patient safety and healthcare quality to the forefront. The notion that patient safety issues are not only common, but they are preventable, challenge previously held industry beliefs, Craig Clapper, a partner in strategic consulting at Press Ganey, said during a recent interview with PatientEngagementHIT.com. In this article he discusses the progress that has been made and what still needs to be done. Looking into the future, Clapper sees an industry that integrates patient safety as a key element of everything it does. While clinicians focus on boosting patient satisfaction, delivering good clinical outcomes, and fulfilling other obligations, they should feel and see the connection with patient safety. “We should talk less about safety culture in isolation and more about how to make it about the entire patient experience,” Clapper concluded. “That'll be our biggest single advantage in the next decade. Instead of having a subculture for every outcome, we must have one seamless performance culture that can emphasize the safety, quality, and experience of care.” Read full story Source: PatientEngagementHIT, 26 November 2019
  10. Content Article
    On the 18 November 2019, Health Law from Browne Jacobson LLP hosted a Patient Safety Strategy Discussion Forum. This was focused on discussing the key proposals within the NHS Patient Safety Strategy, published in July 2019, and what they mean in practical terms. It also provided an opportunity for Trusts to share and hear about the work being done by others to implement the Strategy. The event was attended by a number of leading patient safety and quality experts and investigators from across the Midlands.
  11. 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.
  12. 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.
  13. 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.
  14. Content Article
    The North West London Integration Toolkit is intended to support communities, people and partners as they work towards the shared vision of integrated care. The toolkit is the culmination of over 200 individuals and organisations across North West London coming together to share knowledge and develop ideas as to how to implement whole systems integrated care. The toolkit is a living document and repository of collective learnings. It will evolve and be updated as local areas start to implement their plans and lessons are learned and shared.
  15. Content Article
    A US based study to determine whether medical errors, family experience and communication processes improved after implementation of an intervention to standardise the structure of healthcare provider-family communication on family centered rounds.
  16. Content Article
    Health Education England have produced a toolkit on human factors in healthcare looking at example of training, simulation and speaking up.
  17. Content Article
    This report was prepared for the World Health Organization (WHO) Patient Safety’s Methods and Measures for Patient Safety Working Group. 
  18. Content Article
    One important strategy for system-wide safety improvement involves investigating and addressing the system-wide sources of risk that contribute to unsafe care. Carl MaCrae in his paper published in the Journal of the Royal Society of Medicine highlights five strategies to ensure patient safety investigations actually improve patient safety.
  19. Content Article
    Khudeja Amer-Sharif, Patient Partner at University Hospitals of Leicester NHS Trust, presented at the recent Patient Safety Strategy Discussion Forum the work he is doing with the National Patient Safety team and others to develop the basis of the Patient Safety Partners (PSP) framework. Khudeja shared the work being done to co-produce principles for involving patients both in their own safety and in the wider delivery of healthcare.
  20. Content Article
    Presentation from Mandy Townsend, Associate Director Patient Safety and co-lead for North West Coast Patient Safety Collaborative, at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
  21. 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".
  22. Content Article
    For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience.
  23. 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.
  24. Content Article
    Engaging patients and their families in quality and safety is considered central to providing truly patient-centred care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
  25. Content Article
    Objective: To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors. Originally published in Health Services Research.
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