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Showing results for tags 'Patient safety strategy'.
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EventUnsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. WHO Patient Safety Flagship has initiated a series of monthly webinars on the topic of “WHO Global Patient Safety Challenge: Medication Without Harm”,. The main objective of the webinar series is support implementation of this WHO Global Patient Safety Challenge: Medication Without Harm at the country level. Considering the huge burden of medication-related harm, Medication Safety has also been selected as the theme for World Patient Safety Day 2022. With each transition of care (as patients move between health providers and settings), patients are vulnerable to changes, including changes in their healthcare team, health status, and medications. Discrepancies and miscommunication are common and lead to serious medication errors, especially during hospital admission and discharge. Countries and organizations need to optimise patient safety as patients navigate the healthcare system by setting long-term leadership commitment, defining goals to improve medication safety at transition points of care, developing a strategic plan with short- and long-term objectives, and establishing structures to ensure goals are achieved. At this webinar, you will be introduced to the WHO technical report on “Medication Safety in Transitions of Care,” including the key strategies for improving medication safety during transitions of care. Register
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Content ArticleHow can healthcare organisations work towards becoming true learning organisations in a reliable safety system? At the Health Plus Care conference on the 18 May 2022, Patient Safety Learning's Chief Executive Helen Hughes and Dr Sanjiv Sharma, Medical Director at Great Ormond Street Hospital for Children (GOSH), discussed the activity being undertaken at Great Ormond Street, one the world’s leading children’s hospitals, to transform their approach to patient safety, in collaboration with Patient Safety Learning. See attached their presentation slides.
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Content ArticleJeremy Hunt', former health secretary, has written a new book: 'Zero: Eliminating Preventable Harm and Tragedy in the NHS'. You can’t fault the former health secretary proposals for improving patient care, but his slick prose fails to acknowledge the damage inflicted on the NHS by his party during his tenure as health secretary writes Rachel Clarke, a palliative care doctor.
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EventThis Westminster Health conference will discuss the next steps for professional healthcare regulation in the UK. It is being structured as an opportunity to consider: issues emerging from the Government’s consultations on regulating healthcare professionals measures in the Health and Social Care Act aimed at simplifying and modernising the legal framework for the regulation of health and care professions the impact of the pandemic on the landscape for professional healthcare regulation. Overall, areas for discussion include: priorities - changes in the approach to regulation ◦ placing patient safety at the heart of any new regulatory model. reform - stakeholder perspectives on proposals ◦ development of overarching criteria for regulation ◦ improving regulatory efficiency. impact - supporting regulated professionals to deliver high quality care ◦ preparing the workforce for the challenges of the future ◦ the role of regulatory reforms. safety - aligning reform with patient safety policy ◦ developing the role of regulation in promoting safe practices. education & training - next steps for providers ◦ quality assurance ◦ improving professionalism, leadership & delivery of new healthcare models. streamlining regulators - options & impact ◦ ensuring that there is capacity for any proposed changes to be effectively delivered. fitness to practise - assessing the future ◦ implications and priorities for health & wellbeing. the pandemic - how it has affected the landscape for healthcare regulation ◦ how to safeguard positive regulatory developments in upcoming reforms. Keynote contributions from Charlie Massey, Chief Executive and Registrar, General Medical Council; and Alan Clamp, Chief Executive, Professional Standards Authority. Patient Safety Learning's Helen Hughes will be one of the speakers. Register
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Content ArticleThe Patient Safety Movement's World Patient Safety, Science & Technology Summit took place on the 29-30 April. For those of you who were unable to attend, the entire event is now available on YouTube and is accessible to anyone using the link below.
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Content Article
Patient Safety Authority Annual Report 2021
Sam posted an article in International patient safety
The Patient Safety Authority (PSA) share its 2021 annual report, highlighting the agency’s expansion of education and reporting efforts to improve patient safety throughout the commonwealth. PSA is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires acute care facilities to report all incidents of harm (serious events) or potential for harm (incidents). -
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Peter Lachman explains why safety must be embedded into what we do every day, not what we do only after harm has occurred, and why we need to constantly ask ourselves “what do we need to do to be safe?” His new book, Oxford University Press Handbook of Patient Safety, translates the complex patient safety theories into actions that frontline staff can take to be safe. -
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Yakob Seman Ahmed, former Director General for Medical services in Ethiopia and the chair of national patient safety task force, and a recent Humphrey fellow, Public Health Policy, at the Virginia Commonwealth University, reflects on Patient Safety Learning's recent report 'Mind the implementation gap: The persistence of avoidable harm in the NHS' and the similar challenges Ethiopia faces in implementing its own standards and policies.- Posted
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Content Article
Chilean Journal of Patient Safety
Patient Safety Learning posted an article in International patient safety
The official voice of the Foundation for Patient Safety - CHILE, to spread knowledge and share advances in clinical practices, which allow us to provide safe and quality care, in all areas of health care, from high complexity to home care. Download the latest issue below. (In Spanish, but option to translate to English when you download.) -
News ArticlePatients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership. Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations. “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.” The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement. Read full story Source: BMJ, 8 April 2022
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Content ArticleThis article in the journal Archives of Disease in Childhood examines patient safety theories and suggests principles to tackle safety challenges specific to paediatric care. The authors provide an overview of the evolution of patient safety theories and tools such as huddles and electronic prescribing. They look at the example of Paediatric Early Warning Systems (PEWS), highlighting that the organisational context and culture in which PEWS is used will dramatically affect its effectiveness as a tool. They conclude that approaches to patient safety must see it as a complex interconnected whole, rooted in the culture and environment in which safety interventions act. They also argue that paediatricians must take a lead in improving the safety of the care they deliver on a systems basis.
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News Article
Patients continue to die and be harmed by the failure to learn from unsafe care
Patient Safety Learning posted a news article in News
Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not taking the action needed to prevent harm recurring. The report focuses on six sources of patient safety insights and recommendations, ranging from inquiry reports into patient safety scandals, such as the recent Ockenden report into maternal and neonatal harm at Shrewsbury and Telford Hospital, to the findings of Coroner’s Prevention of Future Deaths reports. It calls on the Government, parliamentarians, and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare and proposes recommendations in each policy area. Patient Safety Learning is calling for system-wide action in healthcare to transform our approach to learning and safety improvement. Helen Hughes, Chief Executive of Patient Safety Learning, said: “Today’s report highlights the all too frequent examples of where healthcare organisations fail to learn lessons from incidents of unsafe care and not taking the action needed to prevent future harm. Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations.” “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learned’ and ‘action will be taken to prevent future avoidable harm to others’. The healthcare system needs to understand and address the barriers for implementing recommendations, not just continually repeat them. Hope is not a strategy.” This report has been published as part of the Safety for All Campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network. Notes to editors: Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Safer Healthcare and Biosafety Network an independent forum focused on improving healthcare worker and patient safety and has been in existence more than 20 years. It is made up of clinicians, professional associations, trades unions and employers, manufacturers and government agencies with the shared objective to improve occupational health and safety and patient safety in healthcare. COVID-19 pandemic has provided a stark reminder of the vital role healthcare professionals play in providing care to those in our society who need it most and this was recognized in the WHO Patient Safety Day in September 2020: only when healthcare workers are safe can patients be safe. In 2020, the Network launched a campaign called ‘Safety for All’ to improve practice in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. -
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In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report. This article contains a summary of the report, which can be read in full here.- Posted
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In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, discusses the connection between procurement, supply chains and patient safety, ahead of an upcoming Safety for All Campaign webinar on this topic. -
Content Article
NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR). It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation. -
Content Article
The third WHO Global Patient Safety Challenge: Medication Without Harm proposes solutions to address obstacles to safe medication practices. WHO aims to achieve widespread engagement and commitment of WHO Member States and professional bodies around the world to reducing the harm associated with medication. This Strategic Framework of the Global Patient Safety Challenge depicts the four domains of the Challenge: patients and the public, health care professionals, medicines and systems and practices of medication. The framework describes each domain through four subdomains. The three key action areas – polypharmacy, high-risk situations and transitions of care – are relevant in each domain and therefore form an inner circle. -
Content ArticleTraining was recognised as a “bridge to quality” 20 years ago and quality improvement is now integrated into appraisal for doctors in training and outcomes for undergraduate medical education. In the UK, expectations for training of doctors in their first two years after graduation are set by the UK Foundation Year curriculum, which states that FY2 doctors are required to contribute significantly to at least one quality improvement project and report their work in their e-portfolio. Two systematic reviews found that teaching quality improvement and patient safety to trainees frequently resulted in changes in clinical processes. However, there are concerns that trainees in the UK are on short rotations, have limited time or support, and may perceive that they lack authority to persuade colleagues that problems need tackling. This article describes an approach which applies evidence about successful quality improvement training to a curriculum on healthcare improvement for doctors in their first two years of training, drawing on the authors’ experiences. The article recommends principles to help integrate quality improvement into medical training.
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Content ArticleThis literature review in the Journal of Patient Safety aimed to assess lessons learned on patient safety in Organization for Economic Cooperation and Development (OECD) countries, and to assess whether they can be applied to humanitarian medicine. The authors concluded that safety culture and strategies will need to be adapted to address different intervention contexts and to respond to the concerns and expectations of humanitarian staff. As there is no overarching authority for the sector, medical humanitarian organisations, have a major responsibility in the development of a general patient safety policy in all their operations.
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Content Article
In this blog, Jayne Flood, Falls Prevention Practitioner at East Kent Hospitals NHS Foundation Trust, describes how her team introduced ‘yellow kits’* to assist patients at high risk of falls in A&E, and evaluated their impact. *Developed in partnership with Medline Industries Ltd.- Posted
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Content ArticleThe 'Policy Makers’ Forum: Patient Safety Implementation on 23–24 February 2022' was convened to sustain the global patient safety movement and initiate national action by policy makers and healthcare leaders for implementation of the Global Patient Safety Action Plan 2021–2030. The forum provided a global platform for engaging with senior policy makers and healthcare leaders in the discussion around implementation approaches for the Global Patient Safety Action Plan 2021-2030 within broader health agenda at country level; and also allowed sharing of best practices and lessons learned in addressing patient safety at policy and practice levels. WHO’s Director-General Dr Tedros Adhanom Ghebreyesus and Deputy Director-General Dr Zsuzsanna Jakab, and Global patient safety advocate Mr Jeremy Hunt, Chair of the UK Health and Social Care Select Committee delivered messages expressing their commitment to patient safety. The event also included keynote addresses, diverse country experiences with innovative implementation approaches, and a panel discussion on the role of policy makers and health care leaders in implementation of the global action plan. WHO introduced a draft consensus statement on the same topic for review and consensus of the event participants, which is currently being finalised based on the inputs received during the highly interactive breakout sessions.
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Content ArticleThis article in BMJ Quality and Safety looks back at how the patient safety movement has developed over the last two decades. It argues that although the aim of the movement is to change systems, in reality this has not happened on a wide scale. The authors suggest that if we are to make quantitative improvements to patient safety, the next stage of the patient safety movement needs to prioritise substantive, system-wide change.
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Content ArticleLast November, the UK, under its G7 Presidency, convened an event on patient safety entitled Patient Safety: from Vision to Reality, co-sponsored with the World Health Organization (WHO). The event was designed to build upon recent prominent initiatives taken forward by the UK Government and partner Member States to demonstrate the importance of taking action and facilitating collaboration to advance patient safety as an urgent global priority. This includes: annual Global Ministerial Summits on Patient Safety (from 2016) a Resolution on Global Action on Patient Safety (adopted by the World Health Assembly in 2019); and, the Global Patient Safety Collaborative developed in 2018 by the UK Government in partnership with the WHO to support patient safety improvement in low- and middle-income countries. Coupled with WHO’s Global Patient Safety Action Plan 2021-2030 and an annual World Patient Safety Day on 17th September, such initiatives will ensure that momentum can be maintained in order to tackle the truly global issue of patient safety within the wider context of strengthening national health systems. The link below is a recording of the event.
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Content ArticleThis blog in the Health Services Journal (HSJ) looks at the risk posed to clinical care by cyberattacks. A recent HSJ webinar in association with Sophos argued cybersecurity should be the business of everyone in the NHS, and looked at how NHS organisations can tackle the issue. Cyberattacks can cause delays and compromise patient safety and are therefore something that all healthcare staff need to consider. Using helpful language to explain the implications of cyberattacks is key to getting involvement right across the spectrum of management and frontline staff, so that it is not seen as 'an IT issue'.
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Content ArticleThis is a video recording of a Health Service Journal (HSJ) Patient Safety Congress webinar, in association with BD, considering some of the key emerging patient safety issues for 2022. The panel discuss the legacy of the Covid-19 pandemic patient and staff safety, what needs to be done to ensure that patient safety is designed into elective care recovery plans and the important role for co-production as part of this.
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News Article
Why America needs a National Patient Safety Board
Patient Safety Learning posted a news article in News
Within hours of the catastrophic Fern Hollow bridge collapse in Pittsburgh, USA, the National Transportation Safety Board was on the scene, finding answers to “Why?” and “How can we keep this from ever happening again?” What could be more obvious than the value of having a team of experts on the alert — and empowered with the authority — to provide promising solutions to dangerous situations? Transportation industries embraced the recommendations because they know what its corporate mission and obligation to the public is: to get people from place to place as efficiently and safely as possible. Sadly, we cannot say the same for health care, says Karen Wolk Feinstein. There is no single federal agency entrusted with a sole mission: to make health care as safe as possible by investigating solutions to major threats. Therefore, there has been comparatively little progress to protect patients from medical mistakes. We don’t understand well enough the preconditions and root causes of adverse events, making it difficult to prevent harm before it happens; we haven’t deployed the safety technology and analytics we have available; and we often don’t share existing lessons learned or actionable solutions, says Karen. That’s why a coalition of US experts, including leaders from hospitals, insurers, patient safety groups, consumer advocates, foundations, universities, technology companies and employers has formed to promote the establishment of an independent, nonpunitive federal agency dedicated to finding data-driven solutions to the problem of medical error. A National Patient Safety Board, modelled after the National Transportation Safety Board, would identify patient safety events, study the root causes of these events and issue recommendations to prevent future lapses. More than 80% of the NTSB’s recommendations are acted upon. Imagine if this occurred in health care: How many lives could be saved? How much needless suffering could be prevented? Read full story Source: Pittsurgh Post-Gazette, 10 February 2022
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