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Found 544 results
  1. Content Article
    This information sheet, published by the World Health Organization (WHO) in 2017, summarises the '5 Moments for Medication Safety', which are the key moments where action by the patient or caregiver can greatly reduce the risk of harm associated with the use of their medication/s. It is part of the 'Medication without harm' global patient safety challenge.
  2. Content Article
    This document describes Never Events, and the revised list of reportable patient safety incidents to be classed as Never Events from 1 April 2018.
  3. Content Article
    This pamphlet, published by the World Health Organization (WHO), is part of the 'Medication without harm' global patient safety challenge, launched in 2017. It aims to engage patients in their care by looking at the 5 Moments for Medication Safety, which are the key moments where action by the patient or caregiver can greatly reduce the risk of harm associated with the use of their medication/s.
  4. Content Article
    At the end of June, Sajid Javid MP was appointed as the new as Secretary of State for Health and Social Care in the UK Government. In this blog, Patient Safety Learning Chief Executive, Helen Hughes, outlines why patient safety should be at top of his agenda, setting out six patient safety priorities for the new Minister.
  5. Content Article
    In this blog Patient Safety Learning outlines key points included in its response to the consultation on the Medicines and Healthcare products Regulatory Agency’s (MHRA) proposed Patient and Public Involvement Strategy 2020-25. It sets out its feedback to this consultation and describes the change required for the regulator to improve its approach to engaging and involving patients to improve patient safety.
  6. Content Article
    This is Patient Safety Learning’s submission to the Women’s Health Strategy: Call for evidence. In seeking to inform the development of its Women’s Health Strategy, the UK Government has requested written submissions of data, research, and other reports of relevance. In its response, Patient Safety Learning outlines the risk to patient safety of sex and gender bias. The consultation is now closed.
  7. Content Article
    In this blog Patient Safety Learning outlines the key points included in its response to the consultation on a proposed Patient Safety Commissioner role for Scotland. This sets out their feedback to this consultation and describes the powers and resources this role will require if it is to effectively influence change and improve patient safety.
  8. Content Article
    The Global Patient Safety Action Plan aims to provide a strategic direction for concrete actions to be taken by countries, partner organisations, care facilities and World Health Organization (WHO). It sets out a vision of a “world in which no patient is harmed in healthcare, and everyone receives safe and respectful care, every time, everywhere” and a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care.
  9. Content Article
    The Care Quality Commission's (CQC) new strategy strengthens its commitment to deliver their purpose: to ensure health and care services provide people with safe, effective, compassionate, high-quality care and to encourage those services to improve.
  10. Content Article
    In this article, published in Human Factors and Ergonomics in Manufacturing & Service Industries, the authors present a model for integrating Human Factors/Ergonomics (HFE) into healthcare systems to make them more robust and resilient. They believe that to increase the impact of HFE during and after the Covid-19 pandemic this integration should be carried out simultaneously at all levels (micro, meso, and macro) of the healthcare system. This new model recognises the interrelationship between HFE and other system characteristics such as capacity, coverage, robustness, integrity, and resilience.
  11. Content Article
    This article, published in ICU Management and Practice, explores how human factors are significant contributors to drug error. To overcome some of these human factors, standardisation and consolidation is needed of agreed drugs and equipment into a compact pre-packed critical care drugs pouch (CCP) for use in non-theatre environments.
  12. Content Article
    This article, published in The Joint Commission Journal on Quality and Patient Safety, explores the effectiveness of shift handoffs (handovers) by staff. It discusses how poor-quality handoffs have been associated with serious patient consequences, and that standardisation of handoff content and delivery improves both quality and safety.
  13. Content Article
    The “WHO handbook for national quality policy and strategy” outlines an approach for the development of national policies and strategies to improve the quality of care. Such policy and strategy can help clarify the structures, roles and responsibilities within national quality efforts, support the institutionalisation of a culture of quality, and secure buy-in from health system leaders and stakeholders. The handbook is not a prescriptive process guide but is designed to support teams developing policies and strategies in this area, and very much recognizes the varied expertise, experience and resources available to countries. It outlines eight essential elements to be considered by teams developing national quality policy and strategy: national health goals and priorities; local definition of quality; stakeholder mapping and engagement; situational analysis; governance and organizational structure; improvement methods and interventions; health management information systems and data systems; quality indicators and core measures. The NQPS handbook was co-developed with countries each finding themselves at different stages of the development and execution of national quality policies and strategies and was informed by the review of a sample of more than 20 existing quality strategies across low-, middle- and high-income countries globally.
  14. Content Article
    This World Health Organization (WHO) document – Delivering quality health services: a global imperative for universal health coverage – describes the essential role of quality in the delivery of health care services. As nations commit to achieving universal health coverage by 2030, there is a growing acknowledgement that optimal health care cannot be delivered by simply ensuring coexistence of infrastructure, medical supplies and health care providers. Improvement in health care delivery requires a deliberate focus on quality of health services, which involves providing effective, safe, people-centred care that is timely, equitable, integrated and efficient. Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
  15. Content Article
    In this opinion piece for The Hill, the authors argue that urgent action is needed to prevent huge amounts of avoidable harm in the American healthcare system. They point to successful strategies under the Obama administration to demonstrate that the right political will can both improve patient safety and save money. They highlight actions that policy makers, official bodies and patients should take to promote the patient safety agenda.
  16. Content Article
    This document compiles good practices produced and submitted by the experts participating in the World Health Organization's Meeting of the Minds on Quality of Care conference in Athens on the 2-3 December. It includes the submission from Patient Safety Learning's Chief Executive Helen Hughes.
  17. Content Article
    The UK Government committed to establishing a Patient Safety Commissioner for England in the Medicines and Medical Devices Act 2021. The decision to create this role came about as a result of a specific recommendation in First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review), published in July 2020. The Department of Health and Social Care held a consultation asking for comments on the proposed arrangements for the appointment and operation of the new Patient Safety Commissioner between 10 June and 5 August 2021. This report analyses responses from the public and other interested parties.
  18. Content Article
    The Royal College of Physicians has published a position paper setting out why we need an explicit cross-government strategy to reduce health inequalities to improve population health and address avoidable differences in health access and outcomes between certain groups. Health inequality was a problem before COVID-19 – with a gap in healthy life expectancy between the richest and poorest areas of around 19 years – but the pandemic has tragically demonstrated how these inequalities can have an impact in just a matter of weeks.
  19. Content Article
    In this opinion piece in The Guardian, Gabriel Scally, professor of public health and member of the Independent Sage committee, argues that the government's response to Covid-19 relies on personal responsibility rather than public health measures. He highlights that this will not be adequate to get the pandemic under control. The author states that a public health-focused response should have three pillars: prevention, vaccination and control, but at the moment the government is using just one of these. He draws attention to the issue of resources being wasted on handwashing and sanitisation, when Covid-19 is primarily airborne, and argues that funding should be redirected to investing in ventilation improvements and promoting the use of more effective face coverings. He also highlights the failure of contact tracing in the UK, and calls for renewed efforts to develop a comprehensive public health response in light of the new Omicron strain.
  20. Content Article
    This report was submitted to the United States Congress by the Department of Health and Human Services, in consultation with the Agency for Healthcare Research and Quality (AHRQ). It sets out effective strategies to improve patient safety and reduce medical error.
  21. Content Article
    Human factors and ergonomics (HF/E) is concerned with the design of work and work systems. There is an increasing appreciation of the value that HF/E can bring to enhancing the quality and safety of care, but the professionalisation of HF/E in healthcare is still in its infancy. In this paper, Sujan et al. set out a vision for HF/E in healthcare based on the work of the Chartered Institute of Ergonomics and Human Factors (CIEHF), which is the professional body for HF/E in the UK. The authors consider the contribution of HF/E in design, in digital transformation, in organisational learning and during COVID-19.
  22. Content Article
    This is the fifth and final of a short series of blogs in which we take a look back at our work in five areas of patient safety during 2021. In this blog we outline how we have been working this year to develop organisational standards for patient safety. Throughout our work, Patient Safety Learning seeks to 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. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable.
  23. Content Article
    Quality 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.
  24. Content Article
    Obstetric incidents can be catastrophic and life-changing, with related claims representing the Clinical Negligence Scheme for Trusts’ (CNST) biggest area of spend. The Maternity Safety Strategy set out the Department of Health and Social Care’s ambition to reward those who have taken action to improve maternity safety supported through the Maternity Incentive Scheme. Year four of the Maternity Incentive Scheme launched on 9 August 2021. The scheme supports the delivery of safer maternity care through an incentive element to trust contributions to the CNST. The scheme, developed in partnership with the national maternity safety champions, Dr Matthew Jolly and Professor Jacqueline Dunkley-Bent OBE, rewards trusts that meet ten safety actions designed to improve the delivery of best practice in maternity and neonatal services. In the fourth year, the scheme will further incentivise the ten maternity safety actions from the previous year with some further refinement.
  25. Content Article
    In the Scottish Government’s Programme for Government 2020-21 it committed to establishing a Patient Safety Commissioner for Scotland. The decision to create this role came about as a result of a specific recommendation in the First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review), published in July 2020. The Scottish Government held a consultation process seeking views on a range of issues relating to the creation of a new Patient Safety Commissioner role between 5 March 2021 and 28 May 2021. This report analyses responses from the public and other interested parties.
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