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Found 535 results
  1. Content Article
    The Joint Commission's National Patient Safety Goals address patient care and safety to give healthcare organisations a framework for improvement. This article from the University of Southern California takes a look at the current National Patient Safety Goals, the role of healthcare administration in patient safety, strategies to implement safety goals in hospitals and evaluating the effectiveness of safety goals.
  2. Content Article
    The Patient Safety Movement Foundation offers a unique educational opportunity for healthcare professionals around the world to expand their knowledge in the theory and practice of patient safety. Please apply to this fellowship programme from the link if you are interested in joining the 2024 cohort of fellows. Application deadline is 1 August 2023.
  3. Content Article
    Video of the 10th Annual World Patient Safety, Science & Technology Summit presentations. The event fostered a high-level exchange of ideas and initiatives to improve global patient safety with expert speakers and panelists, inspiring messages from hospital executives, and the sharing of tragic patient stories. The programme ignited further momentum to reach ZERO harm. You can view all the speaker presentations by clicking on the image below. There is also a link to the Patient Safety Movement Foundation website with all the presentations at the end of the page.
  4. Content Article
    Patients are vulnerable during emergency episodes outside the formal care sector, for example, care provided by paramedics responding to a stroke or heart attack at home. Yet much less is known about the safety of Emergency Medical Services (EMS) as compared with primary or secondary healthcare. This relative lack of information is important given there are aspects of EMS care that create unique patient safety challenges. This BMJ Editorial discusses how we can improve patient safety in the Emergency Medical Services.
  5. Content Article
    This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 9 June 2023. At this meeting, members of the Network were joined by Dr Henrietta Hughes, Patient Safety Commissioner for England. The PSMN is an informal voluntary network for patient safety professionals in England. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out about the network.
  6. Content Article
    The Armstrong Institute for Patient Safety and Quality provides an infrastructure that oversees, coordinates and supports patient safety and quality efforts across Johns Hopkins' integrated healthcare system. Their mission is to eliminate patient harm, achieve best patient outcomes at the lowest possible cost and share that knowledge through research and training The Armstrong Institute for Patient Safety and Quality leads regional, national and international projects that reduce preventable harm, improve patient and clinical outcomes, and decrease health care costs. They apply a scientific approach to improvement, employing robust measures and rigorous data-collection methods that can be broadly disseminated and sustained.
  7. Content Article
    Patient Safety Learning has developed a unique set of patient safety standards, resources and tools to help organisations not only establish clearly defined patient safety aims and goals, but also support their delivery and demonstrate achievement. This page provides an overview of our Standards with links to further information.
  8. Content Article
    In this blog Aiden Fowler, the National Director of Patient Safety in England and a Deputy Chief Medical Officer at the Department of Health and Social Care, reflects on progress made in implementing the NHS Patient Safety Strategy, four years on from its publication. He outlines some of the main programmes of work associated with this and considers their impact on avoidable harm in the NHS.
  9. Content Article
    The role of Patient Safety Specialist was introduced by the NHS in England in 2019, as part of wider plans designed to help improve patient safety. There are currently several hundred Specialists in place. All NHS organisations in England are required to identify at least one Patient Safety Specialist, and they will play a key role in delivering the NHS Patient Safety Strategy. The This Institute wants a detailed understanding of the background to the Patient Safety Specialist role and its implementation to date. This study aims to offer insights into the challenges and opportunities associated with delivering improvement though a designated role like the Patient Safety Specialist. The study aims to highlight ways to support Patient Safety Specialists and provide recommendations to NHS England about future policy and strategy around their role.
  10. Content Article
    The Royal United Hospital Bath NHS Trust project tested different ways to communicate with staff about patient safety, to encourage the reporting of incidents and to promote a learning culture.
  11. Content Article
    This framework supports the health and disability sector to mitigate and respond to healthcare harm in Aotearoa New Zealand. Healthcare harm as defined in this framework can be a physical, psychological, social, spiritual injury or experience that occurs during the provision of care. In Aotearoa New Zealand, harm also occurs and endures due to the impacts of imperialism, colonisation and racism. In te ao Māori, harms are conceived as diminishing of the tapu and mana of people, their environments and their spiritual connection. The framework was developed by the National Collaborative for Restorative Initiatives in Health in partnership with a diverse range of stakeholders over an 18-month period. The recommendations in the framework aim to enhance the overall health and wellbeing of consumers and providers of healthcare, while accounting for the unique features of the health system context.
  12. Content Article
    The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital.
  13. Content Article
    This letter is a resource for patients to help GPs identify the complications of pelvic mesh. It explains signs and symptoms of women presenting with pelvic mesh-related conditions and if required, where to signpost them for further help. It has been issued by the Patient Safety Commissioner for England, developed in partnership with the patient campaign groups Sling the Mesh and the Rectopexy mesh victims and support.
  14. Content Article
    The role of the Patient Safety Commissioner for England is to promote patient safety in relation to medicines and medical devices and to promote patients’ voices. This site provides information and resources related to this role and is for everyone interested in promoting patient safety and making sure that patients’ voices are heard.
  15. Content Article
    The Global Patient Safety Action Plan was formally adopted at the World Health Assembly on 28 May 2021. It provides a 10-year roadmap and actions to work towards its vision of a world in which no one is harmed in healthcare and every patient receives safe and respectful care. This report provides a snapshot of progress made in achieving the strategic objectives and strategies of the global action plan based on the WHO Member State survey coordinated by the secretariat. This interim report will be replaced by a final Global Patient Safety Report 2023 later in the year.
  16. Content Article
    Webinar with Dr Chris Sirrs, Research Fellow at the Centre for the History of Medicine, University of Warwick, on the histories of patient safety in the NHS.
  17. Content Article
    The Patient Safety Authority (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). Long-term care facilities report infections into the Pennsylvania Patient Safety Reporting System (PA-PSRS). The PSA analyses those reports to prevent recurrence—either by identifying trends unapparent to a single facility or flagging a single event that has a high likelihood of recurrence— and disseminates that information through multiple channels. Here is the PSA's 2022 Annual Report.
  18. Content Article
    On 23–24 February 2023, the 5th Global Ministerial Summit on Patient Safety in Montreux, Switzerland, marked the first convening of global leaders to discuss patient safety for more than 3 years. The summit provided the opportunity to reimagine the way safe care is delivered using learnings from the COVID-19 pandemic. In this correspondence in the Lancet, Shaw et al. hopes we will look back at the Montreux summit as a turning point in patient safety: the catalyst for moving from plans to actions, so that at future summits we can discuss shared learning and evaluation of health systems that deliver safe care to all.
  19. Content Article
    The Dutch Hospital Patient Safety Program started in 2008. It initially ran for five years, and its aim was to decrease adverse events by 50% in all Dutch hospitals. A second National Safety Program launched in 2020. This focuses on reflection, interprofessional collaboration and explaining process variation in daily practice. It also looks to foster more patient involvement and shared decision making. The ultimate aim is to reach a significant reduction in preventable patient harm. This webinar provides an overview of patient safety in the Netherlands and discusses these two initiatives and their implementation, outcomes and ongoing impact.
  20. News Article
    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
  21. News Article
    The Care Quality Commission (CQC) will restart inspections from 1 February with a focus on the urgent and emergency care system, the regulator has announced. In December, CQC postponed inspections of some services to support the acceleration of the vaccination booster programme. They also prioritised activity to help create more capacity in adult social care. However, considering the current situation – including the easing of restrictions across the country – they have reviewed and updated their regulatory approach. From 1 February the CQC will inspect where: there is evidence that people are at risk of harm. This applies to all health and social care services, including those where inspections were previously postponed except in cases where we had evidence of risk to life CQC can support increasing capacity across the system, particularly in adult social care a focus on the urgent and emergency care system will help us understand the pressures, where local or national support is needed, and share good practice to drive improvement. Much of their approach is unchanged and remains in line with the update from the Chief Inspectors on 10 December 2021. This includes: achieving their ambition to complete 1,000 infection prevention and control (IPC) inspections in adult social care rapid response to requests to set up new Designated Settings activity to rate adult social care services that are registered and not yet rated inspections of adult social care providers currently rated as Requires Improvement to identify where improvement has taken place and re-rate where possible. Alongside their risk-based activity, CQC will undertake ongoing monitoring of services. This helps to identify where CQC may need to take further action to ensure people are receiving safe care and offer support to providers. It also remains important that people share concerns or examples of good practice, CQC said. Read full story Source: CQC, 27 January 2022
  22. News Article
    Swedish expert has praised Scotland for leading work in improving patient safety, with a decade-long programme which is now expanding into social care. Dr Pelle Gustafson (below), chief medical officer, of Swedish patient insurer Löf, said he was “particularly impressed” by the work in Scotland over the past 10 years during a meeting of the House of Commons Health and Social Care Committee. The Scottish Patient Safety Programme (SPSP), which has been in existence for around 13 years, was set up to make patient safety a priority in NHS Scotland, drawing on lessons from the airline industry such as introducing checklists. Gustafson was asked by Tory MP Dr Luke Evans which country he would hold at the “very top of the pillar” for preventative work during an evidence session on NHS litigation reform last week. He responded: “If you take all preventive work as regards patient safety, I would say that I am personally very impressed by Scotland. “In Scotland, you have a long-standing tradition of working. You have development in the right direction. “You have a system that is fairly equal all over the place and you also have improvement activities going on. I am very impressed by Scotland.” He added: “I am particularly impressed by the Scottish work over the last 10 years. There are a lot of things that we, in the Nordic countries, can learn from Scotland too.” Read full story Source: The National, 16 January 2022
  23. News Article
    On Monday 22 November, the UK under its G7 Presidency convened a meeting on ‘Patient safety: from vision to reality’, co-sponsored with the World Health Organization (WHO). Patient safety is a critical global public health issue and is essential if health systems are to advance and achieve universal health coverage (UHC). This event provided an important opportunity to demonstrate the continued importance of patient safety as an urgent global endeavour, facilitate international collaboration, and support strategic initiatives designed to eliminate avoidable harm in healthcare globally. Since 2016, the UK has worked closely with international partners, including in the G7, to raise the profile of patient safety issues and work together to drive solutions. This engagement led to the establishment of the annual Global Ministerial Summit on Patient Safety and adoption by the 72nd World Health Assembly (2019) of a UK co-led Resolution on ‘Global Action on Patient Safety’ (creating an annual World Patient Safety Day on 17 September) and WHO’s ‘Global Patient Safety Action Plan 2021 to 2030’ by the 74th World Health Assembly (2021). The event on 22 November brought together G7 countries, UK devolved administrations, system partners and patient advocates to share learning and reaffirm the importance of this critical issue. With the unprecedented coronavirus (COVID-19) pandemic, patient safety has become an even more crucial area for international cooperation, and the event underlined the importance of countries continuing to work together to maintain momentum on improving patient safety worldwide. The event was chaired by Dr Aidan Fowler, National Director of Patient Safety for NHS England and NHS Improvement, and was very well attended by global experts. The importance of continued international work to improve patient safety was underlined in the keynote speeches from Dr Tedros Adhanom Ghebreyesus, Director General of WHO, as well as Sajid Javid, Secretary of State for Health and Social Care, and Jeremy Hunt, Chair of the Health and Social Care Committee. The event also provided an important opportunity for sharing learning from around the world; and highlighted the need for and value of continued collaboration between countries on health issues. Interventions from G7 countries and UK devolved administrations provided important insights into how different countries are tackling this shared aim of eliminating avoidable harm in healthcare. It was clear that although health systems differ from country to country, many threats to patient safety have similar causes and similar solutions. Read full story Source: Department of Health and Social Care, 23 November 2021
  24. News Article
    Press release: 23 November 2021 We are pleased to announce that Patient Safety Learning is now a member of National Voices, the leading coalition of health and social care charities in England. Members of National Voices work together to strengthen the voice of patients, service users, carers, their families and the voluntary organisations that work for them. Commenting on today’s announcement, Patient Safety Learning’s Chief Executive Helen Hughes said: “We are delighted to have joined National Voices. To reduce avoidable harm in health and social care we all need to work in partnership to identify patient safety concerns, highlight where changes are needed and share good practice, to help deliver the systemic change required to create a patient-safe future. We look forward to working closely with partners in National Voices going forward to help improve patient safety.” 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. National Voices is the leading coalition of health and social care charities in England. We have more than 180 members covering a diverse range of health conditions and communities, connecting us with the experiences of millions of people. We work together to strengthen the voice of patients, service users, carers, their families and the voluntary organisations that work for them.
  25. News Article
    A freedom of information request by HSJ has for the first time revealed a complete list of participants in NHS England’s maternity safety support programme, with 28 trusts involved since its inception in 2018. London North West University Healthcare Trust, Northern Lincolnshire and Goole Foundation Trust, and Worcestershire Acute Hospitals Trust all entered the scheme at the start, due to pre-existing quality and safety concerns. The trusts were all subsequently removed, having been deemed to have made improvements, but have since been placed back in it following inspections by the Care Quality Commission (see table below). HSJ asked the trusts to explain why they had re-entered the scheme, and why it had failed to deliver sustainable improvements the first time, but they declined to comment. NHSE said in a statement: “Trusts are placed on the maternity safety support programme according to complex criteria, including local insight and external performance measures, including CQC ratings. “Following the success of the programme since its creation in 2018, its criteria was widened to strengthen its role in proactively improving safety and enabling earlier intervention where there are concerns — this has allowed support to be offered to more trusts than in previous years.” However, it would not provide further details on the new entry criteria. Three further trusts — Barts Health, North Devon Healthcare, and the Queen Elizabeth Hospital King’s Lynn — have previously exited the programme and not so far re-entered. Trusts such as Shrewsbury and Telford and East Kent — which have been at the centre of major maternity scandals — have been on the improvement scheme for all four years. Peter Walsh, chief executive of the patient safety charity Action against Medical Accidents, said: “The number of NHS maternity services being found to be needing improvement is worrying. We welcome the fact that NHS England is devoting resources to support trusts to improve their maternity services, but there should be much more transparency about this. “The criteria for needing this support should be published, and indeed should have been subject to consultation.” Helen Hughes, chief executive of patient safety charity Patient Safety Learning, said there should be transparency about resource allocation and the criteria used to make decisions, adding: “It doesn’t appear that this information is easily accessible and in the public domain and rather begs the question, why not?” NHSE said trusts receiving support from the programme detail this in their board papers, although HSJ found this is not always the case. It added trusts are made aware of the rationale for inclusion on an individual basis. NHSE and the Department of Health and Social Care last year described the maternity safety support programme as the “highest level of maternity-specific response”. They have said the programme “involves senior clinical leaders providing hands on support to provider trusts, through visits, mentoring, and leadership development”. Full article here (paywalled) Original source: Health Service Journal
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