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Community Post
The Patient Safety Incident Response Framework
Jon Holt posted a topic in Investigations, risk management and legal issues
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Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?- Posted
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Community PostI am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
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Community PostI have been thinking recently about the challenges which is posed towards larger trusts with regards to patient safety. Particularly with getting information disseminated to all staff and being reliant on endless emails. I have recently done some work with our Action Card App which has posed its own challenges particularly with physically getting around the Departments, spreading the word, and assisting people on the app itself. What really helped us iare screen savers, twitter and having those key conversations with stakeholders within the trust. I was wondering what everyone elses perspectives were?
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Content ArticleAt a recent Patient Safety Management Network meeting, Hester Wain, Head of Patient Safety Policy at NHS England, and Dr Matt Hill, Consultant Anaesthetist, University Hospitals Plymouth NHS Trust & National Clinical Advisor on Safety Culture at NHS England, presented slides on patient safety culture. Download the presentation slides from the attachment below.
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Content Article
Patient Safety Commissioner Annual Report 2022-23 (July 2023)
Patient Safety Learning posted an article in England
The Independent Medicines and Medical Devices Safety review set out the devastating impact on people’s lives when patients’ voices go unheard. Recommendation 2 from the review was the appointment of an independent Patient Safety Commissioner to promote the safety of medicines and medical devices and to amplify the voices and views of patients and the public so that future harm is avoided. The Patient Safety Commissioner (PSC) was appointed on 13 July 2022 and took up her post officially on 12 September 2022. Here is the first Patient Safety Commissioner's first annual report.- Posted
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Content ArticleIn this report, Patient Safety Learning considers the roles and responsibilities of Integrated Care Systems (ICSs) in relation to patient safety, and how this fits in with the wider patient safety landscape in England. This article contains a summary of the report, which can be read in full here or from downloading the attachment below.
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Content ArticleThe 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.
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Content ArticleThe 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.
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Content ArticleVideo 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.
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Content ArticlePatients 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.
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Content ArticleThis 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.
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Content ArticleThe 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.
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Content ArticleIn 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.
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Content ArticleThe 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.
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Content ArticleThe 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.
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- Organisational culture
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Content ArticleThis 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.
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Content ArticleThe 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.
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- Diabetes
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Content ArticleThis 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.
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Content Article
Patient Safety Commissioner for England website
Patient Safety Learning posted an article in England
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.- Posted
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Content ArticleThe 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.
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Content ArticleWebinar 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.
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Content ArticleThe 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.
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Content ArticleOn 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.
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Content ArticleThe 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.
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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- Posted
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